Every finding on record at Decatur Center for Nursing and Healing LLC

Based on observations, staff Interviews, and review of the facility policy titled, Disposal of Garbage and Refuse, the facility failed to ensure garbage and waste refuse was properly disposed of at the Dumpster site; failed to ensure garbage and refuge receptacle containers were covered and failed to ensure dumpster area was clean and free of debris. These failures posed a sanitation hazard with the potential for insect and rodent attractions. Findings include:Review of the Facility's Policy titled Disposal of Garbage and Refuse dated January 2022, and revised April 2024, Policy Statement revealed The facility shall properly dispose of kitchen garbage and refuse. The Policy Section Explanation and Compliance Guidelines .7. Refuse and dumpsters shall be kept outside the facility, shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. The Policy Section Explanation and Compliance Guidelines .8. Dumpsters shall be emptied according to facility contract. Garbage should not accumulate or be left outside the dumpster. Interview and observation on 03/30/2026 at 10:35 AM of the dumpster and perimeter platform at the rear of the facility with the Food Services Director (FSD) and Kitchen Manager (KM) revealed the dumpster, and dumpster platform, was covered with food debris and trash which was both on the platform and in the grass areas adjacent to the dumpster platform near the fence. A grey-colored trash container was overflowing with trash and not covered. These observations were confirmed by both the FDS and KM. Neither the FSD or KM could state with certainty the department(s) responsible for maintaining the area for cleanliness; nor were they familiar with the frequency of when the dumpster was emptied by the sanitation/waste vendor. Interview on 04/01/2026 at 12:15 PM with Administrator revealed cleanliness of the grounds and the dumpster area was a joint interdisciplinary responsibility of both Maintenance and Environmental Service departmental staff.Interview and Observation on 04/01/2026 at 12:20 PM of the dumpster area with the Maintenance Director revealed he made frequent checks of the dumpster area daily. He further stated his assistant also monitored the grounds and the dumpster area. The Maintenance Director stated The County was onsite daily for waste disposal. Further, maintenance staff routinely assessed the grounds and dumpster area at least three times a day - mornings, late afternoons, and before maintenance staff left each evening. On weekends, the Housekeeping and Dietary Staff were responsible for the cleanliness of the dumpster area.Interview on 04/01/2026 at 12:30 PM with the Environmental Services Director revealed Housekeeping and Laundry staff, including the Environmental Director, assessed the dumpster area for cleanliness daily.

Based on observations, staff and resident interviews, and review of the facility policies titled, Preventative Maintenance Program and Linen Operations and Management: The Linen Operation, the facility failed to ensure the environment was maintained in a safe, sanitary, and functional condition. Specifically, Packaged Terminal Air Conditioner (PTAC) air filters in two of ten rooms (rooms [ROOM NUMBERS] on Team A Hall) were observed to contain a significant amount of gray, fuzzy particulate matter. Additionally, clean linens were not consistently available for resident care for six of 47 sampled residents (R) (R39, R8, R101, R89, R90, and R72). The deficient practice had the potential to contribute to respiratory problems for residents due to unclean air filters and to delays in care due to insufficient linen availability.Findings include:Review of the facility policy titled Preventative Maintenance Program revised September 2023, revealed under Policy: A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Under Policy Explanation and Compliance Guidelines: 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, grand rounds, life safety requirements, or experience. 4. The Maintenance Director shall develop a calendar to assist with keeping track of all tasks. 5. Documentation shall be completed for all tasks.Review of the facility policy titled Linen Operations and Management: The Linen Operation, undated, revealed under Linen Inventory: .You should ensure that you have enough linen to meet daily pars as well as sufficient extra on hand in the event of an emergency. There should be enough supply on hand so that no piece of linen needs to be washed more than once per day. That means there must be enough linen to stock all carts for all shifts for that day, linen to start carts for the next day, and extra linen on hand on shelves and in storage for any emergencies or added needs. Further review of Linen Par: Linen Par is the regular amount of linen needed each day, for each shift and each wing, to operate and meet Resident/Patient needs. It is your responsibility, along with he facility, to make sure that linen is delivered to each shift in a timely manner and in adequate quantities.1. Observation on 03/30/2026 at 12:04 PM revealed the PTAC air filters in room [ROOM NUMBER] on the first floor, Team-A Hall, contained a significant amount of gray, fuzzy particulate matter. Observation on 03/30/2026 at 12:56 PM revealed the PTAC air filters in room [ROOM NUMBER] on the first floor, Team-A Hall, contained a significant amount of gray, fuzzy particulate matter.Observation on 03/31/2026 at 12:39 PM revealed the PTAC air filters in room [ROOM NUMBER] and room [ROOM NUMBER] remained soiled with significant amounts of particulate matter.Interviews on 03/31/2026 at 3:59 PM and 04:29 PM with the Maintenance Director confirmed that the air filters in room [ROOM NUMBER] and room [ROOM NUMBER] required cleaning. The Maintenance Director stated that filters were expected to be checked daily and cleaned weekly. The Maintenance Director then directed Maintenance Assistant EE to clean all air filters on the first floor.Observation on 03/31/2026 at 4:20 PM of Maintenance Assistant EE cleaning air filters by removing particulate matter with a duster and disposing of debris into a trash can located in a public restroom on the hallway.Interview on 04/01/2026 at 12:28 PM with the Director of Nursing (DON) stated that failure to maintain clean PTAC air filters could potentially contribute to respiratory concerns. She indicated that filters were expected to be cleaned and maintained regularly to support a safe environment.2. Review of the MDS assessment for R39 revealed a BIMS score of 15, indicating little or no cognitive impairment.Review of the MDS assessment for R8 revealed a BIMS score of 10, indicating moderate cognitive impairment.Review of the Minimum Data Set (MDS) assessment for R101 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating moderate cognitive impairment.Review of the MDS assessment for R89 revealed a BIMS score of 13, indicating moderate cognitive impairment.Review of the MDS assessment for R90 revealed a BIMS score of 10, indicating moderate cognitive impairment.Interviews conducted on 03/30/2026 between 11:30 AM and 01:15 PM with multiple residents (R) and one family member revealed concerns regarding insufficient availability of linens and personal care items:R101 reported the facility did not have enough towels and washcloths, stating she preferred to wash her face each morning but was unable to do so due to lack of linen.R89 reported the facility did not have enough sheets, towels, or gowns, and stated that when staff prepared to provide care, they often had to leave the room to search for supplies and were sometimes unable to even locate a gown.R72's family member at bedside, stated they visited daily, including on the weekends, and reported essential items such as towels, washcloths, and under pads were frequently unavailable and stated he had purchased these items for R72 due to the lack of supplies.During a Resident Council meeting conducted on 03/31/2026 at 11:00 AM with four cognitively intact residents in attendance, concerns were voiced regarding a shortage of essential supplies, including towels, washcloths, and gowns. Additionally, R90 reported having to wait overnight to receive these items.Observation on 03/31/2026 at 11:15 AM revealed a linen cart on the first floor that contained approximately three bed sheets and no additional linen/supplies.Observation on 03/31/2026 at 01:00 PM revealed a linen cart on the first floor contained only one towel, indicating inconsistent linen availability throughout the day.Interview on 04/1/2026 at 12:10 PM with Laundry Aide (LA) JJ revealed that linen was typically delivered between 11:00 AM and 12:00 PM daily. LA JJ stated she believed the reported shortage of linen supplies may be due to staff and/or residents retaining or storing linens once they were distributed.Interview on 04/01/2026 at 12:20 PM with the Environmental Supervisor revealed that two of three dryers were not functioning, which delayed the processing and distribution of linen.Interview on 04/01/2026 at 1:09 PM with Certified Nursing Assistant (CNA) FF, on the first floor, revealed that linen supplies were insufficient or unavailable at the start of the shift (07:00 AM) and were typically not delivered until approximately 12:00 PM, resulting in a gap in availability of up to five hours. CNA FF stated this delay prevented residents from completing morning care and caused frustration.Interview on 04/01/2026 at 12:52 PM with CNA GG, on the second floor, revealed that linen supplies were limited and deliveries were delayed daily, often not arriving until after 11:00 AM, impacting residents' ability to complete morning care and emphasized shortages of essential items such as under pads.Interview on 04/01/2026 at 4:58 PM with the DON stated that insufficient availability of linen supplies may result in delays in providing care and services when needed.Observation on 04/01/2026 at 5:23 PM revealed the Environmental Supervisor opening packaged boxes of linen supplies and stocking linen carts on the first floor.

Based on observations, staff interviews, and review of facility policies titled, Accidents and Incidents and Preventative Maintenance Program, the facility failed to ensure the environment remained free of accident hazards. Specifically, the facility failed to maintain environmental surfaces in a safe condition and failed to implement interim measures to mitigate identified hazards, including a broken handrail with exposed, jagged edges on one of two hallways on the first floor, and a loose, rusted heater cover with sharp edges accessible to residents in one of two shower rooms (first floor central shower room). These conditions had the potential to cause injury, including skin tears and lacerations.Findings include:Review of the facility policy titled Accidents and Incidents revised October 2025, revealed under Policy: It is the policy of this facility for staff to utilize Risk Management System to report, investigate, and review any accidents or incidents that occur or allegedly occur, on or off facility property and may involve or allegedly involve a resident.Review of the facility policy titled Preventative Maintenance Program revised September 2023, revealed under Policy: A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Under Policy Review and Compliance Guidelines revealed: . 2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, grand rounds, life safety requirements, or experience.Observation on 03/31/2026 at 12:26 PM of the handrail on the second floor, outside the elevator area and accessible to residents, was observed with broken and exposed, jagged, sharp edges.Observation on 03/31/2026 at 03:50 pm the same handrail on the second floor was observed in the same condition, broken, exposed, jagged, with sharp edges.Observation and interview on 03/31/2026 at 3:59 PM with the Maintenance Director, they acknowledged the damaged handrail and that it had not been repaired or otherwise mitigated and agreed that the condition posed a safety risk to the residents due to sharp edges.Interview on 04/01/2026 at 11:20 AM with the Administrator revealed that replacement handrails had been delivered on 01/15/2026 but were not installed. The Administrator confirmed that facility staff were expected to maintain a safe environment for residents and that damaged handrails should have been addressed promptly. The Administrator further stated that safety measures should have been implemented until the replacement handrail could be installed.Observation on 04/01/2026 at 11:50 AM, in the presence of the Licensed Practical Nurse (LPN) Unit Manager CC, the first-floor central bath shower room was observed. Rust was noted on the door frame at the entrance and on a heater cover. The heater cover was loose, secured only by the top screw, moved when touched, and had sharp, rusted edges. The Unit Manager confirmed that these conditions posed a safety hazard, as residents were transported into and out of the shower room and could come into contact with the rusted, sharp surfaces. The cover was positioned directly in the path of the shower area, increasing the risk of injury. The Unit Manager stated that a work request would be submitted to repair these hazards.Interview on 04/01/2026 at 12:28 PM with the Director of Nursing (DON) revealed that environmental hazards must be repaired in a timely manner, but in the interim, safety measures must be implemented to protect residents from potential injury until repairs were completed.Interview on 04/01/2026 at 1:42 PM with the Maintenance Director confirmed the damaged door frame and heater cover in the shower room and stated that a work order had been submitted that day for repairs.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Hand Hygiene, the facility failed to ensure staff adhered to appropriate infection control practices during the handling and disposal of contaminated waste. This deficient practice had the potential to increase the risk of infection transmission through cross-contamination.Findings include:Review of the facility's policy titled Hand Hygiene revised June 2023 revealed under Policy: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Under Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.Observation on 03/31/2026 at 1:28 PM was conducted with the Skin Management Specialist (Regional Nurse) BB and Licensed Practical Nurse (LPN) AA following completion of wound care and during disposal of wound care waste. During the disposal process, Regional Nurse BB removed the left glove but retained the right glove and exited the resident room into the hallway without performing hand hygiene, while still wearing the remaining soiled glove. LPN AA, who was also wearing soiled gloves in the hallway, assisted by opening the door to the biohazard room using gloved hands.Interview on 03/31/2026 at 01:32 PM with Regional Nurse BB and LPN AA confirmed both wore gloves in the hallway and did not perform hand hygiene prior to exiting the resident room. Both acknowledged this practice was not appropriate and stated that gloves should not be worn in the hallway due to infection control concerns.Interview on 03/31/2026 at 5:19 PM with the Infection Preventionist (IP) revealed that staff were expected to remove gloves and perform hand hygiene prior to exiting resident rooms. The IP stated staff were trained not to wear soiled gloves in hallways due to the risk of cross-contamination, including the potential to transfer pathogens to environmental surfaces such as door handles.Interview on 04/01/2026 at 12:28 PM with the Director of Nursing (DON) confirmed that staff were expected not to wear soiled gloves in hallways. The DON stated that gloves should be removed and hand hygiene performed prior to entering common areas, as contaminated gloves may contribute to the spread of infection.

Based on observations, staff interviews, and review of the facility's policies titled Sanitation, Refrigeration and Freezers, and Food brought by Family/Visitors, the facility failed to maintain cleanliness for two of the two ice machines and failed to properly store food items in two of the two refrigerators and freezers on the units (First and Second Floor). This deficient practice had the potential to affect residents who received an oral diet. Findings include: Review of the facility's policy titled Sanitation, dated [DATE], under the section titled Guidelines: revealed, 12. Ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy. Review of the facility's policy titled Refrigeration and Freezers, dated [DATE], under the section titled Policy revealed, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation and will observe food expiration guidelines. Under section titled Guidelines revealed, 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Use by dates will be utilized on all prepared food in refrigerators. Expiration dates on unopened food will be observed and adhered to. Use by or open dates will be labeled on food items once opened. 8. Supervisors will be responsible for ensuring food items in pantries, refrigerators, and freezers are not expired or past perish dates. Review of the facility's undated policy titled Food brought by Family/Visitors, under the section titled Policy Interpretation and Implementation revealed, 6. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item, and the use by date. 7. The nursing staff is responsible for discarding perishable foods on or before the use by date. 1. An observation made on [DATE] at 2:43 pm of the ice machine on the First-Floor unit revealed clusters of dark substances located along the white flap on the inside of the ice machine. An observation made on [DATE] at 4:43 pm of the ice machine on the Second-Floor unit revealed clusters of dark substances on the chute of the ice dispenser. In an interview with the Kitchen Manager on [DATE] at 4:27 pm, she confirmed the dark substances of the ice machines on the First and Second Floor units. She revealed that the ice machines on the units were for the residents, and that the nursing staff would use these ice machines to provide iced water and ice for the residents. She further stated that the Maintenance Director was responsible for cleaning the ice machines. In an interview with the Maintenance Director on [DATE] at 11:07 am, he revealed that he cleaned the ice machines monthly and his expectations was that the ice machines should be cleaned thoroughly. When showed the photos taken of the dark substances on the ice machines, he confirmed that it should not be there. In an interview with the Administrator on [DATE] at 6:00 pm, she stated that she expects ice machines to be kept clean so that the ice was clean. She further stated that a potential negative outcome would be that it may affect the taste and cleanliness of the ice. 2. An observation made on [DATE] at 4:33 pm of the refrigerator on the First-Floor unit revealed a container of potato salad that was opened and unlabeled in the fridge. An observation made on [DATE] at 4:40 pm of the refrigerator and freezer on the Second Floor unit revealed the following improperly stored food items: one unlabeled chicken leg, one unlabeled fast food beverage with a straw, one unlabeled plastic container of soup, one unlabeled and opened 12 ounce bottle of strawberry fruit syrup, one unlabeled blue bottle of a drink with a straw, two unlabeled bottles of beverages, one unlabeled item covered with a paper towel with a handwritten room number and date of [DATE], and three containers of unlabeled food with a handwritten room number with date of [DATE]. In an interview with the Kitchen Manager on [DATE] at 4:27 pm, she revealed that she expects staff to label all items in the refrigerators and freezers. She also revealed that the refrigerators and freezers on the units were to be used for residents' items only. She stated that she checks the unit refrigerators and freezers every two days. In an interview with the Administrator on [DATE] at 6:00 pm, she stated that she expects food to be stored in the unit refrigerators with a label and date and discarded when out of date, which was typically considered around five days. She further stated that a potential negative outcome would be that someone could eat old food.

Based on observations, staff interviews, record review, and review of the facility's policy titled How to Puree Foods, the facility failed to follow a recipe, use measuring devices, and use utensils when preparing puree food. This deficient practice had the potential to result in inconsistent texture modification, nutritional imbalance, and increase risk of aspiration for seven of seven residents receiving a puree diet. Findings include: Review of the undated facility's policy titled How to Puree Foods, under the section titled Preparation Steps revealed, 1. Depending on the resident's dietary restrictions, follow the proper recipe. 2. Portion out your prepared food according to the number of pureed meals you have. An observation on 4/24/2025 at 10:14 am in the main kitchen revealed [NAME] GG preparing puree baked chicken, green beans, and cornbread for the seven residents on a puree diet. [NAME] GG was observed pulling apart the baked chicken with gloved hands and placing the chicken into the food processor. [NAME] GG then poured an unmeasured amount of chicken broth into the food processor. [NAME] GG was observed using no recipe and no measuring cups. [NAME] GG stopped the food processor and used a gloved hand to scoop the pureed chicken from the food processor and into a container. [NAME] GG was observed not using utensils while preparing puree food. Further observation of the puree preparation of the green beans revealed [NAME] GG not following a recipe, not using any measuring devices for the green beans or added chicken broth, and not using utensils to scoop the green beans to and from the food processor. Continued observation of the puree preparation of the corn bread revealed [NAME] GG not following a recipe, not using any measuring devices for the corn bread or added chicken broth, and not using utensils to scoop the pureed corn bread from the food processor into a container. An interview on 4/24/2025 at 10:25 am with [NAME] GG confirmed she did not use measuring cups and stated she eyeballed the ingredients as that is what she is used to. When asked if she used a recipe to prepare the puree meals, she stated no. [NAME] GG further stated she used no reference for the amount of chicken stock to use. [NAME] GG further confirmed she did not use any utensils for the puree preparation. An interview on 4/24/2025 at 3:24 pm with the Kitchen Manager revealed that recipes were located in the book to follow and that she expects staff to use the recipes when preparing meals. The Kitchen Manager further stated that she expects staff to use measurement devices and utensils when preparing puree food. The Kitchen Manager further stated that if a recipe was not followed, then the meal was not done the right way, which could affect the texture of the food. The Kitchen Manager further stated that the potential negative outcomes of not following a recipe could include residents choking if the puree food was not the right texture and that the potential negative outcomes if measurements were not used could include running out of the amount of puree food. The Kitchen Manager further stated the potential negative outcomes of using hands and no utensils could include spreading germs to the residents. In an interview with the Administrator on 4/24/2025 at 6:00 pm, she stated that she expect the food policies be followed and when preparing puree meals, a recipe be followed and scoops to be used. The Administrator further stated that potential negative outcomes could affect palatability.

Based on staff interviews, record review, and review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives, the facility failed to assure that the advance directive status was consistently documented in the clinical record for one out of 43 sampled Residents (R) (R167). Findings include: Review of the facility policy titled Residents' Rights Regarding Treatment and Advance Directives, dated February 2024 under Definitions revealed, Advance Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State, relating to the provision of health care when the individual is incapacitated. Under the section titled Policy Explanation and Compliance Guidelines revealed, 9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. Review of R167's Physician Orders for Advance Directives Checklist dated 4/15/2025 revealed that the code status for the resident was a DNR (Do Not Resuscitate) signed by the physician and resident. Review of the Admission Record with admitted [DATE] revealed that R167's code status was Do Not Attempt Resuscitation (DNR). Review of R167's physician orders dated 4/15/2025 revealed, a code status of Full Code. Review of R167's care plan with date initiated on 4/16/2025 revealed that the resident had an established advanced directive listed as Full Code. Review of R167's baseline care plan developed on 4/15/2025 revealed R167's code status as DNR which was signed by Social Service Director and Resident Representative on 4/21/2025 Review of R167's Social Service Director (SSD) Progress Note dated 4/21/2025 revealed: Care Planning/ Discharge Planning- Met with resident and family. Resident will be discharging home with daughters. The writer explain the discharge process that includes Home Health Services and DME equipment that may be needed. Everyone indicated understanding of the information given. No Concerns Noted. Advance Care Planning: Resident wishes to be a DNR. Interview on 4/24/2025 at 4:20 pm with Assistant Director of Nursing (ADON) and SSD revealed additional progress notes were added to resident's electronic medical records related to Advanced Directives status. SSD stated that she corrected her original progress note dated 4/21/2025. ADON confirmed that there were inconsistencies in R167's records. When asked how the facility staff identify correct code status, the ADON stated that facility staff always look for code status in the online profile banner and under physician orders.

Based on observations, record review, staff interviews, and review of the facility policy titled Heating, Ventilation and Air Conditioner (HVAC) Packaged Terminal Air Conditioner (PTAC): Clean air filters, the facility failed to maintain clean PTAC unit grills for two out of 32 Rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) on the First floor. This deficient practice had the potential to compromise the health and safety of the residents by increasing the risk of infections. Findings include: A review of the facility's undated policy titled HVAC (PTAC): Clean air filters, under the section titled Steps revealed, 4. Clean grill on cover. Observations on 4/22/2025 at 11:02 am and 4/23/2025 at 2:24 pm, in room [ROOM NUMBER] revealed, the PTAC unit grills was noted with a black substance. Observations on 4/22/2025 at 11:27 am and 4/23/2025 at 2:26 pm, in room [ROOM NUMBER] revealed, the PTAC unit grills was noted with a black substance. Observations on 4/22/2025 at 11:13 am in room [ROOM NUMBER], and on 4/22/2025 at 11:17 am in room [ROOM NUMBER], was conducted with the Maintenance Director (MD) and Regional Property Manager (RPM). During this time an interview was conducted with the MD, who confirmed the PTAC unit grills in both rooms had the presence of a black substance. The MD revealed the PTAC units were cleaned every three months and as needed. He emphasized that the expectation was for the PTAC units to remain clean and acknowledged that failure to do so could lead to negative outcomes, such as triggering allergies. During an interview conducted on 4/22/2025 at 11:22 am, the RPM also confirmed the PTAC unit grills in both room [ROOM NUMBER] and room [ROOM NUMBER] had the presence of a black substance. He stated that the expectation was for the PTAC units to always be clean. RPM stated a possible negative outcome of poor maintenance could result in allergic reactions and reduced efficiency of the units. An interview conducted on 4/24/2025 at 1:59 pm with the Administrator revealed her expectations were that PTAC units should be kept clean with no black substance. She stated a possible negative outcome could be an issue with resident comfort.

Based on observations, record review, staff interviews and review of the facility's policy titled Medication Administration, the facility failed to provide services that meet professional standards by not ensuring one out of eight Residents (R) (R10) received the correct medication dosage that was observed during medication administration. This deficient practice had the potential to cause adverse medication effects and medication error. Findings include: Review of the facility's policy titled Medication Administration dated January 2023 under the section titled Policy revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standard of practice . Review of the Electronic Medical Record (EMR) revealed that R10 was admitted to the facility with diagnoses that included but not limited to paranoid schizophrenia, dementia and behavioral disturbance. Review of R10's Quarterly Minimum Data Set (MDS) dated [DATE] for Section C (Cognition Patterns) revealed, R10 had a Brief Interview of Mental Status (BIMS) score of 3 which indicated severe cognitive impairment; Section I (Active Diagnosis) revealed diagnosis that included schizophrenia. Review of R10's care plan dated 3/14/2025 included but not limited to a Focus that revealed, The resident uses psychotropic medications related to paranoid schizophrenia; Goal: The resident will be/remain free of psychotropic drug related complications through review date. Interventions: Administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness every shift (q-shift). Review of R10's Physicians Orders dated 4/21/2025 included orders for [Name] Injection Solution (anti-psychotic medication) 5 milligrams per milliliters (mg/ml) (Haloperidol Lactate) Inject 2.5 mg intramuscularly one time only for Agitation. Reassess in 1 hour, if agitation persist repeat dose. Observation and interview on 4/23/2025 at 8:43 am revealed during medication administration, R10 had an order to receive [Name] 2.5 (mg) intramuscular injection for agitation. The medication vial was labeled [Name] 5 (mg/ml). (The nurse should remove 0.5 ml to equal 2.5 mg as ordered). During the observation Licensed Practical Nurse (LPN) DD withdrew 2.5 ml of [Name] for injection to be administered to R10 instead of 2.5 mg (0.5mls). LPN DD then locked the medication cart, knocked on the R10's door entered her room, introduced herself and was about to position R10 on her side to administer the injection when the Surveyor stopped the nurse and asked her for a moment outside the room. While LPN DD was outside of the room, she confirmed the dose was incorrect. LPN DD showed the Assistant Director of Nursing (ADON) the vial and the syringe and the ADON also confirmed the dose was incorrect. The ADON confirmed LPN DD withdrew 2.5 ml instead of 0.5 ml (2.5 mg) of [Name] medication. LPN DD revealed that if R10 had received the incorrect dose of [Name] medication, it could have caused increased agitation. Interview on 4/23/2025 at 9:16 am with the ADON revealed that she expected the nurses to verify and calculate the correct dosage and parameters for medications and administer the accurate dosage to the residents. She stated she expected the nurse to ask the supervisor if needed to verify the accurate dosage for the residents. Interview on 4/23/2025 at 2:56 pm with the Director of Nursing (DON) revealed she stated her expectations were for the nurses to follow the doctor's orders and administer the correct medication doses to the residents. The DON further stated the negative outcome would be the desired effect of the medication would not be reached if the incorrect dose was given. She stated R10 would not get the required dose and R10 would not get the full effectiveness of the medication.

Based on observations, staff interviews, record review, and review of the facility's policy titled Activities of Daily Living (ADLs), the facility failed to provide nail care for one out of three Residents (R) (R45) reviewed for Activities of Daily Living. This failure had the potential to affect the resident's comfort, body image, and increase the risk of infections. Findings include: Review of the facility's policy titled Activities of Daily Living (ADLS), dated January 2024 under the section titled Policy Explanation and Compliance Guidelines revealed, 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of R45's Electronic Medical Record (EMR) revealed R45 was admitted to the facility with diagnoses that included but was not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of R45's Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed, a Brief Interview for Mental Status (BIMS) of 9, which indicated R45 had moderate cognitive impairment; Section E (Behaviors) indicated no rejection of care; Section GG (Functional Abilities and Goals) revealed, R45 was dependent on showering and bathing and personal hygiene. Review of R45's care plan dated 6/10/2023 indicated a focus of ADL deficit related to physical limitations and impaired mobility. Interventions included but were not limited to grooming/ hygiene with extensive assistance of one staff. An observation on 4/22/2025 at 10:47 am revealed R45's fingernails were long with dark substances underneath them. An observation on 4/23/2025 at 2:08 pm revealed R45's fingernails were long with dark substances underneath them. In an interview on 4/23/2025 at 2:08 pm, Certified Nursing Assistant (CNA) HH revealed that R45 required total care assistance. CNA HH stated that staff look for nail care needs during bed baths and brief changes. CNA HH further stated that residents could scratch themselves when fingernails were too long. CNA HH confirmed that R45's fingernails were long and needed to be cut and that there were black substances underneath them. In an interview on 4/24/2025 at 4:03 pm, the Director of Nursing (DON) stated that she expects nail care to be provided when needed. The DON further stated that if dirt can be seen under the fingernails, it must be cleaned. The DON clarified that typically the CNAs would provide nail care, but any staff could provide it. The DON further revealed that staff should be looking for nail care needs daily when providing care. When asked if R45 refuses nail care, the DON stated that she had not been informed of R45 refusing nail care. The DON stated that if a resident refuses care, CNAs should document it and let a nurse know. In an interview on 4/24/2025 at 5:23 pm, the DON confirmed that there was no documentation of R45 refusing care related to nail care.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to follow physician orders for oxygen administration one Residents (R) (R45) and to properly store the oxygen nasal cannula when not in use for R96 out of 15 residents on oxygen. This deficient practice had the potential to cause respiratory distress and infection. Findings include: A review of the facility's policy titled Oxygen Administration, dated December 2022 under the section titled Policy Explanation and Compliance Guidelines revealed, 1. Oxygen is administered under orders of a physician, except in the case of an emergency .5. (e.) Keep delivery devices covered in plastic bag when not in use 1. Review of R45's Electronic Medical Record (EMR) revealed R45 was admitted to the facility with diagnoses that included but was not limited to chronic obstructive pulmonary disease (COPD), asthma, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. Review of R45's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed for Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) of 9, which indicated R45 had moderate cognitive impairment; Section O (Special Treatments, Procedures, and Programs) revealed R45 received oxygen therapy. Review of R45's Physician's Orders included but was not limited to, an order dated 3/12/2025 for oxygen at three liters (L) via nasal cannula continuously. An observation on 4/22/2025 at 10:47 am revealed R45's oxygen was set at 2L (two liters) via nasal cannula. An observation on 4/22/2025 at 3:43 pm revealed R45's oxygen was set at 2L via nasal cannula. An observation on 4/23/2025 at 12:11 pm revealed R45's oxygen was set at 2L via nasal cannula. In an interview on 4/23/2025 at 2:27 pm, Licensed Practical Nurse (LPN) AA confirmed R45's oxygen was set at 2L. LPN AA further confirmed R45's oxygen orders was for 3L (three liters), and that the oxygen should be turned up. In an interview on 4/23/2025 at 2:30 pm, the Director of Nursing (DON) stated that her expectations were for staff to follow the physician orders. The DON further stated that a potential negative outcome for not following physician orders for oxygen was respiratory distress. 2. Review of R96's EMR revealed R96 was admitted to the facility with diagnoses that included but was not limited to cognitive communication deficit and unspecific asthma. Review of R96's 5 (five)- day Minimum Data Set (MDS) assessment dated [DATE] revealed for Section C (Cognitive Patterns), a BIMS of 10, which indicated R96 had moderate cognitive impairment; Section GG (Functional Abilities and Goals) revealed R96 was dependent on transfers from bed to chair; and Section O (Special Treatments, Procedures, and Programs) revealed, R96 was on oxygen therapy. Review of R96's Physician's Orders included but was not limited to, an order dated 3/25/2025 for oxygen at four liters (L) via nasal cannula every evening and night shift for shortness of breath. An observation on 4/22/2025 at 11:02 am revealed R96's oxygen nasal cannula was not in use, uncovered, and laying in the bed. In an interview with R96 that was conducted at this time revealed, he uses his oxygen every night and takes off the nasal cannula in the morning around breakfast. An observation on 4/22/2025 at 3:11 pm revealed R96's oxygen nasal cannula was not in use, uncovered, and laying in the bed. An observation on 4/23/2025 at 12:10 pm revealed R96's oxygen nasal cannula was not in use, uncovered, and placed on the bedside table. An interview on 4/23/2025 at 2:05 pm with Certified Nursing Assistant (CNA) HH revealed that staff helped R96 get out of bed every morning, and as soon as they assist R96 in his wheelchair, the staff make his bed. CNA HH further stated that R96 removed the nasal cannula in the morning when they assist him with getting dressed. In an interview on 4/23/2025 at 2:35 pm with the Director of Nursing (DON), she confirmed the nasal cannula was not in a bag but should be placed in a bag when not in use. The DON stated that R96 uses oxygen at night. The DON further stated that a potential negative outcome when an oxygen nasal cannula was not stored properly was that the nasal cannula could become contaminated.

Based on observations, staff interviews, record review, and review of the facility's policies titled Medication Storage, Labeling of Medications and Biologicals, and Use by Dating Guidelines, the facility failed to lock two of six medication carts on the 100 and 200 halls. In addition, the facility failed to have an open date on one bottle of glucometer strips in one of six medication carts on the 200 hall and failed to remove six bottles of expired nutritional supplements from one of two medication rooms. Findings include: Review of the facility's undated policy titled Medication Storage dated [DATE] under the section titled Policy Explanation and Compliance Guidelines revealed, 1. General Guidelines: (a.) All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) .(c.) During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Review of the facility's undated policy titled Labeling of Medications and Biologicals dated [DATE] under the section titled Policy revealed, All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Review of the facility's undated policy titled Use by Dating Guidelines revealed, Please use this guide to determine a use by date when labelling opened and unopened food that must be used within a certain timeframe Suplement-2.0 (shelf stable), room temperature, use by manufacturer's open date. 1. An observation and interview conducted on [DATE] at 10:52 am revealed, a medication cart labeled Cart A was observed unlocked and unattended on the 100 hall. Licensed Practical Nurse (LPN) AA was observed on the computer at the nurse's station. LPN AA confirmed that she was assigned to the medication cart and acknowledged it was unlocked. LPN AA explained that she had left the medication cart unlocked and stepped away briefly to complete another task. She acknowledged that a potential negative outcome of leaving the cart unlocked was that residents could access the medications. An interview conducted on [DATE] at 12:56 pm with the Director of Nursing (DON) revealed that all medication carts were expected to always be locked when not attended by nursing staff. The DON stated that failure to do so could result in someone gaining unauthorized access to medications, posing a serious safety risk. An interview conducted on [DATE] at 2:05 pm with the Administrator revealed medication carts should not be left unlocked and unattended under any circumstance. The Administrator confirmed that an unlocked cart presents the risk of potential unauthorized access to medications. 50524 2. Observation on [DATE] at 12:36 pm revealed an unlocked medication cart on the 200 hall where residents were observed ambulating freely on the hall. Interview on [DATE] at 12:38 pm with Registered Nurse (RN) BB confirmed she left the medication cart unlock on the 200 hall. She revealed she should have locked it because the residents could have taken the medications, and this could have caused them to get sick. Interview on [DATE] at 10:28 am with the Unit Manager (UM) revealed whenever nurses step away from the medication carts, the medication carts should be locked. She further stated the medication carts should be locked especially if the medication cart was out of the nurses' visual. Interview on [DATE] at 2:56 pm with the DON revealed her expectations were that the medication carts should be locked when they were left unattended. The DON further stated if the medication carts were not locked, the negative outcome would be the residents could go in the cart and take medications, and they could have an allergic reaction to the medication or have negative outcomes. 3. Observation on [DATE] at 5:30 pm of one medication cart on the 200-hall revealed, one bottle of glucometer strips with no open date was found in the medication cart. Interview on [DATE] at 5:31 pm with RN FF confirmed the bottle of glucometer strips in the medication cart did not have an open date on it. She stated there should be an open date on it in order to know how long to use the strips. She stated the strips should be used within 30 days of the open date so if there was no open date then the nurse would not know when the strips were opened, and that the blood sugar readings could be inaccurate if the strips were not any good or expired. Interview on [DATE] at 10:38 am with LPN EE revealed there should be open dates on the bottle of glucometer strips. LPN EE further stated that open dates were placed to track the times it was opened, and that it should be discarded after 30 days of the open date. Interview on [DATE] at 11:49 am with the DON revealed her expectation was that there should be open dates on the bottle of glucometer strips because they should be tossed out after 30 days of the open dates. The DON stated if glucometer strips with no open dates were used on the residents, the blood sugar results could be inaccurate, and the residents could get too much or too little insulin and that could be fatal. 4. Observation on [DATE] at 5:40 pm of the medication room on the 200 Hall revealed, one box that contained six expired [Name] therapeutic nutritional supplements with use by date of February 1, 2025. The box was found on a shelf in front of the door entrance of the medication room. Interview with the Assistant Director of Nursing (ADON), who was present in the medication room during the observation confirmed that therapeutic nutritional supplements were expired and stated they should not be in the medication room. She further stated that the residents could get the expired supplements and get sick. Interview on [DATE] at 5:44 pm with UM CC confirmed the [Name] therapeutic nutritional supplements with use by date of February 1, 2025, were expired. UM CC stated the expired supplements should not be in the medication room and that they should have been thrown out. She further stated the residents could get the expired supplements and get sick. Interview on [DATE] at 11:49 am with the Director of Nursing (DON) revealed the expired [Name] therapeutic nutritional supplements with use by date of February 1, 2025, should be tossed out. The DON further revealed they should not be in the medication room because they could be given to the residents, and the residents could get sick from possible adverse reactions.

Based on observations, record review, staff interviews, and review of the facility's policies titled Glucometer Disinfection and Infection Prevention and Control Program, the facility failed to disinfect the glucometer machine after it was used to check blood sugar for one out of eight Residents (R) R50 observed during medication administration. This deficient practice had the potential to increase the risk of infection transmission and compromise the overall health of residents. Findings include: Review of the facility's policy titled Glucometer Disinfection dated 9/12/2022 under the Policy Explanation and Compliance Guidelines section revealed, 5. Procedure: .(i.) Retrieve (2) disinfectant wipes from container. (j.) Using first wipe, clean first to remove heavy soil, blood and/or contamination left on the surface of the glucometer. (k.) After cleaning, use second wipe to disinfect the glucometer thoroughly, with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry. (l.) Discard disinfectant wipes in waste receptacle. (m.) Perform hand hygiene. Review of the facility's policy titled Infection Prevention and Control Program dated May 2023 under the Policy section revealed, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Review of Electronic Medical Record (EMR) revealed, R50 was admitted to the facility with diagnoses that included but not limited to hypoglycemia and diabetes mellitus. Review of R50's Physician's Orders dated 3/22/2025 revealed, an order for Humalog Solution 100 units per milliliter (unit/ml) (Brand Name of Insulin), Inject as per sliding scale: if 60 - 200 = 0 units Call physician if blood sugar (BS) <60; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401+ Call physician if BS >400, subcutaneously before meals and at bedtime for sliding scale insulin coverage for diabetes must take finger stick blood glucose prior to administration. During medication observation on 4/23/2025 at 12:37 pm with Registered Nurse (RN) BB revealed, she left R50's room with the glucometer machine and placed it in the drawer of the medication cart without disinfecting it. Interview on 4/23/2025 at 12:38 pm with RN BB confirmed she had left R50's room with the glucometer machine and placed it in the drawer of the medication cart without disinfecting it. RN BB acknowledged she should have disinfected the glucometer machine, and that the residents could get infections if the glucometer machine was not disinfected. Interview on 4/23/2025 at 2:56 pm with the Director of Nursing (DON) revealed her expectations were for the glucometer machine to be cleansed with the (Name) disinfectant wipes until it was wet. She further revealed that the dwell time was two minutes, which was the time it takes to kill the germs when allowing it to dry. She further stated that if the glucometer machine was not disinfected the resident could get an infection. Interview on 4/24/2025 at 10:28 am with Unit Manager (UM) CC revealed that staff should use (Name) wipes to disinfect the glucometer machine and leave it to air dry for two minutes which was the kill time for the disinfectant to kill the bacteria. She revealed that staff should saturate the glucometer with the disinfectant wipes and then place it on a clean surface to air dry until the disinfectant process was complete.

Based on observations, staff interviews, and review of the facility's policy titled, Disposal of Garbage Refuse, the facility failed to ensure one of one garbage dumpsters had a tightly fitted lid. In addition, the facility failed to ensure the sliding door was kept close when not in use. The facility census was 123 residents. Findings include: Review of the undated facility's policy titled Disposal of Garbage Refuse, dated April 2024, documented that refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded litter. Observation on 12/2/2024 at 9:02 am revealed, the facility's garbage dumpsters were observed overflowing with stacks of garbage bags. Observation on 12/5/2024 at 9:33 am during a tour of the kitchen with the Dietary Manager (DM) revealed, the garbage dumpster outside was missing a lid and the sliding door was open. The DM attempted to shut the sliding door, but it was stuck and difficult to close. The DM then stated that the lid had been missing for a while and he had notified Maintenance Director about it. Interview on 12/5/2024 at 9:58 am with the Administrator revealed, she was not aware of the lid missing from the garbage. The Administrator asked the Maintenance Director who confirmed he was aware of the missing lid and stated, he had called the county about the garbage lid two weeks ago.

Based on observation, staff interviews, and review of the facility's policy titled Food Receiving and Storage, the facility failed to ensure that opened food stored in one walk-in cooler was covered, labeled and dated. This failure had the potential to affect 121 of 123 residents who received an oral diet from the kitchen. Findings include: Review of the undated facility's policy titled, Food Receiving and Storage dated April 2024 revealed, all foods stored in the refrigerator or freezer will be covered, labeled and dated. Observation on 12/5/2024 at 9:33 am during a tour of the kitchen with the Dietary Manager (DM) revealed, one of the walk-in coolers had an open bag of cabbage with no open date on the bag. The DM stated, it was probably left open from when the salads were being made for lunch. However, the lettuce did not match the premade salads. During the observation, [NAME] EE stated, it may have been left open from the day before. Interview on 12/10/2024 at 10:09 am with [NAME] EE revealed, the bag of cabbage was used for [NAME] slaw. [NAME] EE stated staff must have needed to prepare salad for residents that prefer salads but picked up the cabbage bag in error and didn't cover it back before returning it to the cooler. [NAME] EE confirmed that the bag of cabbage had been opened without a label or open date stating, I saw it for myself.

Based on staff interview and record review, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for one of four sampled residents (R) (R12) reviewed for falls. Findings include: Review of the Electronic Medical Record (EMR) revealed, R12 admitted to the facility on [DATE] with multiple diagnoses that included but not limited to type II diabetes mellitus without complications, sepsis, morbid (severe) obesity with alveolar hypoventilation, edema, indwelling urethral catheter, pressure ulcer of sacral region, stage IV hypertension and chronic pain. Review of R12's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed, Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) of 15 which indicated intact cognition; Section J (Health conditions) revealed, Fall since Admit/prior Assessment, was marked no' Review of a fall incident report dated 7/26/2024 revealed that R12 was trying to get from my chair into the bed and it rolled from underneath me. Review of R12's Progress Notes dated 7/26/2024 revealed, a Left Index finger strain- Xray ordered- Acetaminophen PRN (as needed); Fall: Neuro check and v/s (vital sign) per protocol. Monitor for pain; Monitor for latent sign of injury. During an Interview on 12/11/2024 at 10:18 am, the MDS Assessment Nurse KK revealed her job duties included completing resident assessments and developing care plans. She revealed, falls were discussed, and interventions were developed in morning meetings. The MDS Assessment Nurse KK confirmed R12's had a fall that occurred on 7/26/2024. The MDS Assessment Nurse KK stated she was not sure why that wasn't captured on the MDS. MDS Assessment Nurse KK stated she went back to review the MDS and confirmed it wasn't captured. MDS Assessment Nurse KK stated it must have been an oversight.

Based on interviews, record review and review of the facility's policy titled Medication Administration, the facility failed to administer scheduled medication within 60 minutes before or after the scheduled medication time for one of sampled three residents (R) (R13) reviewed for medication administration. Findings include: Review of the facility's policy titled Medication Administration dated January 2023 under the section titled Policy Explanation and Compliance Guidelines revealed, 11. (b) Administer within 60 minutes prior or after scheduled time unless otherwise ordered by physician. Review of the Electronic Medical Record (EMR) revealed R13 admitted to the facility with multiple diagnoses that included but not limited to type II diabetes, chronic kidney disease, hearing loss, pulmonary hypertension, chronic pain and of automatic (implantable) cardiac defibrillator. Review of R13's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, Section C (Cognitve Pattern) a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident had intact cognition. Review of R13's care plan, initiated on 1/15/2024 revealed the resident is on pain medication therapy: Hydrocodone, Tizanidine, Lidocaine patch, diclofenac gel r/t (related to) pyogenic arthritis, chronic pain disorder, neuropathy, joint pain, muscle spasms. Review of R13's physician's orders revealed, gabapentin oral tablet 600 milligrams: one tablet by mouth three times a day (9:00 am, 1:00 pm and 5:00 pm) for neuropathy. Start date of 5/24/2024 to 12/10/2024. Review of R13's Medication Administration Audit Report documented the following: Schedule date - 11/9/2024; 9:00 am- administration time 11:34 am Schedule date - 11/9/2024; 5:00 pm- administration time 6:22 pm Schedule date - 11/10/2024; 9:00 am- administration time 11:16 am Schedule date - 11/10/2024; 5:00 pm- administration time 7:49 pm Schedule date - 11/11/2024; 1:00 pm- administration time 3:37 pm Schedule date - 11/11/2024; 5:00 pm- administration time 7:37 pm Schedule date - 11/13/2024; 1:00 pm- administration time 2:33 pm Schedule date - 11/14/2024; 1:00 pm- administration time 4:19 pm Schedule date - 11/15/2024; 1:00 pm- administration time 3:45 pm Schedule date - 11/15/2024; 5:00 pm- administration time 6:52 pm Schedule date - 11/17/2024; 1:00 pm- administration time 4:40 pm Schedule date - 11/18/2024; 9:00 am- administration time 11:07 am Schedule date - 11/18/2024; 5:00 pm- administration time 6:39 pm Schedule date - 11/19/2024; 5:00 pm- administration time 7:25 pm Schedule date - 11/20/2024; 1:00 pm- administration time 4:56 pm Schedule date - 11/21/2024; 9:00 am- administration time 10:49 am Schedule date - 11/22/2024; 5:00 pm- administration time 7:28 pm During an interview on 12/2/2024 at 11:24 am, the complainant revealed, that R13 had several instances where her 9:00 am medications wouldn't be administered until 11:00 am and there were times that R13 and her roommate R12 had a difficult time getting their pain medications. Interview on 12/4/2024 at 10:28 am with R13 revealed the medications was always late. R13 stated she and R12 received their gabapentin late. R13 stated their 9:00 am dose would come around 11:00 am and that would push the afternoon dose to like 5:00 pm and then the evening dose even later. During an interview on 12/9/2024 at 3:05 pm, the Director of Nursing (DON) revealed there's a two-hour window (one hour before and one hour after) for the medication to be administrated to the resident. If there's a hole on the MAR, there's a possibility that the medication was missed. The DON stated, I have not had any concerns about late medications, that I can recall. Interview on 12/10/2024 at 12:59 pm with Licensed Practical Nurse (LPN) JJ revealed, the nurses have an hour before and an hour after a scheduled medication time to administer medications. Interview on 12/11/2024 at 10:14 am with R13 stated that whenever her gabapentin was administered late, her neuropathy would act up.

Based on resident and staff interviews and record review, the facility failed to provide showers/baths for one of six sampled residents (R) (R12) reviewed for Activities of Daily Living (ADLs). Findings include: Review of the Electronic Medical Record (EMR) revealed, R12 admitted to the facility on [DATE] with multiple diagnoses that included but not limited to type II diabetes mellitus without complications, sepsis, morbid (severe) obesity with alveolar hypoventilation, edema, indwelling urethral catheter, pressure ulcer of sacral region, stage IV hypertension and chronic pain. Review of R12's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed, Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) of 15 which indicated intact cognition. Review of R12's Care plan, initiated on 7/23/2024 revealed, R12 required extensive assistance by one staff when bathing. Review of the Facility's shower schedule revealed, residents receive two showers per week; Mondays and Thursdays; Tuesdays and Fridays; and Wednesdays and Saturdays. Further review revealed, R12 was scheduled to receive showers on Wednesdays and Saturdays. Review of R12's ADL bathing sheet revealed that R12 received a shower on 7/27/2024 but not on 7/24/2024. Interview on 12/4/2024 at 10:28 am with R12 revealed, that the first few weeks of admission to the facility she only received a shower one time a week. When asked why, R12 stated she wasn't sure why but now the showers were twice a week. During an interview on 12/11/2024 at 10:45 am, the Director of Nursing (DON) revealed, that the shower schedule was on each floor and should have triggered R12 based on what room and bed they were placed in upon admission. The DON confirmed that R12 should have received a shower on Wednesday, 7/24/2024.

Based on observations and interviews the facility failed to provide a safe homelike environment for residents on two of two floors. The tour of the facility revealed trash debris in residents' rooms and bedroom furniture in disrepair. This failure had the potential to place residents at risk for use of unsanitary and a unsafe environment and a potential for diminished quality of life. Findings include: During the initial tour of the facility conducted on 03/21/2023, observations of the following concerns were identified: Observation in the room of R#63 a black 1 inch by 1/2-inch pest that was crawling over the resident's bed. Observation in the room of R#22 a strong musty odor coming from residents' bathroom. Observation in the room of R#17 the wallpaper peeling off the wall. Observation in the room of R#92 the nightstand missing the middle drawer and nicks and scratches were observed on the nightstand. Observation in the room of R#49 the emergency outlet not covered, and the electrical outlet over the resident's bed with multi plugs is not completely covered the outlet. Observation in the room of R#24 the clothing unit with scratch marks. Observation in the room of R#62 the clothing closet missing the door; nightstand had peeling wood, and scratches. Observation in the room of R#105 trash debris on the floor around the resident's bed. During an additional tour on 03/24/2023 at 3:45 p.m. with the Administrator revealed the following was observed: The wall at the entrance to the nurses' station with peeling wallpaper and exposed metal frame. Observation in the room of R#59 trash debris on the floor around the resident's bed; unknown brown substance on the wall next to the resident's bed, and a missing curtain covering the resident's clothing closet. Observation in the room of R74 the nightstand cabinet drawers off track and does not close completely. Observation in the room of R#89 the top portion of nightstand cabinet coming loose. Observation in the room of R#92 the nightstand missing the middle drawer. Observation in the room of R#49 the electrical outlet covering does not completely cover the outlet, and the handicapped handrail in the resident's bathroom was loose. The Maintenance Director was unavailable to be interviewed. Interview on 03/24/2023 at 3:45 p.m. the Administrator revealed the facility recently lost an employee in the maintenance department and they were in the process of hiring another person for that department.

Based on staff and resident interviews, record reviews, and a review of facility's policy titled, Care Plans - Baseline, the facility failed to develop base line care plans for six residents of 35 sampled residents (R) (#67, #92, #105, #117, #279, and #280). This failure had the potential to place newly admitted residents at risk of not receiving necessary care and services. Finding include: Review of the facility's document titled Care Plans - Baseline updated 12/2022 states the facility's policy interpretation and implementation includes the following: A baseline care plan will be developed within 48 hours of the resident's admission. The resident and their representative will be provided a summary of the baseline care plan . 1. Record review of the Admission Record for R#67 located in the electronic medical record (EMR) under section Profile revealed the resident was admitted on [DATE] with diagnoses that included malignant poorly differentiated neuroendocrine tumors, protein calorie nutrition, and drug induced polyneuropathy. Record review of the Social Services Assessment for R#67 dated 02/28/2023, located under the section Assessments in the EMR, revealed Social Services discussed the resident's potential discharge status, code status; review of the facility policies; and plans to monitor dental, hearing, vision, and psychological needs. The assessment did not identify that a copy of this assessment or care plan was given to the resident. This was past the 48-hour assessment period. There was no evidence of a signed baseline care plan on the resident's electronic records. 2. Record review of the Admission Record for R#92 in the EMR located under the section Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that included respiratory hypoxia; congestive heart failure; muscle weakness; polyneuropathy; and diabetes mellitus type II. Record review of the admission MDS for R#92 dated 03/20/2023 located in the section labeled Minimum Data Set MDS in the EMR, assessed the resident with a Brief Interview for Mental Status BIMS score of 15 which indicated the resident was cognitively intact. Interview on 03/21/2023 at 9:50 a.m. with R#92 on 03/21/2023 revealed the resident was unaware of care plans that identified her problems and the facility's interventions to address the problems. R#92 stated she never received a copy of the care plans or asked to sign anything. 3. Record review of the Admission Record for R#105 located in the EMR under the section Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that included end state renal disease with hemodialysis, insulin dependent diabetes mellitus, staphylococcus capitis (blood infection) and osteomyelitis. Record review of the R#105 admission MDS for R#105 dated 03/07/2023 located in the section MDS in the EMR, assessed the resident with a BIMS score of 15 which indicated the resident was cognitively intact. A review of the Social Services Assessment for R#105 dated 03/23/2023, located in the section for Assessments in the EMR revealed no documentation of Social Services having assessed R#105. There was no documentation that the resident received a baseline care plan. Interview on 03/21/2023 at 12:07 p.m. with R#105 on 03/21/2023 at 12:07 p.m. the resident stated he never received or signed a care plan outlined his plan of care. 4. Record review of the Admission Record for R#117 located in the Profile section in the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure hypoxia, unstageable sacral ulcer and ischial ulcers, bacteremia, severe sepsis, and a right above the know amputation (AKA). Record review of the Social Services Assessment for R#117 dated 2/28/2023, located in the Assessments section in the EMR, revealed it was discussed with the resident about short term rehabilitation stay. Social Services discussed the resident code status (full code), reviewed resident rights with R#117 with comprehension. Discussed interdisciplinary team review and discharge planning process. Patient verbalized understanding. The patient's goals for rehab are to be able to manage mobility and resume independence with self-care. The Social Services note documents R#117's plan of care was discussed, and copies of the care plan was given to the resident. However, the Social Services were unable to provide a copy of the resident's signed base line care plan. 5. Record review of the Admission Record for R#279 under the Profile section located in the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses that include wedge compression fracture of third vertebrae, malignant neoplasm of right breast, pressure ulcer of sacral area, and urinary tract infection (UTI). Record review of the Social Services Assessment for R#279 dated 03/15/2023 located in the Assessments section failed to reveal a signed copy of the baseline care for this resident. 6. Record review of the Admission Record for R#280 located in the EMR under the Profile section revealed the resident was admitted to the facility on [DATE] with diagnoses that included displaced right shoulder fracture, Parkinson's disease with dementia, and fall history. Record review of the Social Services Assessment for R#280 dated 03/22/2023 located in EMR under the Assessment section failed to reveal a signed baseline care plan for the resident. Interview on 03/24/2023 at 9:45 a.m. with the Unit Manager (UM) 2 revealed that when a resident is admitted to the facility the nurse documents the resident's diagnosis and potential problems in the electronic baseline care plan system. After that it is the responsibility of the MDS nurse to complete the baseline care plans. However, UM2 was unsure as to who was responsible for ensuring the resident and/or responsible party received a signed copy. Interview on 03/24/2023 at 11:31 a.m. with the Minimum Data Set (MDS) nurse revealed the baseline care plans are started by the floor nurse. But Social Services staff are responsible for reviewing the baseline care plan with the resident and ensuring that they sign and receive a copy of the baseline care within the 24-48-hour timeframe. Interview on 03/24/2023 at 3:20 p.m. with Social Services Director (SSD) revealed social services writes the assessment note in which they discuss the resident's care, code status, and impending discharge. However, she was unaware the resident was to sign and receive a copy of the care plan within the allotted time frame.