Every finding on record at Elon Manor Nursing and Rehabilitation Center

Based on observations, interviews, and record review, the facility failed to promote and facilitate one (1) of one (1) resident's choice to close the room door at night for privacy and personal comfort (Resident #39); and two (2) of two (2) residents right to use electric wheelchairs to support mobility, independence, and the resident's highest practicable level of functioning (Resident #s 44 and 96). This failure caused Resident #44 frustration, anxiety, mental anguish, and self-isolation, which resulted in psychological harm.The findings include:1. Resident #44 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, recurrent; muscle weakness; intermittent explosive disorder (added 09/15/2025); and pain in right elbow. Review of the quarterly Minimum Data Set Assessment (MDS) dated [DATE], revealed the Brief Interview for Mental Status (BIMS) score was 15/15, which reflected intact cognition. MDS dated [DATE] revealed the resident was mobile with an electric wheelchair; dependent on staff for transfers; required substantial/maximum assistance with activities of daily living (ADLs). During an observation and interview on 03/30/26 at 12:27 PM, Resident #44 was seated in a manual wheelchair, in her room, the resident stated, I want my wheelchair back, my electric wheelchair. They took it. I used to go outside every day; I don't go anymore. During a subsequent interview on 04/02/2026 at 12:15 PM, Resident #44 stated, I don't have independence anymore. I stopped eating in the dining room. I don't go out to see my friends here. I stopped going downstairs outside to feed the chickens. I don't go to activities. The resident appeared visibly distressed, clenched her fists, and stated, I can't talk about it. I get too upset. Review of an encounter progress note dated 02/17/2026 revealed, Patient continues to claim that her mood is calm but acknowledges frustration over her limitations. Review of a psychiatry progress note dated 01/17/2026 revealed, The patient spends the majority of her time in her room and is largely self-isolative, with limited interaction with other residents. This pattern has increased since her powerchair was removed. Review of psychological progress note dated 11/23/2025 revealed, The resident spends most of her time in her room following the removal of her motorized wheelchair.10/08/2025 Anxiety: Irritability. Abnormally and persistently elevated, Expansive or irritable mood. Review of the progress note dated 07/09/2025 indicated that following the removal of the motorized wheelchair, Resident #44 refused to get out of bed or participate in activities. Review of a social service progress note on 08/21/2025 the Director of Social Service (DSS) wrote, Resident asked to have her wheelchair returned. she remains largely isolated in her room. Subsequent review of the nursing progress notes indicated nurses and activities staff documented the resident's continued requests for her electric wheelchair returned. Review of the Occupational Therapy assessment dated [DATE] revealed, Pt [patient] was assessed using a motorized wheelchair. Pt is cognitively and functionally able to use her PWR [power] wc [wheelchair]. Pt had swollen legs/feet so tilt in space aspect of the chair is appropriate for pressure relief. Review of a psychological progress note dated 06/04/2025 revealed, The resident used her motorized wheelchair to navigate the facility and its grounds independently. frequently seen moving around the facility independently in her motorized wheelchair. Review of medical records revealed no documented evidence staff promoted or facilitated the resident's use of the motorized wheelchair to return to and maintain previous level of independence and mobility. Further review indicated that after the facility had removed the resident's motorized wheelchair, there was no evidence of a resident-centered plan or communication of timelines or expected outcomes required to facilitate return of the motorized wheelchair. During an interview on 04/01/26 at 12:30 PM, the DSS confirmed the Resident #44's motorized wheelchair had been removed. The DSS stated that for a while, the resident wouldn't use the manual wheelchair. She stays in her room most of the time. She gets frustrated and doesn't do much outside of her room anymore. During an interview on 04/01/26 at 4:20 PM, the Director of Nursing (DON) confirmed the resident's motorized wheelchair had been taken away, without options or timelines to regain or maintain use of her motorized wheelchair. The Administrator and DON did not provide details or a plan of how/if the resident can/will be evaluated for reconsideration to have her motorized wheelchair returned. 2. Resident #96 was admitted to the facility on [DATE] with diagnoses that included chronic inflammatory demyelinating polyneuropathy (CIDP) [a rare, acquired autoimmune disorder of the sheath of peripheral nerves, causing progressive muscle weakness, tingling, and loss of reflexes which damage, slows or blocks nerve signals] and major depressive disorder. During an interview on 03/30/2026 at 12:45 PM, Resident #96 was observed in a manual wheelchair. The resident stated, I had an electric wheelchair, but they told me on admission that I couldn't use my it this admission because they don't allow them anymore. That made me mad and I felt like it took away my independence. They wouldn't even let me use it to go to the Veterans Administration (VA). The resident was care planned to use a motorized wheelchair for mobility. During an interview on 04/02/2026 at 2:41 PM, the Admissions Coordinator and Administrator confirmed the resident was informed, prior to admission, that he could not have his motorized wheelchair in the facility. 3. Resident #39 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #39's BIMS score was 04/15, which reflected severely impaired cognition. During an interview (translated by the resident's daughter) on 03/31/2026 at 1:45 PM, Resident #39 stated that she wasn't allowed to close her door at bedtime. She stated, I want to close my door because I don't like the noise and lights when I'm trying to sleep. I tell the nurses, but they said that they needed to keep the door open so they can see that I'm breathing OK. During an interview on an interview on 04/01/2026 at 9:45 AM, Certified Nursing Assistant (CNA) #1 confirmed, The resident was told that she they must have her door open for her own safety. Also, when she shuts the door, she pushes the black TV tray table or her overbed table behind the door. We need to be able to get to her in case she falls. CNA #1 acknowledged that both the TV tray and overbed tables are light, easily movable, and may not be tall enough to block the door. During a walking tour and interview on 04/01/2026 at 10:22 AM, RN #1 stated that while she rarely works nights, she had been told that the resident wasn't allowed to close her door. RN #1 stated, If it is the resident's preference to close their door at night, it is her right to have her privacy and be comfortable, in her home. We must find a way to accommodate her reasonably requests. During an interview on 04/02/2026 at 1:30 PM, the DON confirmed the resident has the right to close her door at night, if that is her choice.

Based on observation and interview, the facility failed to ensure infection control practices were followed related to: 1) staff performing hand hygiene when completing medication administration, 2) cleaning of multi-use equipment, such as blood glucose monitors and blood pressure cuffs, in between uses on residents, and 3) an uncleanable surface in one of two resident shower rooms in the one west unit. Findings included: 1. On 2/23/26 at 9:20 a.m. during medication administration observation Staff A, Registered Nurse (RN) used her fingers to place vitamin D-3, aspirin, Iron, and sodium chloride pills into a medication cup to administer to Resident #62. On 2/23/26 at approximately 9:23 a.m. after preparing medications for Resident #62, Staff A, RN did not perform hand hygiene (HH) and entered room [ROOM NUMBER] put gloves on and resecured ace bandage on the resident's right arm. Staff A, RN removed gloves, did not perform HH, entered Resident #62's room and administered medications to the resident. On 2/23/26 at 9:39 a.m. Staff A, RN used a wrist blood pressure monitor to check Resident #41's blood pressure then placed the machine directly on top of the medication cart. When preparing medications to administer to Resident #41 Staff A, RN used her fingers to place iron, vitamin B-12, and sodium bicarbonate pills into the medication cup. When asked about cleaning and disinfecting multi resident use items Staff A, RN said red-top disinfectant wipes are available for use. When asked about the process of removing over the counter medications from containers, Staff A, RN said I touched them. In response to not consistently performing HH Staff A, RN said she performed HH, when reminded of the moments HH was not done there was no response. On 2/23/26 at 11:44 Staff J,RN left room [ROOM NUMBER] with a wrist blood pressure monitor and placed the machine in a bag with clean medical supplies. Staff J, RN said the blood pressure monitor should have been disinfected first with disinfectant wipes located in the bottom drawer of the medication cart. The National Library of Medicine provide the following directions when using multi-dose containers: When removing tablets or capsules from a multi-dose bottle, pour the necessary number into the bottle cap and then place the tablets or capsules in a medication cup. Cut scored tablets, if necessary, to obtain the proper dosage. If it is necessary to touch the tablets, wear gloves. https://www.ncbi.nlm.nih.gov/books/NBK593215/ retrieved on 2/27/26. 2. On 2/22/26 at 1:48 p.m., an observation of the one west bathroom, in front of room [ROOM NUMBER] and next to room [ROOM NUMBER], revealed the shower area had a long pipe, from the ceiling to the floor in length. Further observations of the pipe showed it was wrapped in cardboard. On 2/23/26 at 9:30 a.m., an observation of the bathroom/shower room, next to room [ROOM NUMBER], revealed a plunger next to the toilet did not have a bag covering it. Photographic evidence obtained. On 2/24/26 at 2:03 p.m., an interview was conducted with the Director of Nursing (DON). She said the pipe in the shower/bathroom should not have cardboard on it. She stated, Cleanable surfaces need to remain cleanable. The DON said the pipe is a heating pipe and the cardboard was put on there to prevent residents who use the shower from getting burned. She said the cardboard was replaced today with material, specifically for heating pipes, that could be cleaned. The DON said the expectation for plungers in the bathrooms is they should be covered. She stated, If a plunger is used, the expectation is that it be sanitized and put back in a bag. Review of facility policy titled, Infection Control Policy, revised 4/23/25 showed the following: Mission statement: Outbreaks of communicable diseases within the facility will be promptly identified and appropriately handled. Contagious diseases are spread every day. Oftentimes, they are transmitted unknowingly, leaving healthcare staff unprepared for outbreaks. Overview: Infections are a significant source of morbidity and mortality for nursing home residents. Emphasis for prevention and management of infections are a critical aspect. Program oversight includes planning, organizing, implementing, operating, monitoring, and maintaining all of the elements of the program and ensuring that the facility's interdisciplinary team is involved in infection prevention and control. Review of facility policy titled, Hand Hygiene, Nail Length, and Artificial Nails Policy, effective 1/12/26 showed the following: Purpose To outline a facility-wide policy on hand hygiene . Indications for hand hygiene Hand Washing with soap and water: Wash hands with soap and water when hands are visibly soiled or contaminated with patient's body fluids or excretions, mucous membranes, non-intact skin or if exposure to spore forming organisms is suspected or proven, and after using the bathroom. Hand Hygiene with Alcohol-based Hand Sanitizer: Alcohol-based Hand Sanitizer should be used if hands are not visibly soiled, for routinely decontaminating hands in clinical settings including: 1. Before entering resident's room. 2.Before donning gloves. 3. Upon exit of resident's room .

Based on observations, facility record review and staff interviews, the facility failed to ensure handrails were affixed to the wall in a safe and secure manner in two floors (200 and 100) of two floors observed, during three days (2/22/2026, 2/23/2026, and 2/24/2026) of four days observed. Findings included: During a facility wide tour on 2/22/2026 at 9:15 a.m., at 2:00 p.m. and on 9/23/2026 at 8:30 a.m., the following was observed: 1. The 2nd floor hallway handrail located before the shower room was not affixed tightly to the wall. 2. The 2nd floor hallway handrail located across from the nurse station and below the mirror and clock was not affixed tightly to the wall. 3. The 2nd floor hallway handrail located on the right side of the nurse's station door was not affixed tightly to the wall. 4. The 2nd floor hallway handrail located between resident rooms [ROOM NUMBERS] was not affixed tightly to the wall. 5. The 2nd floor hallway handrail located on the left side of resident room [ROOM NUMBER] was not affixed tightly to the wall. 6. The 2nd floor hallway handrail located between resident rooms [ROOM NUMBERS] was not affixed tightly to the wall. 7. The 2nd floor hallway handrail located between resident rooms [ROOM NUMBERS] was not affixed tightly to the wall. 8. The 2nd floor hallway handrail on the right side of the storage closet just before the dining room was not affixed tightly to the wall. 9. The 2nd floor hallway handrail on the right side of the soiled utility room and across from resident room [ROOM NUMBER] was not affixed tightly to the wall. The observations revealed the entire length of the above-mentioned wooden handrails moved and wiggled and had physical play when grabbed, creating a risk for accidents. The observations during the 7-3 a.m. shifts and 3-11p.m. shifts on days 2/22/2026, 2/23/2026 and 2/24/2026 revealed residents were utilizing the above listed handrails when ambulating around the building. On 2/22/2026 at 10:00 a.m. an interview was conducted with Staff D, Certified Nursing Assistant (CNA). Staff D confirmed the loose handrails but did not know about them being loose until at the time of the interview. She stated if she saw any handrails broken or loose, they are to report it immediately via the facility's work order system to maintenance. On 2/22/2026 at 10:05 a.m. an interview was conducted with Staff E, License Practical Nurse (LPN). Staff E stated handrails must be secured to the walls for the resident's safe use. Staff E stated there were times when they are knocked into and they get loose. She stated not knowing how often maintenance observed for the securing of the handrails. But if they are observed by staff being loose, they put in work orders for repairs. Staff E confirmed she had observed residents utilizing the handrails throughout her shift on the second and first floor, and they use the rails as a safety enabler so they can ambulate from one part of the facility to another. On 2/25/2026 at 2:20 p.m. an interview was conducted with Staff C, Maintenance Technician. Staff C revealed there was a process for work orders that included checking if there were any problems with the handrails. He revealed that he and other maintenance staff will try to look at all handrails daily and will pull on them to see if they were secure. Staff C did not have any documented evidence this was conducted daily, weekly, monthly or yearly. Staff C revealed if a staff member noted handrails were loose and not secured to the wall safely, they are to report it via a hand written work order form and it will get to the maintenance department for correction. Staff C confirmed there were loose wall handrails but stated not previously being aware of loose handrails. On 2/25/2026 at 3:00 p.m. an interview was conducted with the Nursing Home Administrator (NHA) about the handrails maintenance and how often they are observed for safe use. She confirmed maintenance department was responsible for the maintenance of the handrails and staff are to report any non-maintained handrails as they see them. The NHA stated they did not have any documentation to support handrails were audited for safety and maintenance. The NHA stated the facility did not have a specific handrail policy and procedure for review. She said, However, all handrails should be tightly affixed to the wall as residents do utilize them throughout the day/night for ambulating. 2. On 2/23/26 at 9:32 a.m., an observation of the one west hallway revealed a resident was ambulating in a wheelchair while holding onto the handrail with their right hand. While the resident was holding the handrail, the hand rail separated off the wall and was observed in their hands. Staff A, Registered Nurse (RN) was observed saying she would call maintenance.A facility policy related to handrails was requested. The facility did not provide a policy. (Photographic Evidence Obtained)

Based on observations, record review, and interviews, the facility failed to notify the Power of Attorney (POA) of a change in condition related to weight loss for one resident (#41) out of five residents reviewed for nutrition. Findings included: Review of the admission record revealed Resident #41 was admitted to the facility on [DATE] and was readmitted on [DATE]. Review of the advance directives revealed Resident #41had a medical and financial decisionmaker/ Power of Attorney (POA) to make his decisions. The medical diagnosis sheet revealed diagnoses to included but not limited to muscle weakness, quadriplegia, contracture of muscle unspecified on upper arm, need for assistance with personal care, contracture lower leg, disorder of bone density, and structure, dysphagia, protein calorie malnutrition, and gastrostomy.Review of the physician's orders for the month of 2/2026 revealed; Diet Order - NPO (nothing by mouth); Enteral feeding Jevity 1.5 75 ml (milliliters) per hour for 1500 liters bid (twice daily) start at 2 p.m.Review of the Minimum Data Set (MDS) assessment (5-day) dated 2/9/2026 revealed; a Brief Interview Mental Status (BIMS) score was not scored, but revealed short term memory problem, and long-term memory ok. Section GG showed the resident was dependent on staff for all ADLs (activities of daily living). Review of Resident #41's medical record on weight/vitals revealed the following weights:On 12/27/2025, 1/13/2026 and 2/10/2026 the resident weighed 195 lbs. (pounds).On 2/17/2026 he weighed 180 lbs.On 2/24/2026 he weighed 176 lbs.The record review revealed Resident #41 began losing weight as follows: 5 lbs. from 1/24/2026 to 2/10/2026, 10 lbs. from 2/10/2026 to 2/17/2026 and 4 lbs. from 2/17/2026 to 2/24/2026. Resident #41 lost a total of 19 lbs. between 1/24/2026 to 2/2/2026, a 7.37% weight loss in one month. On 2/22/2026 at 9:14 a.m. Resident #41 was observed in his room and lying in bed. Resident #41 was observed receiving nourishment via a tube feed system. The resident did not respond to the interview. An interview was conducted with Resident #41's family member/POA on 2/22/2026 at 9:35 a.m., and on 2/24/2026 at 9:15 a.m. The POA confirmed she is and was involved with his care and services and attends care plan meetings with the interdisciplinary team. She stated Resident #41 has been in and out from the Hospital several times the past month for other medical reasons and that he has been declining both physically and cognitively the past few months. The POA revealed she was not aware of any weight loss, much less than 5% or greater. The POA stated she had not been in contact with the facility's Registered Dietitian (RD) with relation to risk for weight loss and nutritional parameters. The POA confirmed she would be the person to be notified of changes, and she had been notified in the past of other changes, just not related to weight loss.Review of the nurse progress notes and dietary assessments from 2/07/2026 through 2/25/2026 revealed the following: On 2/17/2026 an IDT care plan review was conducted, invite sent no attendance. Current medication reviewed; no changes required at this time. Resident's weight reviewed (181), weight loss noted. Significant changes or new concerns noted. Nutrition status assessed and continues to meet resident needs are being followed by wound care for left buttocks and left leg. Current plan of care remains appropriate and will be continued. Plan to be reviewed at next scheduled quarterly review or as clinically indicated.On 2/24/2026 a nutrition/dietary note revealed - Resident with additional wt. (weight) loss which warrants adjustment of tube feeding support increase at this time. Currently being provided with Jevity 1.5 at 75 ml/h for total daily volume infusion of 1500 mLs. daily along with 30ml Prostat 2x/day via Peg. Will continue to monitor and provide additional recommendations as indicated pending clinical course. On 2/27/2026 a nutrition/dietary assessment was completed by the Registered Dietitian which revealed - Resident #41 has had weight loss with new interventions to decrease weight loss and increase weight.The documentation did not show Resident #41's POA was made aware of the weight loss/significant weight loss.On 2/25/2026 at 9:15 a.m. an interview with the Registered Dietitian was conducted. The RD stated he had completed various admission/readmission nutrition assessments for Resident #41 and that he had multiple hospitalizations. The Registered Dietitian confirmed Resident #41 was currently being monitored and cared for related to a significant weight loss and he had not spoken with nor attempted communication with Resident #41's POA related to the weight loss. The Registered Dietitian confirmed this would be a significant weight loss and the POA should have been notified.On 2/25/2026 at 10:00 a.m. an interview with the facility's Director of Nursing (DON) confirmed Resident #41 has had a significant weight loss within the past one month and that he has had multiple hospitalizations that could have contributed to losing weight. She stated the Registered Dietitian had been working with Resident #41 in order to increase his weight back in an upward trend and should have also contacted his POA with relation to the change of condition. The DON confirmed the POA should have been contacted of the significant weight loss. On 2/25/2026 at 4:00 p.m. an interview with the facility's Nursing Home Administrator (NHA) revealed she did not have a specific notification of change policy and procedure but confirmed anytime there is a change of condition to include a resident's significant weight loss, the health care representative is to be notified of the change.

Based on observation and interview, the facility did not ensure a clean and home-like environment in two resident rooms (103 and 201) out of 25 rooms observed, and in one shower room (West Unit) of two observed.Findings included: On 2/22/26 at 9:38 a.m., an observation of the floor in room [ROOM NUMBER], by the resident's bed and bedside table, revealed a cockroach crawling next to the call light located on the floor. On 2/22/26 at 12:18 p.m., an observation of room [ROOM NUMBER] revealed the floor, between the resident's bed and dresser, had a large hole with wood and unidentifiable material exposed, as well as pieces of tile missing. Further observations of room [ROOM NUMBER] revealed the area under the sink had a large hole, that exposed pipes and wood, and cracked tile pieces. The area under the sink revealed multiple pieces of painter's tape that separated from the wall and a clear, thin sheet of plastic material was covering approximately half of the hole. The room further revealed a white dresser located against the wall with a long-broken piece of wood that was separated from the bottom area. An observation of the area surrounding the air conditioning (a/c) unit by the window revealed wood that was eroded and multiple areas with missing paint leaving the wood underneath exposed and bare. On 2/23/26 at 9:30 a.m., an observation of the bathroom/shower room next to room [ROOM NUMBER] revealed the toilet seat as well as the bar underneath had multiple black spots on it. Further observations of the shower area showed a small ledge on the floor had missing tile that exposed hardened, unidentifiable material underneath.On 2/25/26 at 5:15 p.m., an interview with the Nursing Home Administrator (NHA) revealed the facility was completing renovations to include replacing floor surfaces and resident room furniture, re-painting resident room walls, and repairing windowsills and window frames. She said the renovations were completed on the first-floor resident rooms and halls, and currently the facility is working on replacing floors on the second floor. The NHA confirmed she did not have documentation to show when the renovation was identified, as well as purchase orders and timeframes of completion. She said she was not aware of any environment-related concerns in room [ROOM NUMBER].On 2/25/26 at 6:00 p.m., a follow-up interview was conducted with the NHA. She said she verified the concerns in room [ROOM NUMBER] to include the windowsill and window frame, paint that was peeled away from the window frame, the bottom of the dresser door in disrepair and the area under the sink. The NHA said the resident will move out of room [ROOM NUMBER] until the environmental issues are corrected. She said she was not aware of the resident bathroom/shower rooms with flooring and tile concerns and the black spots on the toilet seat. She said that was something the maintenance department and housekeeping should have identified and corrected. The NHA confirmed she was not aware of and did not have documentation of work orders submitted for room [ROOM NUMBER] and the one west bathroom/shower area. A review of the daily work routine for the housekeeper revealed the following: .7:30 AM - Clean 1E[east]/1W[west] Nurse Station, Bathrooms, Hoppers . (High/Low Dusting , sinks, counters, trash cans, baseboards, corner and edges, wall . 1:35 PM - Continue cleaning Bathrooms, Hoppers . A facility policy related to a clean and home-like environment was requested. The facility did not provide a policy. (Photographic Evidence Obtained)

Based on record review and staff interview, the facility failed to complete/update the Pre-admission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for one resident (#5) of 52 residents reviewed for PASARRsFindings included:Review of the admission record showed Resident #5 was admitted to the facility on [DATE] with a primary diagnosis of dementia. Other diagnoses included Parkinsonism, mood disorder, depression, psychosis and cognitive communication deficit.Review of a level I PASARR for Resident #5 dated 9/11/25 revealed a completed Level I PASARR with qualifying diagnoses. The review showed the Level I PASARR was complete, and a level II was not submitted for consideration following qualifying diagnoses.During an interview on 2/25/26 at 12:46 p.m. Staff A, Social Service Director (SSD) said Resident #5 did not need a Level II PASARR because the resident is functioning, able to explain everything going on and not refusing psychology services. She said if a resident was refusing care, services, medications or trying to harm themselves would be indication for a PASARR Level II referral. The SSD confirmed mood disorder and psychosis are serious mental illness diagnosis and said Resident #5 is high functioning. Review of the facility's policy titled PASRR Pre-admission Screen and Annual Review, revised 7/13/25 showed the following:POLICY: It is the policy that all residents must have a PASRR Screen upon admission to [Name of Facility]. In addition, any residents who have been previously identified through the PASRR process as having Serious Mental Illness and/or Intellectual Disability and have experienced a significant change in status will then require a new Patient Review Instrument (PRI) and SCREEN. If triggered, a new Level Il PASRR evaluation will be done.RESPONSIBLE PARTY: Social Services and Nurse Managers (RN)PROCEDURE: 1. Prior to admission, a PASRR Screen is completed from a qualified Screener. The SCREEN is placed in the medical record/resident's chart. If the resident had triggered for a Level Il, the determination and/or Mental Health Evaluation Report become part of the medical record. A copy of the determination and/ or new Mental Health Evaluation Report is also kept in the Social Services office. 2. All residents who qualify for a Level Il with Mental Illness will be referred to [State designated provider] .

Based on observation, interview, and record review, the facility failed to ensure activities of daily living (ADLs) related to nail care were provided for one resident (#9) out of three residents sampled.Findings included:On 02/22/2026 at 12:55 PM, Resident #9 was observed to have brown and red substances underneath the fingernails. Resident #9's fingernails were about half an inch past the fingertips.Review of Resident #9's medical record revealed diagnoses of cerebral infarction, unspecified, muscle weakness (generalized), hereditary and idiopathic neuropathy, unspecified, other lack of coordination, and acquired absence of left and right legs above knees.Review of Resident #9's medical record revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitive function was intact with little to no memory or thinking impairment.A review of Resident #9's ADL sheets did not show documented refusals of personal hygiene care for the month of January 2026. The ADL sheets for the month of February 2026 were not provided for review.A review of Resident #9's shower assessment sheets for December 2025 and January 2026 revealed fingernails were clean and did not need to be clipped on 12/11/2025, 12/15/2025, and 01/08/2026. On 12/22/2025 and 12/25/2025, Resident #9's fingernails were clean and documentation showed, needed to be clipped.Review of Resident #9's care plan revealed a focus area for requiring substantial to total staff assistance for ADL care needs related to generalized weakness and bilateral above the knee amputation. The interventions implemented included - Allow rest period between tasks as per needs, assist resident with ADL care as needed, break tasks into smaller steps to encourage self-tasks, give verbal cues as per resident's needs, keep call light within reach, and physical therapy and occupational therapy as per resident's needs and orders.During an interview on 02/23/2026 at 1:45 PM, Staff N, Certified Nursing Assistant (CNA), stated the personal hygiene care typically provided to residents is changing briefs, feeding assistance, nail trimming in the morning or afternoon during showers, hair washing, or bathing. Staff N stated if a resident refused ADL or personal hygiene care, Staff N would tell the resident's nurse, and the nurse would make attempts to provide the care. Staff N stated having never trimmed Resident #9's nails. Staff N observed Resident #9's nails and stated they were long and stated an intention to provide nail care on 02/23/2026. Staff N said it was a CNA's responsibility to trim a resident's nails. An interview was conducted on 02/24/2026 at 12:28 PM with Staff O, CNA. The interview revealed Resident #9 does not have any known refusals of care. Staff O said nail care is often provided for residents on Sundays as a part of interactive activities and residents should be provided with personal hygiene care every day. Staff O said Resident #9's nails are observed throughout the shift but Resident #9 is often very fatigued after dialysis, and requests to delay persona hygiene care until the following day. Staff O stated CNAs documented showers and personal hygiene care on paper shower sheets. An interview conducted with Staff A, Registered Nurse (RN), on 02/24/2026 at 12:35 PM. Staff A said CNAs are responsible for incontinence and personal hygiene care. Staff A said Resident #9 required set up and assistance with personal hygiene care. Staff O said Resident #9's nails were observed and could be cleaned and clipped. Staff O said nail care should be documented and provided during showers. An interview conducted with the Director of Nursing (DON) on 02/24/2026 at 1:21 PM revealed all residents should be washed, receive oral care, and hair care every morning. The DON said CNAs should document the care they provided for a resident once per shift. The DON said the paper shower sheets are used to document a resident's behaviors, pain, skin condition, and grooming. The DON said paper shower sheets do not specifically document nail care. The DON said if a resident refused personal hygiene care, it should be documented and the nurse should be alerted. The nurse should then attempt to provide the resident with personal hygiene care and educate them on the importance of receiving personal hygiene care. The DON said she did not observe Resident #9's nails and was unsure of the history of refusals.The facility did not provide a policy and procedure for ADL care.

Based on observation record review and interview, the facility failed to ensure physician orders for oxygen were followed for one resident (#24) out of two residents sampled and failed to ensure the resident had physician orders for oxygen use for one resident (#54) out of two residents sampled.Findings included: 1. On 02/22/2026 at 12:00 PM, Resident #24 was observed to have an oxygen concentrator set to a four-liter (L) flow rate. Resident #24 said the concentrator was set to a flow rate of four or five.A review of Resident #24's medical diagnoses revealed chronic obstructive pulmonary disease (COPD), unspecified, COPD with (acute) exacerbation, acute and chronic respiratory failure with hypoxia, centrilobular emphysema.A review of Resident #24's order summary report revealed an order to check oxygen saturation levels as needed and oxygen at 2L (liters) per minute via nasal cannula every shift related to COPD with (acute) exacerbation.An interview with Staff N, Registered Nurse (RN) on 02/24/2026 at 12:43 PM revealed Resident #24 had orders for oxygen via nasal cannula set at a 2L flow rate for COPD. Staff N said the settings on Resident #24's oxygen concentrator were observed this morning at 2L, and the resident does not like the flow rate to be any higher due to comfort. On 02/24/2026 at 1:00 PM, Staff N observed that Resident #24's oxygen concentrator was set to a 4L flow rate. Staff N immediately adjusted the flow rate to 2L.An interview with the Director of Nursing (DON) on 02/24/2026 at 3:46 PM revealed there was an order for oxygen set at 2L for Resident #24. The DON said if staff notices an oxygen concentrator is not set to the flow rate that is ordered, they should immediately return the oxygen concentrator to the ordered flow rate and investigate how the concentrator was adjusted. The DON said that Resident #24 was alert and oriented and should have been able to explain how the oxygen concentrator became set to a flow rate that was different than the physician ordered flow rate. 2. On 02/22/2026 at 12:26 PM, Resident #54 was observed wearing a nasal cannula with an oxygen concentrator set at a flow rate of 3L. A review of Resident #54's order summary report dated 2/24/2026 revealed the resident did not have physician orders for oxygen. or a care plan for oxygen.A review of Resident #54's admission record revealed an admission date of 02/04/2026 with diagnosis to include pneumonia, unspecified organism, unspecified atrial fibrillation, heart failure and essential hypertension.An interview with Staff N, RN on 02/24/2026 at 12:54 PM revealed an inability to produce orders or a care plan related to oxygen therapy for Resident #54. Staff N said Resident #54's oxygen concentrator was set to a flow rate of 3L.Staff N, RN said Resident #54's orders needed to be corrected and then notified the DON. At 1:00 PM on 02/24/2026, Staff N observed Resident #54's oxygen concentrator was set to a flow rate of 3L.An interview was conducted with the DON on 02/24/2026 at 3:46 PM regarding the observation of Resident #54 wearing a nasal cannula in a photo taken by the facility. The DON stated they could not confirm or deny if Resident #54 was wearing a nasal cannula upon arrival to the facility. The DON said according to Resident #54's admission screening on 02/04/2026, the resident was admitted to the facility with hospital orders for oxygen set at a flow rate of 2L via nasal cannula and was not in any respiratory distress upon admission. The DON confirmed Resident #54's orders did not reveal an order for oxygen. The DON did provide paper orders for oxygen for Resident #54.A follow -up interview was conducted with the DON on 02/24/2026 at 3:46 PM. The DON stated a resident would not experience negative physiological effects as a result of receiving an oxygen flow rate that is higher than the physician ordered flow rate unless the flow rate is above 5L. The DON said that education should be provided to staff on duty to verify the settings on residents' oxygen concentrator during morning medication passes. Review of a facility policy titled, Oxygen Therapy, dated 1121/24 revealed - Ordering oxygen therapy is critical process that requires careful consideration of various factors. The healthcare provider must assess the resident's condition, including their oxygen levels and specific respiratory needs. The oxygen therapy is not a one-size-fits all approach. It must be tailored to each individual's needs. Monitoring oxygen is another crucial aspect of its management, regular monitoring allows healthcare providers to Assess the effectiveness of the treatment and make necessary adjustments. This involves checking the residents oxygen levels, observing their response to the therapy, and adjusting the oxygen. It's important to note that the goal of oxygen therapy is not just to increase oxygen levels in the blood but also to improve the residents overall health and quality of life.

Based on observations, record reviews, and interviews the facility failed to ensure a medication error rate of less than 5.00%. Thirty-three medication administration opportunities were observed, and two errors identified for two (#49 and #92) of five residents observed. These errors constituted a 6.06% medication error rate.Findings Include:On 2/24/2026 at 11:15 a.m. an observation of medication administration with Staff B, Licensed Practical Nurse (LPN) conducted with Resident #49. Staff B, LPN performed HH, removed an Novolog FlexPen injector pen from the medications cart. She verified the insulin type/expiration, attach a new needle and turned the dosage dial to administer 4 units. Cleaned the insertion site with alcohol and let it dry and administered the medication.Review of Resident #49 medication orders revealed an order for Novolog FlexPen 100 unit/ml inject as per sliding scale: if 150-199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 6 units; 300 - 349 = 8 units ; 350 - 399 = 10 units, subcutaneously with meals for Diabetes Mellitus (DM) greater than 400, please notify providerReview of the Novolog FlexPen manufacturer instructions for use show the following steps: 1. Check pen, 2. Attach a new needle, 3. Prime pen (turn the does selector to 2 units, press and hold the dose button, make sure a drop appears) 4. Select the dose, 5. Inject the dose .https://www.novonordisk.com/content/dam/nncorp/global/en/our-products/pdf/flextouch/FlexTouch-generic-injection-guide.pdf retrieved on 2/26/2026.During an interview conducted after administering the medication, Staff B, LPN, said she was nervous and acknowledged that the insulin pen should be primed.On 2/24/26 at 8:51 a.m. an observation of medication administration with Staff F, Licensed Practical Nurse (LPN) was conducted with Resident #92. Staff F, LPN administered the following medications -Aspirin 81 mg -Midodrine Hydrochloride 5 mg-Roflumilast 500 mcg-Prednisone 10 mg-Bumetanide 1 mg -Allopurinol 100 mg-Potassium Chloride ER 20 milliequivalents (Meq)-Dapagliflozin 10 mg-Guaifenesin 600 Mg and Dextromethorphan 30mg tabletA review of Resident #92's order summary report dated 2/24/26, showed orders for the following medications:-Aspirin 81mg daily-Midodrine Hydrochloride 5 mg three times daily hold If systolic blood pressure Is greater than 130-Roflumilast 500 Mcg daily-Prednisone 10 mg daily-Bumetanide 1 mg daily-Allopurinol 100 mg daily-Potassium Chloride ER 20 Milliequivalents (Meq) daily-Dapagliflozin 10 mg daily-Guaifenesin ER 600 mg two times daily.On 2/25/26 at 8:20 a.m., during an interview, the Director of Nursing (DON) said new orders are received for over-the-counter medications, staff are required to notify the physician of any medications currently on hand and obtain a corresponding order. She said staff are expected to prime the insulin injector pen prior to administration. (Photographic Evidence Obtained).Review of facility policy titled Medication Administration Policy showed the following: POLICY: Medications will be administered to residents as prescribed and by persons lawfully authorized to do so in a manner consistent with good infection control and standards of practice. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication.PREPARATION: . 2.Prior to administration, the medication and dosage schedule on the MAR is compared with the medication label. If the label and the MAR are different the physician's orders are checked for correct dosage schedule.

Based on observation, record review, and interviews, the facility failed to implement an accurate and up to date system for the accounting of residents' personal funds entrusted to the facility for three (#3, #5, and #6) of three residents sampled for resident funds review. Findings included: Review of accounts records for Resident's #3, #5 and #6 showed the residents' cost of care being withdrawn from their personal funds account did not consistently match what the Medicaid Access eligibility had determined, and Social Security direct deposits for January and February 2025 were not reflected in the accounts. On 02/19/2025 at 10:23 a.m. Resident #6 was observed in her room and she agreed to an interview. During the interview, she stated she had a concern with her resident trust fund, the monies held by the facility. She said, I am not sure if my balance is accurate. A couple of months ago they took a two-month payment at one time and then no payment for my room and board bill. I worry if I have enough money there. On 02/19/2025 at 1:30 p.m. a telephone interview was conducted with Resident #3's representative. She stated she believed there was some kind of fraudulent activity going on with Resident #3's patient trust account. She stated they went in and took 500 dollars out of it, I told them to stop. Review of a grievance filed for Resident #5, dated 02/13/2025, documented Request RFMS (Resident Funds Management System) report thru (through current accounting). An interview with the Nursing Home Administrator (NHA) on 02/19/2025 at 12:50 p.m., when asked the reason for the grievance, she said, it was just a request for his fund transactions. We gave them the statement, that was when we noticed the cost of care payment of $3015.60 withdrawn from Resident #5's account, it did not make sense. The RFMS system is not accurate. Review of Resident #5's admission record showed an admitted ,d+[DATE], with the resident currently residing in the facility. Resident's payor source was listed as Medicaid. Review of Resident #5 's Medicaid Access system print out listed the patient liability - room and board cost to be $1,790.60 per month for 2024 and $1838.60 per month for 2025. Review of Resident #5's Resident Fund statement for 06/2024 through the date of survey, 02/19/2025, revealed: Review of 2024 records showed Resident #5 had a Social Security income of $1948.00 per month. For 2025, no direct deposit of Social Security income was listed for January or February. The Cost of Care charges showed: 06/18/2024=1,790.60 07/24/2024=1,790.60 08/30/2024=1,790.60 09/19/2024=3015.60 10/31/2024=1,790.60 11/20/2024=1,790.60 12/18/2024=1,790.60 No further cost of care listings were listed through 02/19/2025. Review of Resident #3's clinical chart, the Admission Record documented an admission of 08/2023, with the resident currently resident in the facility. Resident's payor source was Medicaid. A review of the Medicaid Access system print out which listed the patient liability (room and board cost) for Resident #3 to be $1,199.64 per month for 2024 and $1240.64 per month for 2025. Review of Resident #3's Resident Fund statement for 01/2024 through the date of survey, 02/19/2025 revealed: Resident #3, during 2024, had a Social Security income of $1626.00 per month. For 2025, no direct deposit of Social Security income was listed for January or February. For Cost of Care charges, the review showed: 01/10/2024=1,307.00 02/23/2024=1,307.00 04/04/2024 (March)=1,307.00 04/16/2024=1,307.00 05/17/2024=1,233.48 06/18/2024=1,199.64 07/24/2024=1,119.64 09/19/2024=2,399.28 10/31/2024=1,199.64 11/20/2024=1,899.28 12/18/2024=1199.64 No further cost of care listings were listed through 02/19/2025. Review of Resident #6's admission record documented an admitted ,d+[DATE], with the resident currently resident in the facility. Resident's payor source was listed as Medicaid. Review of the Medicaid Access system print out which listed the patient liability (room and board cost) for Resident #6 to be $2121.69 per month for 2024 and $2177.82 per month for 2025. Review of Resident #6's Resident Fund statement for 01/2024 through the date of survey, 02/19/2025 showed: Resident #6, during 2024, had a Social Security income of $1231.00 per month. For 2025, no direct deposit of Social Security income was listed for January or February. For Cost of Care charges: 01/10/2024=2100.00 02/23/2024=2188.69 04/04/2024 (March)= 2188.69 04/16/2024=2188.69 05/17/2024=2188.69 05/30/2024=3000.00 06/18/2024=2188.69 07/24/2024=2188.69 08/30/2024=2121.69 10/31/2024=8000.00 11/20/2024=2121.69 12/18/2024=2121.69 12/23/2024 (debit)=2121.69, unknown charge 01/30/2025=2177.82 No further entries were noted The review of records for Resident #3, #5, and #6 revealed the cost of care charges for the three residents was not consistent with the patient liability determined by Medicaid Access. An interview was conducted with the Nursing Home Administrator (NHA) on 02/19/2025 at 12:20 p.m. regarding the RFMS (Resident Fund Management System) print outs of the resident trust fund transactions. She stated the printouts were not accurate. She stated the Business Office Manager had been a contracted person who had come in once a week to handle the resident trust accounts and had left the position the preceding week to the survey. No person was currently in the BOM position. The NHA said she had formulated a Performance Improvement Plan (PIP) for the RFMS. During the interview, the NHA was requested to share the PIP. During the survey, 02/19/2025, no further information was provided to the survey team as to any corrective action the facility had implemented for the irregular debits and credits within the resident trust fund accounts. Requested but did not receive a facility policy on accounting of resident's personal funds.

Based on record review and interview, the facility failed to ensure personal funds deposited with the facility were conveyed to the resident or resident representative within thirty days after discharge or death for three (#4, #7, #8) of three residents sampled for return of funds in a timely manner. Findings included: On 02/19/2025, the facility provided a list of residents with personal trust fund accounts. During the review of the list provided, three residents were sampled for conveyance of funds, Resident #4, #7, and #8. Review of the facility's Resident Fund Management Services (RFMS), listing the following residents and resident fund balances as of 02/19/2025: Resident #4, with a balance of $3, 814.35. Resident #7, with a balance of $1,470.59. Resident #8, with a balance of $340.54 Review of Resident #4's clinical chart the admission record, documented an initial admission of 04/17/2020, readmission of 11/01/2024; and a discharge to the community on 12/17/2024. Review of Resident #7's clinical chart, the admission record, documented an admission of 12/09/2021, and discharge date of [DATE]. Review of Resident #8's clinical chart, the admission record, documented an admission of 09/24/2024, and discharge of 10/04/2024. On 02/19/2025 at 12:20 p.m. an interview was conducted with the Nursing Home Administrator (NHA). She stated the RFMS information was not accurate but provided no alternative information regarding the balances listed. The NHA was asked to provide a policy for conveyance of personal funds. No policy was provided during the survey.

Based on observation record review and interviews, the facility failed to ensure adequate management of tube feeding services for two (#1 and #9) of two sampled tube fed residents out of a total of nine sampled residents related to inaccurate dating of enteral product, non-labeling of product type, rate and time of administration. Findings included: 1. Review of Resident #1's admission record documented an admission of 04/02/2022 and readmission of 06/12/2024. The diagnosis list included but not limited to: Cerebral infarction; chronic atrial fibrillation; aphasia following cerebral infarction; unspecified dementia, unspecified severity without behavioral disturbance psychotic disturbance, mood disturbance; lack of coordination. Review of Resident #1's Care Plan documented a focus - Resident is dependent upon a feeding tube to meet nutritional and fluid needs due to (d/t) dysphagia. The interventions included: Provide feeding and H20 flushes per orders. Review of Resident #1's Tube Feeding & Flushes Flow Record for 02/2025 reflected the following physician orders: -Between 10am & 2pm-flush the G-Tube every hour with 30 ML (milliliter) water The flow sheet had no documentation that indicated staff performed the service on 02/01, 02/02, 02/03 for 10 a.m., 11 a.m., 12 p.m., 1 p.m. and 2 p.m. and on 02/04 and 02/05, no documentation for the 2 p.m. flush. -Provide 200 ML flush every 6 hours (800 ML/Day) The flow sheet had no documentation for 02/01, at 12 p.m. and 6 p.m.; 02/11 at 12 p.m. and 6 p.m.; for 02/14 at 12 a.m. and 6:00 a.m. -Jevity 1.5 @ 45 ML/hour for 20 hours via G tube 10 a.m. off, 2 p.m. on The flow sheet had no documentation for 02/01 02/11. On 02/19/2025 at 2:43 p.m. A review of Resident #1's Tube Feeding & Flushes Flow Record for 02/2025 with the Director of Nursing (DON) was conducted. When the DON was asked about the blanks in the record, she stated she did not know why staff had not initialed. On 02/19/2025 at 2:49 p.m., an observation was conducted with the DON of Resident #1's tube feeding set up. The machine was not on. Resident #1 was observed in bed. An observation of the bag with tube feed product was conducted. No product name was present on the bag. The resident's name, room number, and date of 02/19/2025 was on the bag. No time was documented on the bag or rate. The bag was full with product up to the 1000 mark. An interview was conducted on 02/19/2025 at approximately 2:50 p.m. with Staff A, Licensed Practical Nurse. She stated she was coming on shift and had worked the day before. She stated she had hung the bag at 6:00 a.m. this morning (02/19/2024). She reported the product in the bag was Jevity. When asked why the product had been transferred from the original packaging to the hanging bag, she stated it was a tubing issue, that the spike tubing for the Jevity bottle on the 2nd floor was not available; she said she had completed the hanging process as the preceding nurse had not completed it. 2. Review of Resident #9's admission record documented an admission of 01/29/2025. The diagnosis list included but not limited to Gastrostomy status and bed confinement status. Review Resident #9's chart, a physician telephone order, dated 01/30/2025: Jevity 1.5 @ 60 ml/ hr. for 20 hrs. & Flush 150 ml every 4 hours. Review of Resident #9's Care Plan, Focus area: The resident has nutritional problem r/t (diagnosis), limited mobility, NPO (nothing by mouth) status, enteral nutrition to meet nutritional needs, colostomy. On 02/19/2025 at 9:57 a.m., Resident #9 was observed in bed watching television. Resident #9 was observed to have a tube feeding set up next to her bed. The food product bottle, Jevity, was observed to be empty. The label on the bottle had areas for staff to put the patient's name, room number, date, start a.m. or p.m. and rate. The rate was blank, documented was the name, room number, hung on 02/18 at 14:10. On 02/19/2025 at 3:05 p.m., a review of Resident #9's tube feeding set up was reviewed with the DON. The bottle in place on the stand, Jevity 1.5 calorie, was observed to be full of product, up to the 1000 mark; had Resident #9's name, room number, 02/18 for the date hung, no time, and no rate. Review of the facility's policy and procedure for Enteral Tube Management revised on 11/2024, included - The nurse's responsibilities when caring for a patient with an enteral tube include the following: Assessing the tube placement and patency Assessing and cleansing the insertion site Administering tube feeding Administering medication Irrigating/flushing the tub Suctioning the tube Monitoring for complications (Photographic Evidence Obtained)

Based on record review and interview, the facility failed to ensure a prompt resolution to a grievance for one (#3) of nine sampled residents. Findings included: An interview was conducted on 02/19/2025 at 12:27 p.m. with the Social Service Director (SSD). A review of three grievances for Resident #3 was conducted. The SSD stated, one grievance, received on 11/18/2024, the (resident's representative) wanted the phone bill paid for Resident #3. The (resident's representative) was upset that the bill was not paid. The representative communicated to the business office who said they were going to pay the bill. The representative tracked the phone bill, and it was not paid. Further review of the grievance form reflected the former Nursing Home Administrator (NHA) had signed that the bill had been paid and the grievance resolved on 11/26/2024. The SSD stated, the next grievance received on 12/16/2024, the (resident's representative) was upset because the phone bill was not completely paid. Review of the grievance form reflected the former NHA signed the grievance as completed on 12/18/2024. The SSD stated, the next grievance was received on 02/01/2025, the (resident's representative) was upset because she had been told to pay the bill, and she would be reimbursed. A review of the grievance log reflected the grievance had been resolved on 02/07/2025. An interview was conducted on 02/19/2025 at 12:50 p.m. with the Nursing Home Administrator, she said she had just spoken to the owners of the facility and Resident #3's representative will be reimbursed by the end of the week for the bill. A phone interview was conducted with Resident #3's (representative) on 02/19/2025 at 1:30 p.m. She said, they are not paying Resident #3's phone bill. She said, I have paid it, and they have not reimbursed me. They are not responding to me. The social worker is writing it all down. I am very frustrated. Review of the facility's Resident Grievance Policy & Procedure, revised 06/12/2023, documented the policy: It is the policy of [name of facility] to provide an opportunity and a method for all residents, visitors, or designated representative to express grievances and complaints free of interference, coercion, discrimination, and/ or reprisal It is the policy that all complaints and grievances be addressed in a timely manner.

Based on record review and interview the facility failed to ensure the Dietary Manager met the mandatory minimum qualifications for the Dietary Manager position. Findings included: Review of the Dietary Manager's qualifications revealed the Dietary Manager (DM) was not [Food Certification Service] qualified and was not certified as a dietary or food service manager. During an interview on 12/20/23 at 11:09 a.m., The Dietary Manager (DM) stated I have been working as the Dietary Supervisor for three months now. The DM stated prior to being DM, I was a cook here since 2016. The DM stated she did not have an associate degree in food service or hospitality, and was not certified in food management but was working on obtaining the [Food Certification Service] certification. The DM stated she had a lot of experience working in dietary. The DM stated she attempted the [Food Certification Service] when she first started the DM job on 09/01/23, but did not pass it the first time and took the exam again a week later and was unable pass it again. The DM stated the online site would not allow her to re-take the test again until beginning of January 2024. The DM stated that her plan was to start studying after the New Year and take the [Food Certification Service] test for her certification after the new year. During an interview on 12/20/23 at 3:00 p.m., the Administrator stated the Dietary Manager should have [Food Certification Service] completed or be certified at the very least. The Administrator stated that since being Administrator at the facility for about five weeks now that she had no idea that the DM was not certified or had the appropriate training. The Administrator stated that starting 01/15/2023 [an outside contracted dietary service] would be coming in to take care of food services. Review of the facility's Dietary Manager Job Description showed, Dining Services Manager in Training Assist in ensuring that established sanitation and safety standards are maintained. Assist in overseeing and participating in the preparation and serving of food. Must be able to perform the essential job functions or dietary aids, cook and dishwasher positions. All other duties assigned. Qualifications: High school diploma or equivalent is required. Specialized training in dining services management and nutrition is desirable. Must successfully complete an approved sanitation and safety course. Knowledge, Skills and Abilities: Certificates- Food Safety Manager or Food handler Certification: Current [Food Certification Service] or State Certification Licenses: Acceptable minimum equivalent experience in place of degree: 2 years. There is no replacement for Federal/State/County required certifications/training. A review of the facility's policy titled, Preventing Foodborne Illness- Food Handling revised date July 2014 showed, 3. All employees who handle, prepare and serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food and serving food to residents.

Based on observations and interviews the facility failed to ensure the environment was clean and free from bio-growth for one Hopper Room (East Hallway on the 1st Floor) of four Hopper Rooms observed in the facility. Findings included: An observation on 12/18/23 at 4:00 p.m., revealed a musty like smell in the air on the first floor East Hallway of the facility. An observation on 12/18/23 at 4:25 p.m., revealed a room designated as the Hopper Room on first floor East Hallway. The musty smell was stronger in this area. The Hopper Room was observed to have bio-growth up the walls of the room and also had a big patch of bio-growth on the ceiling. (Photographic Evidence Obtained). During an interview on 12/18/23 at 4:35 p.m. the Maintenance Director (MD) stated he had issues with bio-growth on East Hallway at the First floor Nurses Station before but it was fixed. The MD stated he was unaware of any bio-growth in the facility right now. The Hopper Room East Hallway on the First Floor door was opened and MD stated, I never look in there and then stated there must be a leak to cause the substance to grow on the walls. The MD was asked to confirm bio-growth was present in the Hopper Room and MD stated he was not an expert and would not confirm anything. The MD was asked if he saw the bio-growth on the walls and ceiling and MD stated, There is something there. The MD stated he would have to have the bio-growth tested and may need to have a third-party company to come in to remove the bio-growth again. During an interview on 12/18/23 at 4:40 p.m., the Administrator stated she had never opened the doors to the Hopper Rooms in the facility and didn't know if the rooms were even used. During an interview on 12/19/23 at 9:50 a.m., Staff A, Certified Nursing Assistant (CNA) stated, I use the Hopper Room to dump all Residents' #1 and #2. Staff A CNA stated the Hopper Room was used regularly for Residents' waste. Staff A CNA was asked if she was aware of any bio-growth in the Hopper Room and Staff A CNA stated, I do not speak English that well, I do not understand. During an interview on 12/20/23 at 5:00 p.m., the Administrator stated the facility had called an outside company to come in and test the bio-growth. The Administrator stated an outside company tested the air quality and swabbed the bio-growth. The Administrator stated the facility was now waiting for the results to determine how to get rid the bio-growth correctly.

Based on observations, record reviews, and interviews the facility failed to ensure food was held at a safe and appropriate holding temperatures prior to food tray distribution. The failed practice had the potential to affect 67 of 69 residents in the facility: Findings included: During an interview on 12/19/23 at 11:45 a.m. Staff B, Cook stated hot foods should be held above 150 degrees Fahrenheit and cold foods should be held under 41 degrees Fahrenheit. Staff B, Cook proceeded to check the temperatures of the food to be served for lunch. An observation on 12/19/23 11:45 p.m., showed Staff B, Cook completed a temperature check on all the food being served to residents. The food items/temperatures included: Hamburger- 150 degrees Fahrenheit French Fries- 154 degrees Fahrenheit Puree Broccoli- 140 degrees Fahrenheit Puree Beef- 140 degrees Fahrenheit Puree bread- 140 degrees Fahrenheit Mush- 150 degrees Fahrenheit Brown Gravy- 160 degrees Fahrenheit Broccoli Salad- 78 degrees Fahrenheit Tuna Salad- 60 degrees Fahrenheit During an interview on 12/19/23 at 11:55 a.m. Staff B, Cook stated the puree foods needed to be heated back up in the oven to get to at least 150 degrees. Staff B, Cook stated for the Broccoli Salad at 78 degrees and the Tuna Salad at 60 degrees he would just stick both food items back in the refrigerator to cool them back down prior to serving to the residents. Staff B Cook looked at State Surveyor and stated, So we are good. During an interview on 12/19/23 at 11:57 p.m., the Dietary Manager (DM) stated cold foods should be held under 41 degrees Fahrenheit. The DM stated any cold foods that were above 41 degrees cannot go back into the refrigerator to be cooled again and could not be served. The DM stated, Now what are we supposed to use for substitute food? It is time for tray line. The DM stated Staff B, Cook should not have suggested the cold food be put back in the refrigerator to cool back down. During an interview on 12/19/23 at 12:13 p.m., the DM stated the broccoli salad and tuna salad was not served and grilled cheese sandwiches were made in place for the broccoli salad and tuna salad. The DM stated Staff B, Cook as he knew better than to put the cold items next to the steam table and hot foods. During an interview on 12/20/23 at 11:40 a.m., The Dietitian stated she heard about the food temperatures and she would be assisting the DM with re-training the staff. The Dietitian stated putting cold food near the hot food steam table was not appropriate. The Dietitian stated suggesting putting the cold food items, made with a mayonnaise based, and were above the safety zone temperature back in the refrigerator was a problem and not acceptable. The Dietitian stated she would be helping with the training on this incident as this was a problem that needed to be fixed. A review of the facility's policy titled, Preventing Foodborne Illness- Food Handling revised date July 2014 showed, 3. All employees who handle, prepare and serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food and serving food to residents. 6. Potentially hazardous foods will be cooked to the appropriate internal temperatures and held at those temperatures for the appropriate length of time to destroy pathogenic microorganisms. A review of the facility's policy titled Cold Food Policy revised date October 2022, showed, 3. All prepared cold food items will be stored in cold holding equipment at a temperature of 41 degrees Fahrenheit or lower. 4. Product will be checked for proper temperature of 41 degrees Fahrenheit or lower by Dietary Manager or Cook prior to tray line delivery. 6. Food will be delivered to resident at a temperature of 41 degrees Fahrenheit or lower.

Based on observations, interviews, and record reviews the facility failed to ensure one resident (#8) out of one resident sampled was properly assessed and monitored for self-administration of an inhaler. Findings included: During an interview on 12/19/2023 at 9:30 a.m. Resident # 8 was observed removing an inhaler from her pocketbook and she proceeded to take a puff on the inhaler, she waited approximately five minutes and then took another puff. She then replaced the inhaler into her pocketbook. She stated her Primary Care Physician (PCP) gave an order for self-administration, however the staff could not get the order correct, so the nurse told her the next time she brings the inhaler for her to keep it. During an interview on 12/20/23 at 3:30 p.m. Resident # 8 revealed she still had the inhaler in her pocketbook. She stated she does not remember which nurse gave it to her, or how long she has had the inhaler. The box the inhaler was in revealed the date was worn off. She stated she has days she does not use the inhaler and then there are days she may use the inhaler four times a day especially with all the saw dust during the construction. She stated the nurses do not know she has the inhaler, she just kept it, she stated her doctor told her to keep one for use when she needs it, and she was told by the nurses she could not have the inhaler in her room. During an interview on 12/20/23 at 3:00 p.m. Staff L, Licensed Practical Nurse (LPN) stated for a resident to self-administer medications a physician order would be obtained, the DON (Director of Nursing) would have to be notified, and the resident would have to be assessed for safety of administration. She stated she had no residents in her assignment who self-administered their own medications. She stated Resident #8 had an inhaler in the medication cart, where all medications for the residents on the unit are kept, and per the December 2023 Medication Administration Record (MAR) Resident #8 had only received the Albuterol inhaler two days during the month. She stated the inhaler is ordered as needed. An interview was conducted with the Director of Nursing (DON) on 12/20/23 at 3:50 p.m. The DON stated there were no residents in the facility self-administering medications, especially no types such as inhalers. She stated a physician order would be needed to self-administer medications, a lock box in the room to store the medication for security, the resident would have to be assessed for the ability to administer the medication, and cognitively intact to administer their own medications. The DON stated to ensure there were no residents self-administering medications in the facility she met with all the nurses and reviewed all orders and there are no residents in the facility self-administering medications. Review of Resident # 8's medical record revealed Resident #8 was admitted to the facility on [DATE], and the most recent admitted [DATE], with a diagnoses including chronic respiratory failure with hypercapnia, acute respiratory failure with hypoxia, and generalized anxiety disorder. Review of Section C- Cognitive Patterns of the Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Review of Resident #8's care plan, dated October 30, 2023, revealed no assessment, focus, goal, or interventions for self-administration of medications. A focus area for diagnoses of Chronic Obstructive Pulmonary Disease and respiratory failure revealed a goal as: Resident will display optimal breathing patterns daily through review date of 3/6/2024. Interventions included: oxygen as per physician order, monitor for signs and symptoms of respiratory insufficiency, anxiety, and shortness of breath. Review of Resident #8's physician orders, dated October 30, 2023, revealed no orders to assess Resident #8 for the ability to self-administer medications. The Ventolin - Albuterol HFA Inhaler ordered on October 30, 2023, was two puffs by mouth every four hours as needed while awake for wheezing. No other inhaler orders were noted. Review of Resident #8's November 2023 Medication Administration Record (MAR) revealed the resident did not receive the Ventolin-Albuterol inhaler medication at all during the month. Review of Resident #8 December 2023 MAR revealed the resident received the Ventolin-Albuterol inhaler on 12/1/2023 and 12/3/2023 and it was administered by the staff. A review on 12/20/23 at 2:58 p.m. of policy and procedure Self-Administration of Medications, revised February 2021, revealed the following: Policy Statement: Residents have the right to self-administer medications if the interdisciplinary team has determined it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation: 2. The interdisciplinary team considers the following factors when determining whether self -administration of medications is safe and appropriate for the resident: a. The medication is appropriate for self-administration b. The resident is able to read and understand the medication label c. The resident can follow directions and tell time to know when to take the medication d. The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to the staff e. The resident has the physical capacity to open the medication bottles, remove medications from a container and to ingest and swallow (or otherwise administer) the medication f. The resident is able to store the medication safely and securely 7. I the resident is able and willing to take responsibility for documenting self-administration of medications, the resident is instructed on how to complete a record indicating the administration of the medication. 12. Nursing staff reviews the self-administered medication record for each nursing shift and transfers pertinent information to the medication administration record kept at the nursing station appropriately noting the doses were self-administered. A review on 12/20/2023 3:20 p.m. of policy and procedure Medication Administration revised April 2019 revealed the following: Policy Statement: Medications are administered in a safe and timely manner and as prescribed. Policy Interpretation and Implementation: 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. 2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions 3. Medications are administered in accordance with prescriber orders, including any required time frame. 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined they have the decision-making capacity to do so safely.

Based on record reviews and interview the facility failed to complete a Discharge Minimum Data Set (MDS) Assessment for two residents (#49 and #67) out of two sampled for resident assessments. Findings included: A review of the medical record for Resident #49 revealed the resident was admitted to the facility on [DATE] with a diagnoses including but not limited to, cerebral Infarction affecting left side, Type 2 Diabetes Mellitus (DM), Chronic Obstructive Pulmonary Disease (COPD), hypertension, and repeated falls. The Admission Record revealed Resident #49 was discharged from the facility on 08/21/2023. A review of the MDS assessments for Resident #49 revealed a completed entry assessment dated [DATE] and a completed Admission assessment dated [DATE]. No discharge MDS assessment was located in the record. A review of the medical record for Resident #67 revealed the resident was admitted to the facility on [DATE] with a diagnoses including but not limited to, osteomyelitis, Type 2 Diabetes Mellitus, respiratory failure, and major depressive disorder. The Admission Record revealed Resident #67 was discharged from the facility on 7/20/2023. A review of the MDS assessments for Resident #67 revealed a completed entry assessment dated [DATE] and a completed Admission assessment dated [DATE]. No discharge MDS assessment was located in the record. On 12/20/2023 at 11:19 a.m. an interview was conducted with the MDS Coordinator. The MDS Coordinator stated she was unable to locate the discharge assessments for Residents #49 and #67. She stated Resident #49 had been discharged from the facility on 8/21/2023 and no discharge assessment had been completed for the resident. She stated Resident #67 had been discharged from the facility on 7/20/2023 and no discharge assessment had been completed for the resident. She stated she was responsible for completing the discharge assessments and this had been missed for Resident #49 and Resident #67. She stated she did not know how this occurred. A review of the Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Assessment Summary document, dated October 2019, provided by the facility revealed the following: (Page 2-17) Discharge Assessment-return not anticipated MDS completion date no later than-discharge date + 14 calendar days MDS transmission date no later than-MDS completion date + 14 calendar days

Based on observations, record review, and interviews the facility failed to develop a patient-centered care plan for one resident (#30) out of thirty-three sampled residents related to behavioral monitoring with the use of psychotropic medications. Findings included: Review of Resident #30's Admission Record revealed the resident was admitted on [DATE] and included diagnoses not limited to unspecified nontraumatic subarachnoid hemorrhage, other seizures, most recent episode depressed in partial remission bipolar disorder, bipolar-type schizoaffective disorder, generalized anxiety disorder, metabolic encephalopathy, and alcohol abuse in remission. During an interview, on 12/18/23 at 11:35 a.m., Resident #30 reported abuse occurs All the time, employees are very sadistic and there was bad drug abuse with staff. The resident stated the Nursing Home Administrator (NHA) had been notified of the allegations. The resident did not use the same first name of NHA as the current administrator. The resident reported not getting out of bed, left leg was broken and needed to go to (named) acute hospital, and had been in a major military squirmish Here in [NAME] with the Russian military a year ago. An interview was conducted with Staff D, Registered Nurse (RN) on 12/20/23 at 9:57 a.m. The nurse reported Resident #30 got out of bed 2-3 times a week for about 1-2 hours then asks to go back to bed. Staff D said the resident was very confused, sometimes asks for police, and to call a politician because someone is drugging him. The staff member said the resident says it every day and had never reported someone abused him, just drugged him. During an interview on 12/21/23 at 7:24 a.m., the Nursing Home Administrator (NHA) reported Resident #30 had reported to her of being in pain, wanting to go to the local Cancer Center, and staff flipped legs over when doing incontinent care. The NHA stated the resident reported the Second-in-command had a girlfriend who was a terrorist and caused pain. The NHA reported Resident #30 had reported similar complaints in January (2023) and had a history of confabulation. She reviewed the resident's care plan and confirmed the care plan did not include the resident's history of confabulation. She stated the care plan should reflect the history of confabulation. The NHA provided a copy of thirteen of the thirteen page care plan reviewed at the time of interview. During an interview on 12/21/23 at 8:05 a.m., Staff G, Licensed Practical Nurse (LPN), stated Resident #30 was confused, said inappropriate things, and reported staff did things to him. The staff member reported asking the resident why would he say that. Staff G said the resident would ask to go to the hospital and local Cancer Center. The staff member did not remember the last time the resident had said anything as she had just started Working back here. Review of Resident #30's care plan focus' included but not limited to the following: - Resident had a recent decline in self-performance of Activities of Daily Living (ADL) and independent mobility. - Resident is alert and oriented and able to make needs and wants known. (Resident) has some intermittent periods of confusion and forgetfulness. - Resident has a history (Hx) of falls prior to admission and requires reminders to call for assist with transfers and ambulation as well as diagnosis (dx) of seizures. - (Resident) takes daily psychotropic medications. - (Resident) is at nutritional risk due to (d/t) mechanically altered diet and Body Mass Index (BMI) elevated. - (Resident) is at risk for pain. - (Resident) is at risk for skin breakdown related to incontinence and decreased mobility. - (Resident) is at risk for impaired gas exchange related to (r/t) Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #30's December Medication Administration Record (MAR) revealed the resident was administered Lacosamide for seizures, Levetiracetam for seizures, Melatonin for insomnia, Oxcarbazepine for seizures, Quetiapine for schizophrenia, and Valproic Acid for seizures. A review of Resident #30's care plan did not reveal the resident had a history of confabulation and did not include the behaviors exhibited related to the use of psychotropic medications. Review of Resident #30's December Psychoactive Medication Monthly Flow Record for Lacosamide, Quetiapine, Valproic acid, Levetiracetam, and Oxcarbazepine did not reveal the resident had exhibited any behaviors. A review of Resident #30's nurse's notes from 11/1/23 to 12/19/23 revealed on 12/11/23 at 8:30 a.m., the resident was combative and confused and on 12/18/23 at 9:20 a.m., the resident refused oxygen. The notes did not reveal how the resident was combative or if the resident had increased confusion. The psychiatry provider note, dated 12/20/23, revealed the resident had Presence of active symptoms (worsening of previous symptoms or new symptoms). The note showed the resident had expressed dissatisfaction with the treatment received at the facility according to staff. The provider noted the resident was displaying acute symptoms of psychosis, including hallucinations, delusions, and accusatory behavior. During an interview on 12/21/23 at 11:17 a.m., Staff J, Social Service Director (SSD) reported doing some of the behavior care plans which triggers on the Minimum Data Set (MDS), and nursing does some of them. The staff member stated Resident #30 does have a history of confabulation, watches a lot of television and he thinks its real and is not consistent with stories. The SSD reviewed the care plan provided in the morning by the NHA and asked why the NHA had given the writer that one. The SSD stated the MDS Director, NHA and herself had revised the care plan this morning to include a focus revealing the resident confabulated stories. On 12/21/23 at 1:56 p.m., the Director of Nursing stated the care plan of Resident #30 should include the behaviors exhibited to validate the necessity of psychotropic medications. The facility provided a copy of regulation 42 CFR 483.21 - Comprehensive person-centered care planning, up to date as of 12/19/2023, which revealed in section 483.21 (b) (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observations, interviews, and record review the facility failed to conduct an accurate smoking assessment for one resident (#32) out of three residents sampled for smoking. Finding Included: On 12/18/23 at 11:55 a.m., Resident #32 was observed outside in the designated smoking area smoking a cigarette without supervision. The resident was observed with a band aid and burn marks on his left fingers. The resident said when his cigarette burns, he is not able to feel it because he has neuropathy so that's why he has burn marks on his fingers. Review of Admission Record, dated 12/19/2023, showed Resident # 32 was originally admitted on [DATE] with diagnoses to include but not limited to Type 2 Diabetes Mellitus, Atherosclerotic heart disease of native coronary artery without Angina Pectoris, and unspecified lack of coordination. Review of a Hospice Comprehensive Assessment, dated 10/24/2023, showed Resident #32 was admitted to hospice on 10/24/2023 with diagnoses to include but not limited to severe peripheral neuropathy, Carpel Tunnel, and unable to use hands well. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed Section C, Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Review of a Smoking Safety Evaluation, dated 12/4/2023, signed by the Director of Nursing (DON), showed Resident #32 was an independent smoker who did not need assistance. Review of a Smoking Care plan, dated 3/18/2023, showed Resident #32 was currently a smoker. An intervention, dated 3/18/2023, showed resident may carry their own smoking materials and keep in a locked drawer in room when not in use. During an interview on 12/18/23 at 01:10 PM with Staff G, License Practical Nurse (LPN), she said she has not noticed any burn marks on Resident #32's fingers. She stated the skin assessments were done on Thursday's 7am to 7pm shift. She stated the last skin assessment was done on 11/11/2023 and showed he had no new skin issues. During an interview on 12/18/23 at 01:35 PM with the Director of Nursing (DON), she said resident #32's skin checks were done more frequently than just on Thursdays because he was seen by wound care, and he is on hospice. She stated nursing had missed two skin checks that should have been completed but upon review she noticed that they were not done. She stated his last skin check was complete on 11/11/2023 showing he has no new skin issues. She stated prior to that skin assessment he had another assessment done on 10/14/2023 which showed no new skin impairments. She stated the last smoking evaluation was completed on 12/4/2023 which showed he was an independent smoker without supervision, but he should have been reassessed for a new smoking evaluation to show that he needs to be supervised especially if he has neuropathy and is burning his fingers. She stated she would have expected her staff to report the resident's fingers had burn marks so an appropriate assessment could have been completed on him. She stated the care plan should have been updated also showing he was a supervised smoker. She stated, I did not notify the resident's doctor because his burn marks are not an acute condition, and he was threatening to leave the facility. I just did not know what else to do. During an interview on 12/20/23 at 11:32 a.m., with Staff E, License Practical Nurse(LPN), she stated she saw the black marks on the resident's fingers when he was first downstairs, but she never reported it because she did not think it was a burn she just thought it was dirt on his fingers. Review of the facility's policy, titled, Smoking Policy-Residents, revised July 2017 included, in part, the following: Policy: This facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). 7. The Staff shall consult with the attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 8. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff.