Every finding on record at Daybreak Nursing Center

Based on observation, interview, and record review, the facility failed to ensure all residents were kept free from possible accident hazards when the facility staff failed to monitor one resident (Resident #10) out of four sampled residents and one resident (Resident #29) outside the sample during scheduled resident smoke breaks. The facility census was 66. Review of the facility's policy titled, Smoking Policy - Residents, dated October 2023, showed:- This facility has established and maintains safe resident smoking policies;- Prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences;- Smoking is only allowed in designated resident areas, which are located outside of the building. Smoking is not allowed inside the facility under any circumstances;- Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation);- Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.Review of the Smoke Schedule Time posting showed: - Smoke breaks scheduled for 6:00 A.M., 8:00 A.M., 10:00 A.M., 1:00 P.M., 3:00 P.M., 6:00 P.M., and 8:00 P.M.;- All smoke breaks are taken outside;- The door is at the end of the 300 Hallway.1. Review of Resident #10's medical record showed:- admitted on [DATE];- Diagnoses of tremors (involuntary, rhythmic shaking movements affecting hands, arms, legs, head or voice), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) of left, non-dominant side, cerebral infarction (stroke), unspecified dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) and seizures (abnormal brain activity). Review of the resident's Care Plan, dated 09/30/25, showed:- A smoker;- Supervision when smoking due to a history of behavioral/mental health issues;- At risk to make poor decisions;- An apron needed to smoke for safety. Burn marks had been noted to clothing.Review of the resident's Safe Smoking Evaluation, dated 08/20/25, showed:- Dementia and cognitive loss;- Dexterity problems (skill performing tasks with hands);- Left sided arm weakness;- Required supervision;- Safe to smoke with supervision;- Did not address the need for a smoking apron.During an observation on 10/01/25 at 1:06 P.M., of the resident smoking showed:- The resident sat outside in the designated smoking area;- Supervised by staff;- Did not wear a smoking apron;- Did not have on socks or shoes and had a 1 1/2-inch ash on the end of the cigarette that fell to the ground near the resident's right foot.During an interview on 09/29/25 at 12:11 P.M., the resident said he/she smoked cigarettes. During an interview on 10/02/25 at 1:41 P.M., Certified Nurse Assistant (CNA) B said Resident #10 should have worn a smoking apron when he/she smoked. The smoking aprons were kept at the nurses' station. 2. Review of Resident #29's medical record showed:- admitted on [DATE];- Diagnoses of dementia, type II diabetes mellitus (DM - a condition that affects the way the body processes blood sugar), chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), low back pain and hypertension (high blood pressure).Review of the resident's Care Plan, revised 07/29/25, showed: - A smoker;- Observe clothing and skin for signs of cigarette burns;- Required supervision while smoking. Review of the resident's Safe Smoking Evaluation, dated 09/24/25, showed:- Dementia and cognitive loss;- Vision difficulty;- Could light own cigarette;- Safe to smoke with supervision. Observations on 10/01/25 of the resident's smoke break showed: - At 1:08 P.M., the resident sat unsupervised in in his/her wheelchair under the smoke area with an awning with his/her eyes closed; - At 1:16 P.M., the resident awakened when CNA A spoke to the resident and gave him/her a cigarette to hold in each of his/her hands; - At 1:18 P.M., CNA A lit the resident's cigarette in the left hand, walked away to the other smoke area in front of the 300 Hallway exit door, and left the resident to smoke without supervision; - At 1:19 P.M., with no supervision, the resident took a puff of the cigarette held in his/her left hand;- At 1:23 P.M., the resident sat unsupervised in his/her wheelchair, his/her eyes closed, the lit cigarette in his/her left hand with a visible ash and the burnt cigarette paper at the end of the cigarette; - At 1:24 P.M., the resident sat unsupervised in his/her wheelchair, his/her eyes closed, the lit cigarette in his/her left hand, and ashes lay on the area beside his/her left foot;- At 1:29 P.M., the resident sat unsupervised in his/her wheelchair, his/her eyes closed, and the cigarette held in his/her left hand was no longer lit;- At 1:34 P.M., CNA A walked over to the resident to check on him/her. During an interview on 09/29/25 at 11:23 A.M., the resident said he/she smoked cigarettes. During an interview on 10/01/25 at 1:34 P.M., CNA A said he/she should not have left Resident #29 unsupervised if he/she had to wake up the resident prior to smoking and should not have left the resident unsupervised as he/she had just woke up. He/She should have moved the resident to the smoke area where he/she was supervising and monitoring other residents for safety purposes. During an interview on 10/02/25 at 2:04 P.M., the Assistant Director of Nursing (ADON) said if a resident was asleep during a smoke break, he/she should not have been woken up to smoke. Staff should not leave the resident but rather stay to ensure he/she was safe to smoke. Staff should move the resident to the area where staff could monitor and supervise during smoke breaks. There needed to be two staff members supervising and monitoring the residents' scheduled smoke breaks. Smoking aprons were provided to residents that had been assessed to use for safety purposes.During an interview on 10/02/25 at 2:11 P.M., the Director of Nursing (DON) said staff should notify the charge nurse when a resident was asleep outside during a smoke break to get guidance on what to do. Staff should not leave the resident after lighting his/her cigarette upon being woken up, should stay to ensure the resident was safe to smoke, and should move the resident to the area where other residents were monitored and supervised during the smoke breaks. Smoking aprons should be placed on residents that were required for safety.During an interview on 10/02/25 at 2:14 P.M., the Administrator said staff should not leave the resident after lighting his/her cigarette upon being awakened. The resident should not receive two cigarettes at one time. The staff should stay to ensure the resident was safe to smoke and should move the resident to the area where other residents were monitored and supervised during smoke breaks. Smoking aprons should be placed on residents that were required for safety.

Based on interview and record review, the facility failed to identify, assess, and provide supportive interventions for two residents (Residents #42 and #50) with a diagnosis of post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of four sampled residents. The facility's census was 66.The facility did not provide a PTSD policy.1. Review of Resident #42's medical record showed:- admitted on [DATE]; - Diagnoses of bipolar disorder (a mental disorder that causes unusual shifts in mood), PTSD, schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations), major depressive disorder (MDD - long-term loss of pleasure or interest in life), anxiety (persistent worry and fear about everyday situations) disorder and craniosynostosis (a rare birth defect that occurs when the fibrous joints between a baby's skull bones fuse too early, before the brain is fully formed).Review of the resident's September 2025 Physician's Order Sheets (POS) showed: - An order for Depakote (an anticonvulsant medication) extended release 24 hours 500 milligram (mg) two tablets at bedtime for bipolar disorder, dated 08/22/25;- An order for Invega Sustenna (an antipsychotic (medications used to treat psychotic disorders) 156 mg/milliliter (ml) intramuscularly (IM - injection into the muscle) every day shift every 28 days related to schizophrenia, dated 06/27/25;- An order for sertraline (an antidepressant medication) 100 mg 1.5 tablet one time a day related to major depressive disorder, dated 04/21/25.Review of the resident's Preadmission Screening and Resident Review (PASARR - a federal program to prevent inappropriate admission and retention of people with mental disabilities in nursing facilities), dated 10/22/24, showed:- Diagnoses of chronic PTSD, bipolar disorder, and MDD;- Reported triggers of being picked on and seeing other people being picked on;- History of abuse;- An altercation with another resident due to him/her becoming upset because he/she didn't like to see others be rude and aggressive towards staff, dated 02/16/25.Review of the resident's Behavioral Notes showed:- On 07/16/25, the resident held the back door down to the smoke area and let himself/herself out of the facility;- On 08/24/25, the resident was on a smoke break, was goofing around, and unintentionally knocked off another resident's hat and caused the resident's glasses to fall off.Review of the resident's Trauma Informed Care Assessment, dated 04/08/25, showed:- Physical and sexual assault or abuse.Review of the resident's Care Plan, revised 06/17/25, showed:- Mood diagnoses of bipolar, MDD, and anxiety;- Monitor/document/report as needed (PRN) any signs or symptoms of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, and tearfulness;- Did not address PTSD;- Did not address the resident's past trauma or any triggers that would cause the resident to have behaviors.During an interview on 10/01/25 at 10:55 A.M., the resident said he/she had PTSD due to being picked on in school by classmates and abused physically by family members. Loud noises and people fighting upset him/her. He/She did not like to be yelled at or for people to make fun of his/her forehead. 2. Review of Resident's #50's medical record showed:- admitted on [DATE];- Diagnoses of schizoaffective (a chronic mental health condition characterized by symptoms of both schizophrenia and MDD) disorder bipolar type ,PTSD, intellectual disabilities (significant limitations in intellectual functioning and adaptive behaviors that are present before the age of 18), other stimulant abuse in remission, alcohol abuse in remission, cannabis abuse in remission, dependent personality disorder (a mental health condition characterized by an excessive and pervasive need for others to care for and make decisions for them), unspecified dementia (a decline in cognitive function that does not meet the diagnostic criteria for a specific type of dementia), unspecified psychosis (a mental health condition characterized by a loss of touch with reality), and anxiety.Review of the resident's September 2025 POS showed: - An order for alprazolam (an antianxiety medication) 0.5 mg by mouth at bedtime for anxiety, dated 08/14/25;- An order for clozapine (an antipsychotic medication) 400 mg by mouth at bedtime for schizoaffective disorder, dated 09/04/25;- An order for clozapine 50 mg by mouth in the morning for schizoaffective disorder, dated 09/04/25;- An order for Depakote 500 mg by mouth three times daily for schizoaffective disorder, dated 09/04/25;- An order for mirtazapine (an antidepressant medication) 7.5 mg by mouth at bedtime for schizoaffective disorder, dated 08/14/25;- An order for Prazosin (a blood pressure medication) 5 mg by mouth at bedtime for PTSD, dated 06/24/25; - An order for risperidone (an antipsychotic medication) 1 mg by mouth at bedtime for schizoaffective disorder, dated 08/14/25.Review of the resident's PASARR, dated 02/08/21, showed:- Diagnoses of schizophrenia paranoid type, schizoaffective disorder, bipolar type, delusional disorder, MDD, anxiety, PTSD, polysubstance abuse, mild intellectual disability, and dementia;- Poor impulse control when demands were not met; - Suicidal ideations and attempts due to stress.Review of the resident's Behavioral Notes showed:- On 06/23/25, the resident said he/she needed to go to the mental hospital. The resident expressed the same paranoid thoughts that he/she experienced since admission. He/She believed the scanners through the tv and radio were talking to him/her and that the scanners were listening to him/her as well. The resident said his/her medication was not the same as it was at the other place;- On 07/28/25, the resident said the scanner and speaker were attacking his/her brain and he/she needed something really bad to stop the noise. He/She needed help. The Assistant Director of Nursing (ADON) notified the psychiatric physician and received a one-time order;- On 08/20/25, the resident burst into the Administrator's office during the morning meeting yelling and cursing. He/She was hearing voices, had scanners, and was acting aggressive. The Administrator calmly tried to de-escalate the situation and reassured the resident he/she was safe and did not need to be afraid or upset. The resident said the facility was keeping him/her against his/her will and wanted to be in a lock down unit. The Administrator again calmly redirected the resident, asked him/her would like to smoke a cigarette, and the resident agreed; - On 09/21/25, the resident used a thumbtack to inflict five scratches to his/her left forearm down to the wrist. He/She was depressed and cut his/her arm so that he/she could go to the hospital. He/She had scanners in his/her head, was out of medicine, breakfast was always late, and his/her guardian was taking his/her money. The Director of Nursing (DON) was called, and the resident was placed on 15-minute checks. The resident said he/she was going to run away. The resident went down to his/her room and sat on the bed.Review of the resident's Trauma Informed Care Assessment, dated 06/20/25, showed:- Experienced an event that was unusually or especially frightening, horrible, or traumatic. During an interview on 10/02/25 at 12:02 P.M., the Social Service Director (SSD) said when a resident was admitted with a PTSD diagnosis, a Trauma Informed Care Assessment was completed and triggers were documented on the form, and given to the Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) Coordinator to be included on the care plan under behaviors. If triggers that caused behaviors were documented on the resident's PASARR, it should be included as well. During an interview 10/02/25 at 12:05 P.M., the MDS Coordinator said if a resident had a diagnosis of PTSD, his/her triggers with interventions should be part of the care plan. The SSD completed a Trauma Informed Care Assessment and gave him/her a copy of the form with its findings, so it could be included on the resident's care plan. If triggers that cause behaviors were documented on the resident's PASARR, it should be included as well.During an interview on 10/02/25 at 1:54 P.M., the Administrator said if a resident had a diagnosis of PTSD, his/her triggers with interventions should be included on the individualized care plan.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 28 opportunities with three errors made, resulting in an error rate of 10.71% for three residents (Residents #15, #31 and #59) out of five sampled residents. The facility's census was 66.Review of the facility's policy titled, Insulin Administration, last revised March 2025, showed:- Did not address insulin administration using an insulin pen.Review of the Humalog/lispro (a rapid insulin that helps lower mealtime blood sugar spikes) Kwik Pen (insulin in a pen-type device) instructions, revised July 2023, showed:- Prime the pen by turning the dose knob to two units;- Hold the pen with the needle pointing up;- Tap the cartridge holder gently to collect air bubbles at the top;- Push the dose knob in until it stops, and zero is seen in the dose window, count to five slowly, insulin will be visible at the tip of the needle;- Select the dose;- Give the injection after selecting the area and cleaning the site with an alcohol swab.Review of the Fiasp/Novolog/insulin aspart (fast-acting insulin that helps lower mealtime blood sugar spikes) Flex Pen administration instructions, dated September 2021, showed:- Prime the pen by turning the dose selector to two units;- Keep the needle upwards and press the push-button until the dose selector reads zero;- Turn the dose selector to select the number of prescribed units;- Push the needle into the skin, then press the dose button until the dose selector indicates zero;- Keep the push-button fully pushed in after injection;- Leave the needle under the skin for six seconds and then remove it.1. Review of Resident #15's Physician Order Sheet (POS), dated October 2025, showed:- An order for Humalog insulin 100 unit/milliliter (ml) inject subcutaneously (injection under the skin) per sliding scale before meals and at bedtime: if blood sugar 60-110= 0 units; 111-150 = 4 units; 151-200= 8 units; 201-250 = 10 units; 251-300 = 12 units; 301-350 = 14 units; 351-800 = 16 units and notify the physician, dated 09/23/25.Observation on 10/01/25 at 11:15 A.M., of the resident's medication administration showed:- Licensed Practical Nurse (LPN) D administered 16 units of Humalog subcutaneously for a blood sugar of 398;- LPN D failed to prime the Humalog Kwik pen per the manufacturer's instructions prior to the insulin administration.2. Review of Resident #31's POS, dated September 2025, showed: - An order for Humalog KwikPen 100 unit/ml inject subcutaneously per sliding scale before meals and bedtime: if blood sugar 60-110 = 0 units; 111-150 = 4 units; 151-200 = 8 units; 201-250 = 10 units; 251-300 = 12 units; 301-350 = 14 units; 351-999 = 16 units call the provider, dated 06/21/25.Observation on 09/30/25 at 11:29 A.M., of the resident's medication administration showed: - LPN D administered 4 units of Humalog subcutaneously for a blood sugar of 130;- LPN D failed to prime the Humalog KwikPen per the manufacturer's instructions prior to the insulin administration.3. Review of Resident #59's POS dated, October 2025, showed: - An order for Humalog insulin 100 unit/ml inject subcutaneously two times a day per sliding scale: if blood sugar 60-110 = 0 units; 111-150 = 2 units; 151-200 = 4 units; 201-250 = 6 units; 251-300 = 8 units; 301-350 = 10 units; 351-999 = 12 units and notify the physician, subcutaneously two times a day, dated 05/22/25.Observation on 10/01/25 at 11:41 A.M., of the resident's medication administration showed:- LPN D administered 4 units of Humalog subcutaneously for a blood sugar of 200;- LPN D failed to prime the Humalog KwikPen per the manufacturer's instructions prior to the insulin administration. During an interview on 10/01/25 at 11:49 A.M., LPN D said he/she wasted 2-3 units, removed the needle, and dialed up the prescribed units per the sliding scale. The rationale for priming the insulin pen was to ensure the bubbles in the pen were not administered to the resident. During an interview on 10/02/25 at 11:51 A.M., LPN C said he/she wasted 2 units to prime the pen needle that was placed on the insulin pen before administering insulin to the resident.During an interview on 10/02/25 at 10:51 A.M., the Director of Nursing (DON) said she would expect nursing staff to dial up 2 units of insulin and waste them to prime the needle of the insulin pen.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 65. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; - The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting which includes a clean, sanitary and orderly environment. Observations on 10/07/24 at 2:12 P.M., and 10/09/24 at 2:26 P.M., showed several areas of peeled paint and exposed sheetrock located at the head of the bed located by the window in room [ROOM NUMBER]. Observations on 10/08/24 at 2:16 P.M., and 10/09/24 at 2:30 P.M., showed a large area of peeled paint and exposed sheetrock on the wall beside the bed located by the window in room [ROOM NUMBER]. Observations on 10/08/24 at 2:19 P.M., and 10/09/24 at 2:34 P.M., showed a long, narrow opening in the wall with several areas of peeled paint and exposed sheetrock behind the headboard of the bed located by the window in room [ROOM NUMBER]. Observations on 10/09/24 at 3:04 P.M., and 10/09/24 at 4:02 P.M., of the shower room located by the Director of Nursing (DON) office, showed: - A trash can overflowed with gowns, gloves and miscellaneous trash; - Several used gloves lay on the floor by the trash can; - [NAME] stained areas on top of the toilet lid; - [NAME] smeared areas on the shower curtain by the toilet; - A shower drain broken and bent with a buildup of grime and dirt; - The bottom edges of the shower stall floor with a buildup of black grime and missing caulk; - A dried brown substance on a yellow trash can lid; - A dried brown substance on a green trash can lid; - A soiled wash cloth lay at the bottom of the whirlpool tub; - An open bag of potato chips lay on top of a towel on the clean linen shelf by the whirlpool tub. Observation on 10/10/24 at 9:16 A.M., showed several areas of peeled paint and deep scrapes on the bottom part of the door upon entering room [ROOM NUMBER]. During an interview on 10/10/24 at 9:19 A.M., the resident in room [ROOM NUMBER] said he/she would like someone to paint the door because it looked bad and was missing a door cover at the bottom of it. Observation on 10/10/24 at 1:12 P.M., showed a whole in the bottom of the bathroom door approximately four inches (in.) by two in. located in room [ROOM NUMBER]. Review of the Maintenance log, dated 09/05/24 through 10/05/24, showed no areas of concern addressed. During an interview on 10/10/24 at 8:36 A.M., Housekeeper B said he/she did not always report things that needed to be addressed by the maintenance department. He/She should be more proactive in this area. During an interview on 10/10/24 at 8:42 A.M., Housekeeper C said he/she had reported things to maintenance to be repaired and wrote them down on the maintenance log located at the nurse's station. He/She also verbally told maintenance when something needed to be repaired. Everything should be on the maintenance log that he/she had reported. During an interview on 10/10/24 at 11:44 A.M., Shower Aide E said whoever gave the showers should be cleaning up the shower room afterwards to ensure cleanliness. Staff should not be eating food and/or leaving food in the shower rooms. During an interview 10/10/24 at 11:59 A.M., the Maintenance Supervisor (MS) said staff would verbally tell him/her about environmental concerns. He/She would prefer staff to write down environmental concerns and repairs on the maintenance log at the nurse's station. Staff had been told to write down any issues needing addressed in the past. During an interview on 10/10/24 at 1:51 P.M., the Director of Operations (DOP) said she would expect staff to write down any environmental concerns or repairs needed for the MS to be addressed in a timely manner.

Based on observation, interview, and record review, the facility failed to provide adequate personal hygiene for one resident (Resident #10) out of 16 sampled residents and two additional residents (Resident #2 and #57) and failed to provide showers at least twice a week for one resident (Resident #2) outside the sample. The facility census was 65. Review of the facility's policy titled, Dignity, revised February 2021, showed: - Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; - Residents are treated with dignity and respect at all times; - The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs; - This begins with the initial admission and continues throughout the resident's facility stay; - Individual needs and preferences of the resident are identified through the assessment process; - When assisting with care, residents are supported in exercising their rights. For example, residents are: groomed as they wish to be groomed (hair styles, nails, facial hair, etc.); encouraged to attend the activities of their choice, including religious, political, civic, recreational, or social activities; encouraged to dress in clothing that they prefer; allowed to choose when to sleep, eat and conduct activities of daily living; and provided with a dignified dining experience. 1. Review of Resident #2's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 08/14/24, showed: - Partial or moderate assistance for personal hygiene; - Substantial/maximum assistance for bathing. Review of the resident's care plan, dated 07/18/24, showed: - Activities of daily living (ADL) self-care performance deficit related to paralysis and weakness. Required monitoring to ensure safe and adequate completion of ADL's due to weakness and impaired cognitive/communication ability; - Usually able to wash part of him/herself in the shower but needed substantial assist of one to complete a shower safely and adequately. Assess for adequate completion and offer assist as needed; - Assist as needed with transfers in and out of the bath/shower. Review of the facility's shower schedule showed Resident #2 scheduled for showers three days weekly on Tuesday, Thursday and Saturday. Review of the resident's shower sheets, dated 08/01/24-10/09/24, showed: - For August 2024, 13 missed out of 14 opportunities for showers and nail care; - For September 2024, 12 missed out 12 opportunities for showers and nail care; - For October 2024, three missed out of four opportunities for showers and nail care. Observations of the resident on 10/07/24 at 11:29 A.M., and 10/08/24 at 8:30 A.M., showed the resident's hair greasy and toenails long and untrimmed. During an interview on 10/09/24 at 11:50 A.M., the Assistant Director of Nursing (ADON) said there were only two shower sheets for Resident #2 because the resident was care planned to do showers by him/herself. During an interview on 10/09/24 at 3:48 P.M., Resident #2 said he was unable to wash his/her hair, back, lower legs and feet by him/herself. He/She would prefer to receive showers more often and would like his/her toenails trimmed. 2. Review of Resident #10's quarterly MDS, dated [DATE], showed: - Dependent on staff for assistance for personal hygiene. Review of the resident's care plan, dated 07/25/24, showed: - ADL self-care performance deficit due to history of a stroke. Needed assist to complete most ADL's; - Personal hygiene needed extensive to full assist of one staff to complete personal hygiene tasks. Observations of the resident on 10/107/24 at 11:32 A.M., 10/08/24 at 8:33 A.M., 10/09/24 at 2:00 P.M., and 10/10/24 at 10:08 A.M., showed he/she had facial hair on his/her chin and upper lip. During an interview on 10/07/24 at 11:32 A.M., Resident #10 said he/she had facial hair on his/her chin and upper lip and would like it to be shaved, but the staff would not shave it. 3. Review of Resident #57's annual MDS, dated [DATE], showed: - Dependent on staff for assistance for personal hygiene. Review of the resident's care plan, dated 07/30/24 showed: - Severely impaired cognitive, communication, and functional status, and dependent on staff for all ADL's; - Dependent on staff for completion of hygiene. Shave on shower days and as needed. Review of the facility's shower schedule showed the resident scheduled for showers three days weekly on Monday, Wednesday and Friday. Review of the resident's shower sheets, dated 08/24/24-10/10/24, showed: - For August 2024, 13 missed out of 13 opportunities for nail care; - For September 2024, 13 missed out of 13 opportunities for nail care; - For October 2024, four missed out of four opportunities for nail care. Observations on 10/07/24 at 3:38 P.M. and 10/9/24 at 3:20 P.M., showed the resident lay in bed with untrimmed toenails and fingernails and several areas of flaky dry skin. During an interview on 10/10/24 at 10:45 A.M., Shower Aide E said he/she didn't do all of the showers, because the Certified Nurse Assistants (CNAs) will do certain residents. He/She always completed a shower sheet even if the resident showered themselves or refused. He/She knew some of the CNAs forgot to complete the sheets. The nurses should be doing the diabetic residents' nails, but otherwise the CNAs should be doing them. Sometimes the staff would forget to document they checked/clipped the residents' nails. Any of the CNAs could cut the residents' nails unless they were diabetic. During an interview on 10/10/24 at 2:13 P.M., the Director of Nursing (DON) said she would expect a shower sheet to be completed every time a resident took a shower or refused a shower. She would expect the CNAs to complete nail care and nurses to complete nail care for the diabetic residents.

Based on observation, interview, and record review, the facility failed to store medications in accordance with accepted professional standards of practice. This deficient practice had the potential to affect all residents residing in the facility. The facility also failed to properly label medications in a safe and effective manner. The facility's census was 65. Review of the facility's policy titled, Medication Labeling and Storage, dated 2001, showed: - Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses station or other secured location. Medications are stored separately from food and are labeled accordingly; - Policy did not address checking and the appropriate refrigerator temperatures or labeling over the counter medications with an opened date. 1. Review of the Medication Refrigerator Temperature Log, dated 08/01/24 - 10/08/24, showed: - For August 2024, the medication refrigerator's temperature was not documented for 11 out 31 opportunities, and 18 out of the 20 completed temperatures were above 41 degrees; - For September 2024, the medication refrigerator's temperature was not documented for eight out of 30 opportunities, and 21 out of the 22 completed temperatures were above 41 degrees; - For October 2024, the medication refrigerator's temperature was not documented for two out of eight opportunities, and six out of the eight completed temperatures were above 41 degrees. 2. Observation on 10/08/24 at 10:27 A.M., of the medication cart showed: - An opened Byetta (an anti-diabetic medication) injection pen, undated and unlabeled; - One opened bottle of over the counter prenatal vitamins (supplements that contain vitamins for a healthy pregnancy), undated; - One opened bottle of over the counter geritussin (helps to thin mucus), undated; - One opened bottle of over the counter clearlax (used to treat constipation), undated; - One opened bottle of over the counter pepto bismuth (used to treat heartburn or upset stomach), undated; - One opened bottle of over the counter fiber powder (used to treat constipation), undated. During an interview on 10/08/24 at 10:35 A.M., the Assistant Director of Nursing (ADON) said sometimes the nurses forgot to write an open date on the over the counter medications when they were opened. The temperature log should be checked daily by the evening nurses. During an interview on 10/10/24 at 11:19 A.M., the Director of Nursing (DON) said that she expected nurses to be checking the refrigerator temperatures daily and the weekend evening nurse had not been doing it like he/she was taught. She did expect staff to write an opened date on over the counter medications when a new bottle was opened.

Based on observation and interview, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents who are served food from the kitchen. The facility census was 65. 1. Observation on 10/07/24 at 2:24 P.M., of the dry food storage room showed: - A large bag of elbow pasta opened with the top of the bag twisted, not sealed and undated; - Three bags of cereal opened, undated, and one unsealed; - Opened graham cracker crumbs in a labeled box with the bag unsealed. 2. Observation on 10/07/24 at 2:25 P.M., of the storage area showed: - Two large baking sheets with black carbon build up on the sides/bottom. 3. Observation on 10/07/24 at 2:26 P.M., of a white single door residential-style stand up freezer located in the front of the kitchen showed: - Two Ziploc bags of frozen items unlabeled and undated. 4. Observation on 10/07/24 at 2:27 P.M., of a white single door residential-style stand up freezer located in the back of the kitchen showed: - Six bags of frozen items unlabeled and undated. 5. Observation on 10/08/24 at 9:47 A.M., 1:00 P.M., 1:11 P.M., and 1:13 P.M., and 10/09/24 at 2:00 P.M., and 10/10/24 at 12:00 P.M., showed no dietary staff wore hair nets while working and preparing food in the kitchen. 6. Observation on 10/08/24 at 1:13 P.M., of the kitchen staff preparing food showed: - Dietary Aide D knocked two skillets onto the floor from a shelf and put the two skillets back on the shelf; - Dietary Aide D put on gloves, touched the refrigerator, a cutting board and a knife, and then touched a green pepper without changing gloves and performing hand hygiene; - Dietary Aide D used one of the skillets that was knocked onto the floor from the shelf to saute green peppers without changing gloves and performing hand hygiene. During an interview on 10/10/24 at 12:00 P.M., the Dietary Manager (DM) said he/she would expect opened packages of food to be wrapped or put into appropriate storage containers, and to be labeled and dated. He/She would expect kitchen cookware to be free from carbon buildup, the staff to wear hair nets in the kitchen, to change gloves after touching dirty surfaces, and to wash a skillet if it was dropped on the floor before using it to prepare food.

Based on interview, and record review, the facility failed to maintain an effective pest control program. This had the potential to affect all residents in the facility. The facility's census was 65. Review of the facility's policy titled, Pest Control, revised May 2008, showed: - The facility shall maintain an effective pest control program; - This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents; - Pest control services are provided by a contracted pest control company; - Maintenance services assist, when appropriate and necessary, in providing pest control services. Review of the most recent pest control invoices showed no details of the areas of concern or what treatment was provided. During an interview on 10/10/24 at 1:04 P.M., Resident #34 said he/she saw four or five spiders in his/her room. He/She thought they were brown recluse spiders. During an interview on 10/10/24 at 1:09 P.M., Resident #42 said he/she had seen three spiders in his/her room. During an interview on 10/10/24 at 1:01 P.M., Resident #64 said he/she saw spiders in the facility within the last month. During an interview on 10/10/24 at 1:05 P.M., Resident #26 said on 10/09/24, staff were changing him/her and a spider crawled on his/her back. Resident #26 said luckily, he/she did not get bit, but it was scary having it on his/her back. During an interview on 10/08/24 at 10:51 A.M., Housekeeper A said there had been spiders and the residents had complained about them. Traps were put in the resident's room. He/She didn't know what kind of spiders they were. During an interview on 10/10/24 at 10:46 A.M., the Maintenance Supervisor (MS) said the facility did have a spider issue about 1 1/2 months ago. An outside vendor came in and treated the facility for over two hours. There are still a few spiders reported throughout the facility. MS said the pest control vendor was at the facility on Tuesday for the monthly service and inspection. During an interview on 10/18/2024 at 1:06 P.M., the Administrator said they have a pest control company spray the facility once a month. He/she said they have had a couple residents that said they have seen spiders. The Administrator said he/she has not seen them. He/she said maintenance and housekeepers will check the rooms if someone says they have seen them in their room and maintenance will put out safe spider traps.

Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 53. Review of the facility's policy titled, Maintenance Service, revised December 2022, showed: - Maintenance shall be provided to all areas of the building, grounds, and equipment; - The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; - Functions of maintenance personnel include maintaining the building in good repair and free from hazards and providing routinely scheduled maintenance service to all areas. Observation on 05/16/23 at 10:47 A.M., and 05/17/23 at 11:18 A.M., of the 100 Hall showed: - A ceramic figurine on top of a light fixture above the bed located by the door in room [ROOM NUMBER]; - Three, 4 inch (in.) x 5 in. and two 5 in. x 7 in. picture frames on top of a light fixture above the bed located by the window in room [ROOM NUMBER]. Observation on 05/16/23 at 12:03 P.M., and 05/18/23 at 12:18 P.M. of the 100 Hall shower room showed: - A six in. brown smeared substance on a vinyl curtain in front of five shelves containing miscellaneous items located to the left side of the door upon entering; - Three areas of a dried buildup substance on a vinyl privacy curtain located in front of the toileting area; - A six in. x 30 in. ceiling area with peeling paint and blue tape located by a light fixture and air vent; - A six in. x 34 in. area of peeling paint located above and behind the top of toilet lid; - Several missing ceramic tiles with exposed rigid wood edges located on the front of the sink basin. Observation on 05/17/23 at 06:18 P.M., of the 200 Hall shower room showed a build up of dust and debris on an air vent near the shower stall. Record review of the maintenance log binder dated 04/05/23 through 05/17/23 showed no current requests for areas of concern documented. During an interview on 05/18/23 at 09:12 A.M., Housekeeper E said he/she reported any concerns or repairs needed to the supervisor. There was also a maintenance log that staff could write down repairs at the nurse's station. He/she had not written down any thing recently that needed addressed. During an interview on 05/18/23 at 09:22 A.M., Nursing Assistant (NA) F said he/she reported any concerns to the supervisor and would sometimes write needed repairs in the maintenance log book. He/she had not seen anything to report in terms of repairs or environmental issues. During an interview on 05/18/23 at 09:26 A.M., Licensed Practical Nurse (LPN) G said there was a maintenance log book to write down any needed repairs. He/she had not reported any environmental issues or other areas of concern recently. During an interview 05/19/23 11:08 A.M., Certified Nursing Assistant (CNA) D said he/she informed his/her supervisor of any needed repairs and would sometimes write concerns down on the maintenance log. He/she had not reported any environmental concerns recently. During an interview on 05/22/23 at 09:56 A.M., the Administrator said she would expect staff to write down needed repairs or environmental concerns on the maintenance log to be addressed and followed up on in a timely manner.

Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS) (a federally mandated assessment tool completed by the facility) assessment for one resident (Resident #18) out of three sampled residents. The facility's census was 53. Review of the facility's policy titled, Comprehensive Assessments, dated March 2022 showed: - Significant change in status assessment is a comprehensive assessment for a resident that must be completed when the interdisciplinary team (IDT) (a group of health care professionals from diverse fields who work in a coordinated effort toward a common goal for a resident) has determined that a resident meets the significant change guidelines for either major improvement or decline. 1. Review of Resident #18's medical record showed: - The quarterly MDS, dated [DATE], showed the resident received hospice (health care focused on the quality of life of a terminally ill person) services; - A discharge date of [DATE] from hospice services; - The facility failed to complete a significant change MDS within 14 days after the discharge of the resident's hospice services. During an interview on 05/18/23 at 09:15 A.M., the MDS Coordinator said the resident discharged from hospice services on 04/19/23. He/she was new to the MDS role and was not aware of the significant change not being completed. During an interview on 05/18/23 at 02:54 P.M., the Resident Assessment Instrument (RAI) Coordinator said the facility had two different MDS Coordinators in the last month. The significant change MDS was missed on the resident.

Based on interview, observation and record review the facility failed to provide resident rights information on how to formally file a complaint to the Department of Health and Senior Services (DHSS) about the care they were receiving. This deficient practice had the potential to affect all residents in the facility. The facility census was 53. Review of the facility's policy titled, Resident Rights, revised February 2021, showed: - Employees shall treat all residents with kindness, respect and dignity; - Federal and state laws guarantee certain basic rights to all residents of the facility; - Be free from abuse, neglect, misappropriation of property, and exploitation; - Communication with and access to people and services, both inside and outside the facility; - Communicate with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term ombudsman, protection or advocacy organizations, etc.) regarding any matter. During a group interview on 05/18/23 at 10:56 A.M., five residents (Residents #2, #17, #19, #22, and #50) said they had not been given information or informed on how to make a formal complaint to the DHSS about the care they received. Record review of February, March and April 2023 resident council meeting minutes, showed no documentation of the resident rights information given to the residents in attendance regarding how to file a formal complaint to the DHSS. During an interview on 05/18/23 at 11:07 A.M., the Activity Director said he/she was not aware of any information verbally given to the residents or visible signage with information on how to file a formal complaint to the DHSS. He/she had not went over resident rights which addressed how to make a formal complaint to the DHSS. During an interview on 05/19/23 at 8:15 A.M., the Social Service Director (SSD) said he/she had not informed residents on how to file a formal complaint to the DHSS during the monthly resident council meetings and thought the signage might have been taken down. He/she was still new in the role as the SSD. Observation on 05/19/23 at 9:02 A.M., showed an 8 inch (in.) x 10 in. frame with the DHSS contact information in very small print displayed above wheelchair height on the left side wall of a small hallway leading to the Administrator's office located at the front entrance. During an interview on 05/19/23 at 9:04 A.M., the Administrator said residents should be informed on how to file a formal complaint to the DHSS. She said signage with the DHSS contact information would be placed in a public area accessible for all residents to view. During an interview on on 05/19/23 at 9:17 A.M., Resident #15 said the social security office was called with any complaints he/she has about the care received at the facility. He/she did not have a contact number to call the DHSS and was not aware of how to file a formal complaint about the care being received at the facility.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 53. Review of the facility's policy titled, Sanitization, revised November 2022, showed: - The food service area is maintained in a clean and sanitary manner; - All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks, chipped areas that may affect their use or proper cleaning; - All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. Observations on 05/16/23 at 10:02 A.M., 05/16/23 at 02:04 P.M., and 05/17/23 at 09:18 A.M., of the kitchen area showed: - A buildup of a white substance on the top, the sides, and the front panel of the dish machine; - A buildup of a white substance on the front panels and leg supports of the wash, rinse, and sanitize three compartment sink; - A buildup of dust and debris on top of the Manitowoc ice machine; - A buildup of dust on the front panel of the air conditioning wall unit located by the Manitowoc ice machine; - A black baked on substance along the edges of a 3 inch (in.) x 18 in. x 26 in. sheet pan and a 3 in. x 18 in. x 26 in. deep dish pan on a stack with other miscellaneous pans stored on the top shelf located in the pots and pans room. Observation on 05/16/23 at 10:02 A.M., 05/16/23 at 02:04 P.M., and 05/17/23 at 09:18 A.M., of the kitchen area showed no documentation of a kitchen cleaning schedule and/or a kitchen cleaning checklist. During an interview on 05/16/23 at 10:04 A.M., Cook A said cleaning tasks were completed in the kitchen and would expect the equipment, the pots and the pans to be free of white and black substances and dust buildup. There was no documentation to show kitchen tasks had been completed or were on a cleaning schedule. During an interview on 05/16/23 at 10:06 A.M., Kitchen Aid B said cleaning tasks were completed in the kitchen and would expect the equipment, the pots and the pans to be free of white and black substances and dust buildup. There was no documentation to show kitchen tasks had been completed or on a cleaning schedule. During an interview on 05/16/23 at 10:08 A.M., Kitchen Aid C said cleaning tasks were completed in the kitchen and would expect the equipment, the pots and the pans to be free of white and black substances and dust buildup. There was no documentation to show kitchen tasks had been completed or on a cleaning schedule. During an interview on 05/16/23 at 10:16 A.M., the Dietary Manager (DM) said the staff cleans the kitchen area on a daily basis, but there was no documentation at this time. Before the move to the current facility, the kitchen cleaning tasks were on a daily cleaning schedule and signed off on when completed by staff. The kitchen equipment, the pots and the pans should be free of white and black substances and dust buildup. During an interview on 05/22/23 at 09:56 A.M., the Administrator said she would expect the kitchen equipment, the pots and the pans to be free of white and black substances and dust buildup. The kitchen cleaning tasks should be on a cleaning schedule and signed upon completion for review.

Based on observation, interview and record review, the facility failed to ensure a dumpster was closed at all times and maintained to keep pests out and/or to keep the garbage contained in the dumpster. The facility census was 53. Review of the facility's policy titled, Sanitization, revised November 2022, showed: - All kitchens, kitchen areas and dining areas are kept clean, free form garbage and debris, and protected from rodents and insects; - Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactors with lids (or otherwise covered); - Areas used for garbage disposal are free from odors and waste fats, and maintained to prevent pests. Observations on 05/16/23 at 8:33 A.M., and 05/16/23 at 9:03 A.M., of the outside trash dumpster located near the maintenance shed showed: - The dumpster lid opened; - Several black birds flew out of the opened dumpster; - Three white opened trash bags lay on top of broken down boxes with exposed briefs, tissue paper, miscellaneous wrappers and soda cans; - No staff used the dumpster. Observations on 05/17/23 at 9:18 A.M., and 05/17/23 at 9:55 A.M., of the outside trash dumpster located near the maintenance shed showed: - The dumpster lid opened; - Four black birds perched on top of the opened dumpster; - No staff used the dumpster. During an interview on 05/16/23 at 10:04 A.M., Cook A said staff should make sure the dumpster lid was closed when not in use. During an interview on 05/16/23 at 10:06 A.M., Kitchen Aid B said staff should make sure the dumpster lid was closed after throwing away trash. During an interview on 05/16/23 at 10:08 A.M., Kitchen Aid C said when staff throw away trash, the dumpster lid should be closed afterwards. During an interview on 05/16/23 at 10:16 A.M., the Dietary Manager (DM) said the dumpster lid should be closed at all times and when not in use. He/she would expect staff to close the dumpster lid each time trash was disposed. During an interview on 05/19/23 at 11:08 A.M., Certified Nursing Assistant (CNA) D said staff should close the lid to the dumpster each time trash was thrown away. During an interview on 05/22/23 at 9:56 A.M., the Administrator said she would expect staff to close the dumpster lid after disposing of trash. The dumpster lid should be closed at all times and when not in use.

Based on interview and record review, the facility failed to document preparation and orientation for transfer to the hospital for two residents (Resident #38 and #87) out of 12 sampled residents. The facility's census was 36. 1. Record review of Resident #38's progress notes showed: - The resident transferred to the hospital on [DATE] and not readmitted to the facility. Record review of the resident's medical record did not contain documentation which showed the resident was prepped and oriented for transfer out of the facility. 2. Record review of Resident #87's progress notes showed: - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Record review of the resident's medical record did not contain documentation which showed the resident was prepped and oriented for transfer out of the facility. During an interview on 10/9/20 at 10:45 A.M., the Director of Nursing (DON) said she was sure the staff were doing that and it is just not documented but they will start doing that. Record review of the facility's policy titled, Discharge/Transfer of Resident, dated March 2015, showed the policy did not address documentation for preparation and orientation for transfer.

Based on observation, interview, and record review, the facility failed to ensure the accuracy of assessments for one resident (Resident #10) out of 12 sampled residents. The facility's census was 36. 1. Record review of Resident #10's medical record showed: - A quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by facility staff, dated 6/30/20, showed the resident had an indwelling urinary catheter (a flexible tube that drains urine from the bladder to a collection bag); - A physician's orders [REDACTED]. - A care plan for an indwelling catheter, last reviewed 3/31/20. Observation on 10/06/20 at 1:33 P.M. showed Resident #10 had no indwelling urinary catheter. During an interview on 10/06/20 at 2:55 P.M., the Director of Nursing (DON) said the resident no longer had a urinary catheter. During an interview on 10/08/20 at 3:45 P.M., the MDS Coordinator said the urinary catheter should not have been on that MDS. He/she had looked through the nurse's notes but had not seen where the catheter had been discontinued. During an interview on 10/09/20 at 10:45 A.M., the DON said she would expect the MDS assessment to be accurate. Record review of the facility's policy titled, Resident Assessment Instrument, dated October 2019, showed Federal regulations require the assessment accurately reflect the resident's status.

Based on interview and record review, the facility failed to develop and implement an individualized comprehensive care plan with specific interventions for two residents (Resident #32 and #87) out of 12 sampled residents. The facility's census was 36. 1. Record review of Resident #32's physician's orders [REDACTED]. Record review of the resident's quarterly the Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility) dated 8/15/20, showed: - Limited physical assistance of one staff for bed mobility, transfers, and toileting; - Extensive physical assistance of one staff for locomotion (moving from one place to another), dressing, personal hygiene, and bathing. Record review of the resident's Fall Risk Assessment, dated 5/22/20, showed moderate fall risk. Record review of the resident's progress notes, dated 8/23/20, showed resident found lying on the floor, able to move all extremities with no pain or discomfort. Resident stated he/she had a bump on his/her head that hurt. Hematoma noted to left side of the resident's head. No other injuries noted. Record review of the resident's comprehensive care plan, updated 3/20/20, showed no interventions or plan of care for falls. 2. Record review of Resident #87's POS, dated 10/1/20 through 10/31/20, showed: - [DIAGNOSES REDACTED].>- An order, dated 9/4/20, for levetiracetam (an anticonvulsant medication) 500 milligram (mg) twice daily. Record review of the resident's progress notes, dated 5/22/20, showed readmit: - Resident on way back to facility; - New [DIAGNOSES REDACTED]. - New order for [MEDICATION NAME] (levetiracetam) 500 mg twice daily. Record review of the resident's comprehensive care plan, updated 3/20/20, showed no interventions or plan of care for [MEDICAL CONDITION]. During an interview on 10/9/20 at 10:45 A.M., the Director of Nursing (DON) said she would expect a resident at risk for falls to have a care plan addressing falls. She would expect a resident with [MEDICAL CONDITION] to have a care plan addressing [MEDICAL CONDITION]. Record review of the facility's policy titled, Care Plan Comprehensive, dated March 2015, showed: - An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; - The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility); - Assessment of each resident is an ongoing process and the care plan will be revised as changes occur in the resident's condition.

Based on observation, interview, and record review, the facility failed to revise and update comprehensive care plans with specific interventions to meet the individual needs of two residents (Resident #10 and #87) out of 12 sampled residents. The facility's census was 36. 1. Record review of Resident #10's physician's orders [REDACTED]. An observation on 10/06/20 at 1:33 P.M. showed Resident #10 did not have an indwelling urinary catheter. Record review of Resident #10's care plan, last reviewed 3/31/20, showed a care plan in place for an indwelling catheter and did not reflect the catheter had been discontinued. 2. Record review of Resident #87's POS, dated 10/1/20 through 10/31/20, showed: - [DIAGNOSES REDACTED].), [MEDICAL CONDITION], hypertension, muscle weakness, toxic metabolic encephalopahy ([MEDICAL CONDITION] from failure of other internal organs)and [MEDICAL CONDITION] (a condition causing damage to the major blood vessels that supply the heart with blood, oxygen, and nutrients.) Record review of the resident's nurse's progress notes showed: - On 5/22/20, readmit, - New [DIAGNOSES REDACTED]. - New order for 1500 milliliter (ml) fluid restriction; - On 8/17/20, resident refused [MEDICAL TREATMENT] today; - On 8/19/20, resident is refusing to go to [MEDICAL TREATMENT] again today; - On 8/26/20, resident refusing to go to [MEDICAL TREATMENT] on this day; - On 8/27/20, resident does not want to go to [MEDICAL TREATMENT] again on this day. Resident sent to hospital for altered mental status and [MEDICAL CONDITION]; - On 9/14/20, resident left [MEDICAL TREATMENT] on 9/11/20 before time to be done, stating he/she didn't feel good. Guardian called with concerns that resident continues to be at times non compliant with this; - On 9/22/20, resident found sitting on bottom in floor, beside bed. No apparent injuries noted. When asked what happened, the resident said he/she slid out of bed onto the floor because the wheelchair doesn't lock right. Denied striking head. Record review of the resident's comprehensive care plan, updated 3/20/20, showed: - Care plan not updated with new order for fluid restriction and not placed on intake and output monitoring; - Care plan not updated for refusals of [MEDICAL TREATMENT]; - Care plan not updated with new interventions following fall on 9/22/20. During an interview on 10/08/20 at 3:45 P.M., the Minimum Data Set (MDS, a federally mandated assessment completed by the facility) Coordinator said he/she is responsible for several homes. Some things may have been missed, but any nurse can update the care plans. During an interview on 10/9/20 at 10:45 A.M., the Director of Nursing (DON) said she would expect the care plan to be updated for a resident with a new order for fluid restriction, refusals of [MEDICAL TREATMENT], new interventions after a fall and after an indwelling urinary catheter had been removed. The MDS Coordinator calls on the phone for updates on the residents and makes the residents' changes. The DON said she had not been shown how to make changes in the computer charting and would expect any nurse to be able to update the care plan. Record review of the facility's policy titled, Care Plan Comprehensive, dated March 2015, showed the interdisciplinary care plan team is responsible for the periodic review and updating of care plans when a significant change in the resident's condition has occurred, at least quarterly, and when changes occur that impact the resident's care. Record review of the facility's policy titled, [MEDICAL TREATMENT], Care of a Resident Receiving, dated March 2015, showed: - Residents with fluid restrictions due to [MEDICAL TREATMENT]: The resident will be placed on I&O to monitor the resident's fluid intake and output. The physician will be notified of non-compliance. All the above will be addressed on the care plan as indicated.

Based on interview and record review, the facility failed to follow physician's orders for one resident (Resident #87) out of 12 sampled residents. The facility's census was 36. Record review of the facility's policy titled, [MEDICAL TREATMENT], Care of a Resident Receiving, dated March 2015, showed: - Checking the Thrill Sensation: Nurses will check the thrill daily and document daily. This will be documented on the resident's treatment record. If no thrill sensation is felt, notify the physician; - Residents with Fluid Restrictions due to [MEDICAL TREATMENT]: The resident will not have a water pitcher in their room. The resident will be placed on I&O (intake and output) to monitor the resident's fluid intake and output. The physician will be notified of non-compliance. All of the above will be addressed on the care plan as indicated. Record review of Resident #87's Physician's Order Sheet (POS), dated 9/01/20 through 9/30/20, showed an order written [REDACTED]. Record review of Resident #87's POS, dated 10/01/20 through 10/31/20, showed: - [DIAGNOSES REDACTED].), [MEDICAL CONDITION], hypertension, muscle weakness, toxic metabolic encephalopahy ([MEDICAL CONDITION] from failure of other internal organs)and [MEDICAL CONDITION] (a condition causing damage to the major blood vessels that supply the heart with blood, oxygen, and nutrients); - an order written [REDACTED]. Record review of the resident's Treatment Record showed: - For August 2020, four out of 31 opportunities to check bruit and thrill missed on day shift, 21 out of 31 opportunities missed on evening shift, and three out of 31 opportunities missed on night shift; - For September 2020, four out of 27 opportunities missed on day shift, 19 out of 27 opportunities missed on evening shift, and one out of 27 opportunities on night shift; - For October 2020, no treatment to check bruit and thrill in right arm every shift for 10/1/20 through 10/9/20. During an interview on 10/9/20 at 10:45 A.M., the Director of Nursing (DON) said she would expect treatment orders to be followed as written. She would expect the nurse to check the new POS to make sure it was correct.

Based on observation, interview, and record review, the facility failed to ensure the dignity of one resident (Resident #2) out of a sample of 12. The facility census was 35. 1. Record review of Resident #2's Baseline Care Plan (a beginning plan of care upon admission), dated 2/11/19, showed: - Resident's cognition as confused; - [DIAGNOSES REDACTED]. - Need for assistance with toileting; - Bladder and bowel goals to preserve or achieve highest practicable level of independence and dignity with bowel/bladder functions while maintaining appropriate hygiene/safety/health; - Bladder and bowel interventions include use of incontinence briefs. Record review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 5/21/19, showed: - Resident requires extensive assistance for personal hygiene, dressing, and toileting; - Resident uses wheelchair for mobility. Observation of the dining room on 6/3/19 showed: - At 12:05 P.M., Resident #2 sat in his/her wheelchair at a table in the middle of the dining room; - A large puddle of yellow urine under his/her wheelchair which ran under the table to sit at the opposite side of where the resident sat; - At 12:30 P.M., multiple staff walked by the resident and did not offer to remove resident and provide personal care; - At 12:30 P.M., multiple staff walked by the resident and did not attempt to cover or clean up the puddle of urine; - At 12:32 P.M., a staff member asked the resident if he/she had finished their meal and took him/her to their room. During an interview on 6/6/19 at 8:11 A.M., Certified Nurse Aide (CNA) B said if a resident has a puddle of urine under their wheelchair in the dining room, they should be removed right away and taken to their room to be cleaned up, and then returned if not finished with their meal. During an interview on 6/6/19 at 8:42 A.M., Licensed Practical Nurse (LPN) A said if a resident has a puddle of urine under their chair in the dining room, he/she would ask a CNA to take them to their room to be cleaned up, and ask housekeeping to clean the floor. During an interview on 6/6/19 at 10:39 A.M., the Director of Nursing said if a resident had a puddle of urine under their wheelchair in the dining room, she would expect nursing staff to remove the resident right away to be cleaned up, and make sure the floor is cleaned also. The facility did not provide a Resident Dignity policy.

Based on observation, interview, and record review, the facility failed to assess the use of finger control mittens (designed to restrict the movement of one or both hands) to determine if they were a restraint, failed to document the finger control mittens on the care plan, failed to identify a medical symptom that supported the use of the finger control mittens, failed to document the least restrictive use for the finger control mittens, failed to document an ongoing re-evaluation for the use of the finger control mittens, and failed to correctly secure the finger control mittens for one resident (Resident #9) out of 12 sampled residents. The facility census was 35. Record review of the facility's Restraints, Physical policy, dated 3/2015, showed: - Assess resident's need for restraint use; - Develop or review the resident's care plan for the type of restraint, reason for use, alternate methods to be used and method of application, list medical symptoms to be treated and methods to reduce and eliminate the restraint; - Place resident in a supervised area and check frequently; - Remove restraint every two hours; - Use other nursing measures, diversion programs, activity programs and supervision to control behavior whenever possible. Record review of the Resident #9's (MONTH) 2019 Physician order [REDACTED]. - [DIAGNOSES REDACTED]. - an order for [REDACTED]. The facility failed to identify a medical symptom that supported the use of the finger control mittens Record review of the resident's significant change Minimum Data Set (MDS), a federally mandated comprehensive assessment tool completed by facility staff, dated 3/24/19, showed: - Severely impaired cognitive skills; - Extensive assistance of one to two staff for activities of daily living (ADL's); - No restraint use. Record review of the resident's medical record showed: - No assessment for the finger control mittens to determine if used as a restraint; - No documentation of the least restrictive use for the finger control mittens; - No documentation of the finger control mittens released every two hours. - No documentation of ongoing re-evaluations for the use of the finger control mittens. Record review of the resident's care plan, revised on 3/28/19, did not address the finger control mittens. Record review of the resident's progress notes, dated 1/01/19 through 6/05/19, showed: - On 5/25/19, the staff secured the resident's finger control mitten with tape due to the resident removed it; - On 5/28/19, the staff secured the resident's finger control mittens with tape so the resident cannot remove them. Observations of the resident on 6/03/19, showed: - At 11:04 A.M., 11:42 A.M., 12:05 P.M., and 3:59 P.M., the resident lay on his/her bed with finger control mittens to both hands with the mittens secured with tape; - At 1:40 P.M., the resident sat in a Geri-chair (a medical recliner) with finger control mittens to both hands with the mittens secured with tape in his/her room. Observations of the resident on 6/05/19, showed: - At 7:55 A.M. and 10:48 A.M., the resident lay on his/her bed with finger control mittens to both hands; - At 11:30 A.M., the resident sat in a Geri-chair with finger control mittens to both hands in his/her room. During an interview on 6/5/19 at 11:43 A.M., Certified Nurse Assistant (CNA) H said he/she puts the finger control mittens on the resident but he/she doesn't secure them with tape. During an interview on 6/5/19 at 12:03 P.M., the Director of Nursing (DON) said the resident is to wear the finger control mittens on both of his/her hands as ordered. During an interview on 6/6/19 at 10:15 A.M., the MDS Coordinator said a resident's use of finger control mittens should be care planned. He/she wasn't aware the resident used the finger control mittens. During an interview on 6/6/19 at 10:27 A.M., the DON said she would expect an assessment to be completed and the protocol for the finger control mittens to be followed prior to use. She would also expect the hand control mittens to be secured appropriately.