Every finding on record at Cove's Edge Inc

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's care plan was developed to reflect the current needs of the resident for 2 of 16 residents reviewed for care planning (Resident #3, #35).Findings:1. Resident #3 was admitted in January 2025 with diagnoses to include complete heart block and presence of cardiac pacemaker.Review of Resident #3's Quarterly Minimum Data Set (MDS) assessment, dated 10/19/25, indicates presence of cardiac pacemaker. Review of Resident #3's physician orders revealed an order with a start date of 7/31/25 for St. [NAME] pacemaker.A review of Resident #3's care plan, revised on 11/3/25, lacked evidence that goals and interventions were developed and implemented for the pacemaker. On 1/7/2025 at 12:07 p.m. during an interview, Registered Nurse (RN) #5 reviewed Resident #3's care plan and confirmed that it had not been developed or implemented in the area of the pacemaker. 2. Resident #35 was admitted in November 2025 with diagnoses to include chronic obstructive pulmonary disease (COPD), heart failure, and chronic lower extremity edema.On 1/5/26 at 9:05 a.m. observation of Resident #35 seated in his/her recliner chair located next to his/her bed. Resident #35's bed was neatly made, and the surface of the bed was covered with various personal belongings. During an interview at this time, Resident #35 stated he/she needs help from the staff applying his/her compression socks each day because he/she loses his/her balance easily.On 1/7/26 at 11:40 a.m., a surveyor observed Resident #35 seated in his/her recliner with Tubigrips (a tubular bandage that provides compression for swelling) in place on his/her bilateral lower legs. During a follow-up interview at this time, Resident #35 stated that he/she wears the Tubigrips every day and that the Certified Nursing Assistant (CNA) helps him/her apply them each morning and remove them before bed.On 1/7/26 at 11:44 a.m. during an interview, CNA #6 stated Resident #35 sleeps in his/her recliner and that he/she wears compression stockings every day.On 1/7/26 at 11:50 a.m. during an interview, Registered Nurse (RN) #8 and CNA #5 stated that Resident #35 wears Tubigrips daily. Review of Resident #35's clinical record revealed a Quality Review progress note dated 12/4/25 that states, . chooses to sleep in [his/her] recliner.Review of Resident #35's care plan states, I have an ADL [Activities of Daily Living] self-care performance deficit.Will have no injuries from use of side/enabler rail device.BED MOBILITY: I use an enabler to maximize independence repositioning in bed. and I have potent [potential] for skin integrity r/t [related to] decreased mobility.pressure relieving device on bed. Further review of the care plan revealed, Altered cardiovascular status r/t CHF.chronic lower leg edema. and lacked evidence of Resident #35's daily use of Tubigrips.On 1/7/26 at 12:37 p.m. during an interview, the above finding was discussed with RN #5 and the DON. At this time, RN #5 reviewed Resident #35's care plan and stated that Resident #35 has slept in his/her recliner since admission and confirmed that the bed mobility and side/enabler rail interventions on Resident #35's care plan do not reflect his/her current care needs. RN #5 then stated that the Tubigrips should have been included on Resident #35's care plan.

Based on observations, interviews and facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and failed to ensure foods were labeled and dated in the reach in refrigerator for 2 of 2 kitchen tours. (1/5/26 and 1/5/26)Findings:1. On 1/5/26 at 9:06 a.m., observation of the kitchen with the Dietician and the Food Service Director (FSD) the following findings were observed and confirmed.- The walk-in freezer ceiling had built up ice in front of the fans, the floor was littered with food and bagged food/packages including French fries, frozen yogurt/ice cream single serve cup and several packages of an unknown food product. Under the shelving unit was a built up ice mound in the right back corner. There were open unlabeled/dated bag of waffles and a bag of personal pizzas.- The stand up mixer had dried food/debris on the mixing arm, the protective cage and the shield. At this time the FSD and the cook stated the last time the mixer was used was Friday (3 days ago) for making cinnamon buns.- The 3 bin plastic storage containers for flour, panko and sugar had food/debris particles covering the container and lids.- The Cook's cooler had a pan of sliced deli meat (roast beef) with an orange sticker/label with a used by date of 1/4/26.2. On 1/6/26 at 8:20 a.m., during a follow up observation of the kitchen with the FSD, the walk-in freezer ceiling had built up ice in front of the fans and under the shelving unit was the built up ice mound in the right back corner. The FSD stated I didn't realize it was that harsh.We will probably be hitting it by the end of the week.On 1/6/26 at approx. 3:30 p.m., observation of the built up ice in the walk in freezer was removed.The facilities Food and Supply Storage policy revised 1/25 states, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Most, but not all, products contain an expiration date. The words sell by, best by, enjoy by, or use by should precede the date. The sell-by date is the last date that food can be sold or consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the use-by, sell-by, best-by, or enjoy-by date should be discarded. Cover, label ad date unused portions and open packages. Use the Medvantage/Freshdate labeling system or complete all sections on the [NAME] orange label. Products are good through the close of business on the date noted on the label.

Based on observations, interviews and record review, the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection by failing to apply appropriate interventions including Transmission Based Precautions (TBP) and Enhanced Barrier Precautions (EBP). In addition, facility failed to demonstrate staff competency for Infection Control in the areas of TBP and EBP in 2 of 2 units (Periwinkle and hummingbird). Findings: 1. On 1/6/26 at 9:52 a.m., during a medication administration observation for Resident #6 on the Periwinkle Unit with Certified Nursing Assistant-Medication Tech (CNA-M) #7, a Contact Precautions sign that indicated a gown and gloves are to be worn when entering the room and a Personal Protective Equipment (PPE) storage bag was hanging on the front of the door. At this time, the surveyor asked CNA-M #7 to verify the type of precautions in place, and CNA-M #7 stated Resident #6 is not on precautions but that his/her roommate is on precautions for urine. When the surveyor asked to clarify what type of precautions are in place for Resident #6's roommate, CNA-M #7 sanitized his hands, donned (put on) a mask and gloves and stated he is wearing a mask because Resident #6 is coughing but could not tell the surveyor what type of precautions were in place. The surveyor donned PPE according to the instructions on the Contact sign. On 1/6/26 at 2:13 p.m. the surveyor and the Director of Nursing (DON) observed the contact sign and PPE bag hanging on outside of Resident #6's door. At this time, the DON stated neither Resident #6 or his/her roommate is on Contact precautions and that the Contact sign was placed in error. The DON then stated Resident #6's roommate is on EBP and that the PPE and an EBP sign should have been placed on the back of the door. 2. On 1/6/26 at 11:21 a.m. observation of room [ROOM NUMBER] with a Personal Protective Equipment (PPE) bag hanging on the back of the room door, there was no visible EBP sign or TBP posted instructing staff on what to wear during care or which resident in the room required the PPE. On 1/6/26 at 11:21 a.m. the above was confirmed with RN#3, who stated that they know who is on EBP or TBP by looking at the Treatment Administration Record (TAR). 3. On 1/5/26 at 12:21 p.m., observation of room [ROOM NUMBER] with a PPE bag hanging on the back of the room door, there was no visible Enhanced Barrier Precautions sign or TBP posted instructing staff on what to wear during care or which resident in the room required the PPE. At this time, during an interview with the resident, he/she stated he/she has a supra pubic (SP tube) catheter. He/she was asked if staff wear personnel proactive equipment when providing direct care for his/her SP tube. He/she stated some do some don't. On 1/6/25 at approx. 1:55 p.m., the DON and 3 surveyors discussed the lack of EBP posting on several rooms and a TBP (Contact) posted on a room that was not required. The DON stated that the EBP rooms should all have Contact precaution sign posted, stating EBP is contact precautions If the resident did not have an active infection and was on EBP then the PPE bag will be on the inside of the door until the resident is discharged . The surveyor asked if there was posted EBP signage for those residents, the DON stated no. At this time, the DON and the surveyors went to the Hummingbird unit and observed room [ROOM NUMBER]. On the back of the door was the hanging PPE bag now with a Droplet Precaution (TBP) sign posted. At this time, DON was asked which resident was on droplet precautions. The DON stated neither resident was on droplet precautions and that the posted TBP was incorrect. The surveyor asked how does staff or visitors know which resident is on TBP or EBP. The DON stated there is a list at the station. The DON was unable to find the list in the wall hanging station on the Hummingbird unit and then asked the Certified Nurses Aide (CNA#2) where the list of EBP residents is located. After ruffling through papers CNA#2 found an undated paper that contained a list of residents. On this list it had nonpharmacological interventions, which resident required a daily weight, and who was on EBP. At this time CNA #2 stated she doesn't know how old the list is or when it was made but one of the residents on the list was discharged a while ago.

Based on observations and interviews, the facility failed to provide care for a resident in a dignified manner when a Certified Nursing Assistant (CNA#1) was observed transporting a resident in a shower chair when a resident wasn't provided a cover in a dignified manner exposing their bottom in a facility hallway (Resident #3). Findings: On 1/5/26 at 11:39 a.m., observation of CNA #1 transporting Resident #3 in a shower chair from Periwinkle Place unit, past the front entrance of the facility and nurses station down onto the adjacent unit shower room. Resident #3 had a sheet over his/her lap; however, his/her bottom was visible/exposed, hanging out from under the commode seat as well as his/her foley catheter. At this time, the surveyor intervened, discussing that Resident #3 was left exposed during the transport. CNA #1 stated he/she must have moved the sheet from his/her lap.On 1/5/26 at approx.11:45 a.m., the above observation was discussed with the Director of Nursing.

Based on record reviews and interview, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 1 of 16 residents reviewed for care planning (Resident #35).Finding:Review of Resident #35's clinical record revealed an MDS admission Assessment was completed on 11/25/25. Further review of Resident #35's clinical record lacked evidence that an IDT meeting was held within 7 days following the assessment.On 1/7/26 at 12:46 p.m. the above finding was discussed during an interview with the Director of Nursing (DON) and Registered Nurse (RN) #5. At this time, RN #5 stated that she documents the IDT meeting notes in the resident's electronic medical record (EMR). RN #5 then reviewed Resident #35's EMR and confirmed that an IDT meeting was not held following the above assessment.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice in the area of medication administration and treatments for 2 of 19 sampled residents (Residents #35 and #2).1. On 1/6/26 at 11:56 a.m. observed Registered Nurse (RN#3) push the medication cart to R#2's room, proceeded to pull the medications out of the cart and then crushed them without verifying the medications to the resident's chart. The surveyor questioned the practice, but RN#3 stated she did it by memory and that the order is on the resident's Treatment Administration Record (TAR). Even after surveyor intervention RN#3 did not review the TAR before giving the resident the medications. On 1/6/26 at 12:00 p.m. the above finding was confirmed with RN#3. 2. Resident #35 was admitted in November 2025 with diagnoses to include heart failure and chronic lower extremity edema. On 1/5/26 at 9:05 a.m. during an interview, Resident #35 stated he/she needs help from the staff applying his/her compression socks each day because he/she loses his/her balance easily. On 1/7/26 at 11:40 a.m., a surveyor observed Resident #35 seated in his/her recliner with Tubigrips (a tubular bandage that provides compression for swelling) in place on his/her bilateral lower legs. During a follow-up interview at this time, Resident #35 stated that he/she wears the Tubigrips every day and that the Certified Nursing Assistant (CNA) helps him/her apply them each morning and remove them before bed. On 1/7/26 at 11:44 a.m. during an interview, CNA #6 stated Resident #35 wears compression stockings every day. On 1/7/26 at 11:50 a.m. during an interview, Registered Nurse (RN) #8 and CNA #5 stated that Resident #35 wears Tubigrips daily. A review of Resident #35's active physician orders lacked evidence of an order for the Tubigrips. On 1/7/26 at 12:44 p.m., the above finding was discussed with the Director of Nursing (DON).

Based on observations, record reviews, and interviews, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 3 of 4 residents reviewed for respiratory care (Residents #24, #35, and #41). In addition, the facility failed to ensure physician orders were obtained and provided proper monitoring for 1 of 5 residents (Resident #6) receiving oxygen therapy and failed to ensure that physician orders were followed for 1 of 4 residents (Resident #24) receiving oxygen therapy.2. On 1/5/26 at 9:33 a.m. and on 1/6/26 at 8:14 a.m. a surveyor observed the following: Resident #24 seated in his/her recliner chair, wearing nasal cannula (NC) oxygen tubing, dated 1/3/26, with the oxygen concentrator set to 2.5 liters per minute (L/min). Resident #24's unbagged, undated NC oxygen tubing attached to a portable oxygen tank stored in the pocket on the back of his/her wheelchair. The nasal cannula prongs were in direct contact with the surface of the wheelchair. A review of Resident #24's clinical record revealed the following active orders: An order with a start date of 2/25/25 for Oxygen: Continuous Oxygen via NC, 1-2 L/ min Maintain 02 [oxygen] Sat [saturation] > 92% Check 02 SAT: Q shift Titrate: SP02 [oxygen saturation] greater than 92% every shift for Dyspnea [shortness of breath] An order with a start date of 9/5/25 for Change oxygen tubing. once weekly on Friday per facility protocol. *REMEMBER TO DATE TUBING. On 1/5/26 at 9:35 a.m., during an interview, Resident #24 stated that he/she uses oxygen continuously and uses the portable oxygen quite often when he/she goes to the bathroom or leaves his/her room. On 1/6/26 at 9:01 a.m. during an interview, Registered Nurse (RN) #2 stated nursing staff apply Resident #24's portable oxygen when he/she transfers to his/her wheelchair and that Resident #24 just used the portable oxygen last night when he/she went to the dining room for the evening meal. On 1/6/26 at 1:20 p.m. during a follow-up observation, Resident #24 was asleep in his/her recliner, and his/her oxygen tubing was draped behind the oxygen concentrator, with the nasal cannula in direct contact with the floor. The oxygen concentrator was off. On 1/6/26 at 1:21 p.m. during an interview, RN #3 stated that Resident #24 needs continuous oxygen at 2L/min and that his/her oxygen saturation drops to 88% without it. At this time, the surveyor discussed the above observation with RN #3. At 1:24 p.m., the surveyor, RN #3, and CNA #8 entered Resident #24's room and observed his/her nasal cannula touching the floor. RN #3 proceeded to pick up the oxygen tubing and turn on the oxygen concentrator. Despite surveyor intervention, RN #3 continued to place the nasal cannula in Resident #24's nose. The surveyor then asked how oxygen tubing is stored when it is not in use. RN #3 stated that she usually just hangs it on the concentrator. CNA #8 stated she wraps the tubing with a tissue. On 1/6/25 at 2:05 p.m. the above concerns, including the oxygen flow rate being set outside of the physician's order parameters, the unbagged and undated tubing, and RN #3 placing the nasal cannula on Resident #24 after it was in direct contact with the floor, were discussed with the Director of Nursing (DON). At this time, the surveyor and the DON observed Resident #24's concentrator set to 2.5 L/min and his/her unbagged oxygen tubing connected to the portable tank on the back of the wheelchair, and the DON stated that to her knowledge, the facility does not have a process in place for storing oxygen tubing when it is not in use. 3. On 1/5/26 at 9:09 a.m., a surveyor observed Resident #35's unbagged nebulizer tubing and mouthpiece connected to a nebulizer machine, stored on top of Resident #35's bed. The mouthpiece was in direct contact with a pile of papers on top of the bed. On 1/6/26 at 1:16 p.m. during a follow-up observation, Resident #35's nebulizer machine with attached tubing and mouthpiece was stored on top of Resident #35's bed, and the mouthpiece was in direct contact with his/her bed linens. Review of Resident #35's clinical record revealed active physician orders for Ipratropium-Albuterol Inhalation Solution. inhale orally every 6 hours as needed for wheezing and Nebulizer Disinfect daily: in clean container/ bowl, soak items in three parts hot water, to one part white vinegar for 30 mins. [minutes] remove items from disinfectant sol. [solution], rinse under hot tap water. air dry, store Review of Resident #35's January 2026 Medication Administration Record and Treatment Administration Record (MAR/TAR) lacked evidence that the Nebulizer is disinfected and stored according to the above order. On 1/6/26 at 1:20 p.m. during an interview, the above observations were discussed with RN #6. At this time, RN #6 stated Resident #35 has Chronic Obstructive Pulmonary Disease and has used nebulizer treatments since he/she was admitted to the facility and that his/her nebulizer machine and mouthpiece should not be stored on his/her bed. RN #6 then stated that after use, the mouthpiece should be cleaned and air dried and stored on a surface but that she is not sure exactly how it should be stored. On 1/6/26 at 2:00 p.m., the surveyor discussed the finding with the DON. At this time, the DON stated she thinks nebulizer tubing and mouthpieces may have been stored in a plastic bag at one point but that she is not sure if the facility has a consistent practice now. 4. On 1/5/26 at 9:42 a.m. a surveyor observed Resident #41's oxygen concentrator next to his/her bed with unbagged and undated nasal cannula oxygen tubing coiled up with the nasal cannula prongs in direct contact with the surface of the concentrator. On 1/6/26 at 1:23 p.m., a surveyor observed Resident #41 seated in his/her wheelchair in the hall, and a portable oxygen tank was stored in the pocket on the back of his/her wheelchair with unbagged, undated nasal cannula oxygen tubing coiled up on top of the tank. At this time, Resident #41 stated that he/she stated never uses the concentrator anymore but sometimes uses this tank, gesturing toward the tank stored in the back of his/her wheelchair. Review of Resident #41's clinical record revealed documented vital signs indicating the last time Resident #41 used oxygen was 11/19/25. Review of Resident #41's November Medication Administration and Treatment Administration Record (MAR/TAR) indicated, Check O2 sat every shift. Titrate oxygen to be >91% every shift for was on oxygen at the hospital. The MAR/TAR indicated this order was discontinued 12/9/25. On 1/6/26 at approximately 2:10 p.m., the surveyor and the DON observed Resident #41's oxygen concentrator and the surveyor discussed the above finding. At this time, the DON stated Resident #41's oxygen concentrator and tank should have been removed when the oxygen was discontinued. On 1/6/26 at 2:44 p.m., the above findings were discussed with the Administrator. Findings: On 1/06/2026 at 9:52 a.m., a surveyor observed Resident #6 wearing oxygen via nasal cannula (n/c) during a medication administration observation. On 1/06/2026 at 12:11 p.m., during an interview with Resident #6, a surveyor observed an oxygen concentrator set at 2 liters and the nasal cannula tubing dated 1/1/26. Resident #6 stated he/she wears oxygen all the time. Record review for Resident #6 revealed an admission in November, 2025, with diagnoses that included COPD (Chronic Obstructive Pulmonary Disease). On 1/3/25, Resident #6 was evaluated in the emergency department for difficulty breathing and diagnosed with COPD exacerbation and pneumonia. A review of provider orders lacked a current order for oxygen use. admission orders, dated 10/24/25, included PRN (as needed) Orders, which stated Oxygen 2 liters per minute via nasal cannula as needed for dyspnea, comfort and/or an oxygen saturation below 90. Resident #6's record did not specify the amount of oxygen in use or staff documentation of regular monitoring of oxygen saturation. On 1/6/25 at 12:50 p.m., in an interview with the Director of Nursing and the Long Term Care Unit Manager, a surveyor discussed that Resident #6 has worn oxygen continuously since his/her return from the emergency room on 1/3/25. The surveyor discussed the clinical record lacked a current provider's order for oxygen use. In addition, the clinical record lacked evidence of staff documentation of amount of oxygen in use and the results of oxygen saturation monitoring. The Director of Nursing acknowledged the findings and stated she would have the provider clarify the orders.

Based on record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 sampled residents reviewed for positioning and mobility (Resident #3).Finding:Resident #3 was admitted to the facility in January 2025 with diagnoses to include left hip fracture and left hip surgical repair.A review of Resident #3's clinical record revealed the following active physician orders:An order with a start date of 1/16/25 for Elevate affected extremity to prevent swellingAn order with a start date of 1/16/25 for Incentive Spirometer 10 x QH [every hour] while awake An order with a start date of 1/16/25 for Call for persistent or worsening drainage . Review of Resident #3's baseline care plan, initiated 1/17/25 states, L [left] hip surgical incision r/t [related to] Left femur fracture [NAME] gamma nail.my surgical incision will heal .by review date. A review of Resident #3's revised care plan indicated the focus, goal, and interventions were resolved on 7/2/25.On 1/7/26 at 11:59 a.m. during an interview, the above finding was discussed with the Director of Nursing (DON). At this time, the DON stated that the order for persistent drainage should have been discontinued because Resident #3 no longer has a surgical wound but that she is not sure about the other orders and the nurse would know better.On 1/07/2026 at 12:07 p.m. during an interview with Registered Nurse (RN) #5 and RN #6, RN #6 stated Resident #3's left leg is no longer being elevated and that the Incentive spirometer is no longer being used and that the above orders are no longer accurate. At this time, RN #5 stated the nurse should have asked the provider to discontinue the orders.

Based on observations and interviews, the facility failed to ensure the resident environment remained as free of accident hazards, as is possible, related to a patient lift on 2 of 2 units (Periwinkle and Hummingbird) and for 1 of 3 days of survey. (10/21/24) Findings: 1. On 10/21/24 at 6:16 a.m., during a tour of the Periwinkle unit, two surveyors observed a Easy Way Smart patient lift, available for use, which was missing one of the safety clips on an arm. 2. On 10/21/24 at 6:23 a.m., during a tour of the Hummingbird unit, two surveyors observed a Easy Way Smart patient lift, available for use, which was missing one of the safety clips on the an arm. The surveyor reported the unsafe lifts to nursing at approx. 6:38 a.m. on 10/21/24. He/she stated that the Maintenance Director would be notified when he arrives. On 10/21/24 at 7:23 a.m., the above missing safety clips were discussed with the Senior Facilities Manager. On 10/21/24 at 7:26 a.m., observation of the Periwinkle easy lift to have both safety clips in place. On 10/21/24 at 7:33 a.m., during an interview, the Senior Facilities Manager stated both lifts have the safety clips in place.

Based on observation, facility policy, record review and interviews the facility failed to adequately ensure medications were monitored and stored at appropriate temperatures in 1 of 1 refrigerator observed. Finding: On 10/21/24 at 11:45 a.m., a surveyor observed the medication refrigerator temperature logs with Registered Nurse (RN). Review of these temperature logs from 7/2024 through 10/2024 showed temperatures were not being monitored properly, with the following information missing: > July 2024 temperatures are documented out of range for 30 out of the 30 days > August 2024 is missing temperature readings for 5 out of 31 days and temperatures are documented out of range for 31 out of 31 days > September 2024 is missing temperature readings for 3 out of 30 days and temperatures are documented out of range for 30 out of 30 days > October 2024 is missing temperature readings for 5 out of 21 days and temperatures are documented out of range for 21 out of 21 days reviewed. Facility policy and procedure for Storage of Medications dated 5/1/2018 states under procedure subsections J Medication storage conditions are monitored on a regular basis by the facility and corrective action taken if problems are identified. Subsection L states, All medications are maintained within temperature ranges noted in the United States Pharmacopeia . Refrigerated 36 F to 46 F. Subsection E states, The facility should maintain a temperature log in the storage area to record temperatures at least once a day. On 10/21/24 during an interview, the above information was confirmed with the Director of Nursing.

Based on interviews and record review, the facility failed to provide specialized rehabilitative services or obtain the required services from an outside resource that is a provider of specialized rehabilitative services for 1 of 2 residents reviewed for rehabilitative services. (#43) Findings: On 10/21/24 at 2:12 p.m. during an interview, Resident #43, stated that he/she was admitted to the facility on [DATE], and thought he/she was there for rehab but had not seen anyone from Physical Therapy (PT) or Occupational Therapy (OT). Review of the medical record contained a Physician order dated 10/7/24 for PT and OT evaluation. On 10/22/24 at approximately 11:30 a.m., in an interview with the PT/OT staff that were working on the unit, a surveyor asked if they had provided therapy for Resident #43. They stated that they could not because he/she is waiting for an evaluation prior to starting his/her therapy. On 10/22/24 at approximately 11:45 a.m., in an interview with the Admissions Coordinator, she stated the facility has been waiting on an available staff member to complete the Therapy Evaluation for Resident #43. On 10/22/24 approximately 12:00 p.m., during an interview, the Administrator stated they had lost their contract with the prior Therapy company and decided to bring the staff in house, and they have had difficulty staffing the Therapy Department. At this time, the Administrator confirmed Resident #43 had been waiting since 10/7/24 for a therapy evaluation.

Based on facility policy, interviews, record review, the facility failed to label resident's personal belongings and keep them safe and secure for 2 of 3 residents reviewed for personal property. (Resident #15 and #34) Findings: 1. On 10/21/24 at 7:28 a.m., during an interview Resident #15 stated he/she is missing 5 nightshirts and has told multiple staff about this, and no one has come to talk to him/her about it. On 10/22/24 at 12:00 p.m., during an interview with the Environmental Services Supervisor, she states laundry only knows about 2 missing nightshirts. When asked what the process of finding missing items, she states they first check the resident's room, laundry room, and then other residents' rooms. If it is not found, they will call the family to see if they have taken it home. If they still cannot find the item, they will replace it if requested by family or resident. When specifically asking about Resident #15's missing nightshirts, she states they have not found it in laundry and have not done anything further. Resident #15's medical record contained a History of Personal Possessions form which lacked evidence of documented clothing. The Cove's Edge CNA (Certified Nursing Aid) Admission form indicates the CNA had labeled Resident #15's clothing. In addition, the Missing Items form in laundry states Resident #15 is missing only one Turquoise T-Shirt. Facility policy titled Personal Property revised 1/2024 states, All personal clothing and possessions are identified with the residents name. 44049 2. On 10/21/24 at approximately 8:00 a.m. during an interview, with Resident #34, stated that he/she has had some of his/her personal clothing go missing since he/she has been at the facility and most had come back but he/she was still missing a 'sleep T' that was blue with horizonal stripes. He/she stated the loss had been reported to laundry. On 10/22/24 at approximately 9:00 a.m a surveyor observed the laundry room and asked how lost items from the resident's laundry were searched for. Laundry worker #1 stated that when they receive word that a resident is missing an item, they enter the information in a log that is kept on a clip board on the shelf above the dryers. The information entered is the bed number, the item and a description. There is no place for the resident's name or a date the loss was reported. The item for Resident #34 was listed, but they have not yet found it. Laundry worker #1 stated that items that do not have a resident tag on them are placed across the hall in the folding room. An observation of the folding room did not contain the missing item. She stated that they will just continue to look in other residents' clothes because items do get placed in the wrong rooms. On 10/22/24 at approximately 11:30 a.m., the Director of Nursing presented the Personal Property Policy dated 9/97. The Director of Nursing stated that all residents' clothes will be marked upon entry, and a list of clothing and other properties will be placed in the residents' record, either electronically or in the physical chart. On 10/22/24 at approximately 1:15 p.m., the Director of Nursing confirmed there was lack of documentation and follow through with residnet's lost clothing stating, she had found a blank inventory sheet in Residents #34's room.

Based on observation, interview, and the facility's Food Receiving and Storage Policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for ceiling vents, the surrounding ceiling, and a food disposal unit. Additionally, the facility failed to ensure foods were dated and labeled in the walk-in refrigerator and the walk-in freezer for 1 of 1 tour. Findings: Review of the facility's Food Receiving and Storage Policy (last reviewed 4/4/23) noted: II. Scope: he Dietary Director, Dietary Supervisor, and Cooks are responsible for receiving and storing all food and non-food items. These tasks are delegated as needed. III. Policy/Procedure: 6) All opened foods and beverages, prepared foods and leftovers are dated. On 8/7/23 from 9:10 a.m. to 9:50 a.m., a surveyor conducted an initial kitchen tour with the Food Service Director in which the following findings were observed: > There were 4 ceiling vents, along with the surrounding ceiling areas, that were dirty/dusty throughout the kitchen. These ceiling vents were above clean dish storage areas, food preparation areas and food service areas. > The food disposal unit, attached the right side of the two bay vegetable sink, had dried food spatter, dried liquid residue and spots rust on it. > The walk-in refrigerator had one previously opened bag of broccoli florets that was not labeled and dated. > The walk-in freezer had one case of French Bread Pizzas that were open to the air and not sealed and dated, one package of cauliflower that was not dated and labeled and one package of cinnamon buns that was not dated and labeled. On 8/7/23 at 9:50 a.m., in an interview, the Food Service Director confirmed the findings.

Based on observation and interview, the facility failed to post the current daily nurse staffing information that includes the facility name, and a breakdown of the number of hours of registered and unlicensed nursing staff responsible for direct resident care in a prominent place readily accessible to residents and visitors for 2 of 3 survey days. (8/7/23 and 8/8/23) Findings: On 8/7/23 at 10:00 a.m., during a facility tour, a surveyor observed that the nurse staffing information was not posted in a prominent place readily accessible to residents and visitors. On 8/8/23 at 9:30 a.m., during a facility tour, a surveyor observed that the nurse staffing information was not posted in a prominent place readily accessible to residents and visitors. On 8/8/23 at 9:45 a.m., in an interview, with the Director of Nursing (DON) stated that the daily nurse staffing hours are kept on a clip board behind the nurse's station. At this time, the DON confirmed that the daily nurse staffing listing was not posted in a prominent place that is accessible to residents and visitors.

Based on observations, interviews, record review of the facility's refrigerator and freezer temperature logs, and the facility's kitchen policy and procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the walk-in refrigerator fans, ceiling vents, and an exhaust fan; failed to secure, label and/or date foods in the reach-in refrigerator and the walk-in freezer; and failed to document refrigerator and freezer temperatures for 2 of 2 kitchen tours on 2 of 3 days of survey. (8/30/21 and 8/31/21) Findings: On 8/30/21 from 9:10 a.m. to 9:45 a.m., a surveyor conducted a tour of the kitchen with the Kitchen Supervisor/Certified Dietary Manager in which the following were observed: 1. The ceiling vent over the walk-in refrigerator door, was dusty/dirty. > The ceiling vent and surrounding ceiling over the steam table were dusty/dirty. > The ceiling light over the steam table was dusty/dirty. > The ceiling vent over the cart storage area was dusty/dirty. > Two ceiling vents above a food preparation area were dusty/dirty. > The ceiling above the cook stove had soiled brownish areas. > The kitchen janitor closet had a yellowish stained exhaust fan. 2. The following was observed in the walk-in refrigerator : > air circulation fan that had dirty/dusty grill covers. > unlabeled and undated opened package of cheese. > A large bag of frozen blue berries, a large bag of mixed vegetables, and a large bag of vegetable burgers that were open to the air (not sealed) and not dated. Also, there was an undated, unlabeled half a pie. On 8/30/21 at 9:45 a.m., in an interview, the Kitchen Supervisor/Certified Dietary Manager confirmed the findings. 3. On 8/31/21, during a kitchen tour with the Kitchen Supervisor/Certified Dietary Manager and the Food Service Director, the following documentation was reviewed. The facility's Quality policy(05.6780.26) noted under Procedure: 3. Dietary Department refrigerator/freezer temperatures are recorded twice daily. The Food Service Department, Kitchen Refrigerator/freezer Temperature Record noted *Per the recommendation of Food and Drug Administration(FDA) + Federal/State Regulations Hazardous Analysis Critical Control Point(HACCP), temperatures should be taken twice daily(opening and closing procedure). The following dates and times were not completed on the stated refrigerators and freezers. *July 2021- Little Refrigerator- July 23 - p.m, July 24 -a.m., and July 28- p.m. *July 2021- Cook's Reach-in Refrigerator - July 21 - p.m., July 23 - p.m., July 24 - a.m., July 27 - p.m., and July 28- a.m. *July 2021- Walk-in Freezer - July 20 - p.m., July 23 - p.m., July 24 - p.m., July 27 - p.m., and July 28 - a.m. *July 2021 - Walk-in Refrigerator - July 23 - p.m. and July 24 - a.m. *July 2021 - Ice Cream Freezer - July 21 - p.m. July 23 - p.m., July 24 - a.m, July 27 - p.m., and July 28 - a.m. *July 2021 - Aide's Refrigerator- July 21 - p.m July 23 - p.m., July 24 - p.m., July 27 - p.m., and July 28 - p.m. *August 2021 - Freezer - July 31 - a.m. and p.m. *August 2021 - Walk-in Refrigerator - July 31 - a.m. and p.m *August 2021 - Cook's Reach-in Refrigerator - July 30 - a.m. and p.m., July 31- a.m. and p.m. *August 2021 - Ice Cream Freezer - July 30 - p.m. and July 31, 2021 - a.m. and p.m. *August 2021 - Aide's Refrigerator- July 30 - p.m. and July 31, 2021 - a.m. and p.m. On 8/31/21 at 9:00 a.m., in an interview, the Kitchen Supervisor/Certified Dietary Manager and the Food Service Director, confirmed that the refrigerator and freezer temperatures logs were not filled out on the above days and times, according to facility policy and procedure.

Based on observations and interviews, the facility failed to ensure expired medications were removed from the supply and available for use in 2 of 2 medication rooms. Findings: 1. On 9/01/21 at approximately 10:50 a.m., a surveyor observed (the refrigerator across the hall from the Nurse's station near Hummingbird Lane) an open, multidose vial of [MEDICATION(S)] with an opened on date of 7/10/21; and 31 doses of Influenza vaccine that expired on 6/30/2021. This was confirmed by Registered Nurse #10 at that time of the finding. The Medication Storage in the Facility policy (Revised January 2018), Expiration Dating (Beyond -use dating) section states, D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1. The facility staff shall place a date opened sticker on the medication and enter the date opened and the new expiration date. It goes on to state, The expiration date on the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. Accordingly, the [MEDICATION(S)] should have been discarded 30 days after opening. The Registered Nurse removed this vial from the refrigerator and stated it would be thrown away. 2. On 9/1/21, at approximately 12:15 p.m. a surveyor observed (the refrigerator in the skilled unit med room) 96 [MEDICATION(S)] Suppositories that had an expiration date of 7/31/21 and 10 doses of Influenza vaccine that expired on 6/30/21. This was confirmed by Registered Nurse #11 at that time of the finding. On 9/1/21 at 12:22 p.m. these findings were also confirmed with the Assistant Director of Nursing.

Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and sanitary condition, on 2 of 3 units(Hummingbird and Periwinkle) and the kitchen hallway, for 1 of 1 environmental tours. Findings: On 9/1/21 from 10:25 a.m. to 10:45 a.m., an Environmental Tour was conducted with the Maintenance Mechanic and the Administrator in which the following findings were observed. Hummingbird Lane Unit: > The hallway wall, outside of resident room 101 had chipped/missing paint creating an uncleanable surface. >Resident Room 103-1 - The foot board was gouged and had worn off sealer. The wall had chipped/missing paint on the left as you enter the room. The floor/caulking, around the base of the toilet was dirty. All creating uncleanable surfaces. > Resident Room 105-1 - The foot board was gouged and had worn off sealer. There was chipped/missing paint on all four walls. The bathroom door and door jamb had chipped/missing paint creating uncleanable surfaces. > Resident Room 109-1 - The room entrance door jamb had chipped/missing paint creating an uncleanable surface. > Resident Room 111-2 - The foot board was gouged and had worn off sealer. The wall behind the bed, had chipped/missing paint. Both created uncleanable surfaces. > Resident Room 113-1 - The room entrance door had chipped/missing paint. The wall across from the beds, had chipped/missing paint. The closet doors and drawers were gouged and had worn off sealer. The bathroom door and closet door had chipped/missing paint. All created uncleanable surfaces. > The exit door near room 117 had chipped/missing paint creating an uncleanable surface. Periwinkle Unit: > Resident Room 118-1 - The surface coating of the commode in the bathroom was peeling off creating an uncleanable surface. > Resident Room 123-2 - The floor/caulking around the base of the toilet was dirty creating an uncleanable surface. > Resident Room 124-2 - The floor/caulking around the base of the toilet was dirty creating an uncleanable surface. There were chunks of debris in the bathroom exhaust fan. Kitchen Hallway: > There were eight ceiling tiles in the hallway outside the kitchen that had brownish stains on them. On 9/1/21 at 10:45 a.m., in an interview, the Maintenance Mechanic and the Administrator confirmed the findings listed above.

Based on record review and interviews, the facility failed to develop a comprehensive care plan for monitoring of antiepileptic medications for 2 of 2 residents reviewed for seizures/[CONDITION(S)]. (#13, #34) Findings: 1. Resident #13's clinical record indicated that the resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #13's's physicians orders dated 10/2/20 instructed staff to administer the following antiepileptic medications: [MEDICAL RECORD OR PHYSICIAN ORDER] .), give 125 mg. by mouth (p.o.) at bedtime for [CONDITION(S)], and [MEDICATION(S)] tablet, 100 mg., give 100 mg. p.o. two times a day for [CONDITION(S)]. The Quarterly Minimum Data Set (MDS) 3.0 dated 7/30/21, indicated in Section I- Primary Medical Condition Category - Fractures and Other Multiple Trauma. Section I- I5400 indicates - [CONDITION(S)] or [CONDITION(S)]. Resident #13's clinical record lacked evidence of a care plan that was developed for monitoring of antiepileptic medications. Resident #34's clinical record indicated that the resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #34's physicians orders dated 8/20/21 instructed staff to administer the following antiepileptic medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . ([MEDICATION(S)] ER) give 1500 mg. two times a day for [CONDITION(S)]. The Significant Change Minimum Data Set (MDS) 3.0 dated 8/13/21, indicated in Section I- Primary Medical Condition Category - Non-Traumatic Brain Disfunction. Section I- I5400 indicated - [CONDITION(S)] or [CONDITION(S)]. Resident #34's clinical record lacked evidence a care plan was developed for monitoring of seizures/[CONDITION(S)] and antiepileptic medications. On 8/31/21 at 11:35 a.m., in an interview, the Clinical Nursing Supervisor confirmed that Resident #13's and Resident #34's care plans were not developed and did not reflect the current status of the residents to include specific interventions as related to [CONDITION(S)] disorders or [CONDITION(S)] and [CONDITION(S)] disorders or [CONDITION(S)] medication monitoring. The care plans were updated on 8/31/21 after surveyor intervention.

Based on record review, observations and interview the facility failed to provide appropriate treatment to prevent the risk of complications related to enteral feeding, for 1 of 1 resident review for enteral feeding (#42). Finding: The Facility's Enteral Medication Administration Policy and Procedure Effective 8/1997 instructions state to 8. Unclamp the tube, inject 10 cc (cubic centimeter) of air into the feeding tube while auscultating with your stethoscope approximately 3 below the sternum to hear for air bubbling. 9. Draw back on the piston of the syringe to see if there are gastric contents in the syringe, which will confirm that the tube is placed into the stomach. If no gastric contents appear or you meet resistance, the tube may be lying against the gastric mucous. Attempt to reposition the patient or withdraw the tube slightly. Review of Resident #42's care plan dated 2/14/19, instructs staff to Monitor/document/report PRN any signs and symptoms of: aspiration-fever, SOB, (shortness of breath) tube dislodged, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distention, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration. On 8/31/21 at approximately 12:00 p.m., during an observation of medication preparation and administration with Registered Nurse (RN) #12 for Resident #42, who requires medications through his/her Gastrostomy tube (G-Tube), the following was observed: The RN had the medications and prepared to administer the medications through the Gastrostomy (G-tube). Surveyor intervened and asked RN if he/she was going to check placement and residuals, RN stated she had not been trained to do that for Resident #42. The RN stated she knows they usually do that but had not been trained to do that for this resident. The RN then asked the resident if other employees do that and resident responded no. On 9/01/21 at approximately 1:30 p.m., in an interview with the Administrator, a surveyor confirmed the RN did not follow facility policy and procedure when adminstering medications via G-Tube to Resident #42.

Based on record review and interview, the facility failed to ensure an as needed (PRN) [CONDITION(S)] medication met the required 14-day limit for 1 of 5 residents reviewed for unnecessary medications (#44). Finding: A review of Resident #44's physician orders dated [DATE] instructs staff to administer Lorazepam ([MEDICATION(S)]) 0.5 mg (milligrams) (an anxiolytic medication) - give 0.25 mg by mouth as needed for anxiety, agitation TID (three times daily). A review of Resident #44's clinical record revealed a pharmacist recommendation, printed [DATE], which stated the Resident has an order for [MEDICATION(S)] PRN (as needed): Beginning [DATE], PRN orders for [CONDITION(S)] medications (excluding antipsychotics) are limited to 14 days. Order may be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order. Attending physician or prescribing practitioner should document the rationale for the extended time period in the medical record and indicate a specific duration. Provider may wish to review current order and document need for continued use and that order will be reviewed every 60 days. On [DATE], the provider indicated he/she agreed with the recommendation. The provider did not write a new order to continue the medication until [DATE], at which time the order was electronically renewed to continue the PRN dosing. Additionally, the provider ordered the medication to be given scheduled four times a day for anxiety and agitation. A review of the Resident #44's Medication Administration Record indicated Lorazepam was administered 13 times after the 14-day order had expired on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 1:15 p.m., the Clinical Nursing Supervisor confirmed that the provider did not renew the order until [DATE], 7 days after the PRN order had expired on [DATE], and that Resident #44 had received additional doses after the order had expired.