Every finding on record at Fairland Center

Based on complaint, reviews of clinical records, all pertinent facility administrative records, and interviews with the facility staff, it was determined that the facility nursing staff failed to follow the physician's specific pulse and blood pressure parameters before administering cardiac medications to residents. This was evident for 1 (Resident #10) of 3 residents reviewed during a complaint survey. The findings include: Review of complaint 3029833 on 07/08/26 revealed that 06/01/26 at 1:47 pm the Office of Health Care Quality received an allegation that residents in the facility were not receiving quality of care. Review of Resident #10's clinical record on 07/08/26 at 11:30 am revealed that Resident #10 was admitted to the facility on [DATE] with diagnoses that include but not limited to a stroke with right side weakness, chronic atrial fibrillation, congestive heart failure, edema, and a pacemaker. A review of Resident #10's MOLST form, dated 06/10/25, indicated Resident #10 was a full code and wants all life sustaining procedures. On 03/19/26 the facility staff conducted a BIMS assessment on Resident #10 and obtained a score of 10/15. The BIMS (Brief Interview for Mental Status) score is a 0-15-point tool used in healthcare, particularly long-term care, to assess cognitive function, with higher scores indicating better cognition. It evaluates immediate recall, temporal orientation, and short-term memory. A score of 13-15 indicates intact cognition, 8-12 moderate impairment, and 0-7 severe impairment. Resident was measured for a height of 70 inches.On 07/09/26 at 11 am, a review of the facility policy Medication Administration General Guidelines, Section 7.1, under the heading of Medication Administration, indicated the nursing staff has to, under #2 - Obtain and record any vital signs as necessary prior to medication administration. Further review of Resident #10's clinical record revealed a physician's order dated 03/25/26 instructing the nursing staff to administer the medication, Metoprolol Succinate ER Oral Tablet, Extended Release 24 Hour, 25 MG, Give 2 tablet by mouth one time a day for hypertension. Hold the medication if the systolic blood pressure (SBP) is less than 110 or the heart rate (HR) is less than 60. Metoprolol succinate (extended release) is a beta-blocker taken once daily to manage high blood pressure, treat chest pain (angina), and lower the risk of heart failure complications. It works by slowing your heart rate and reducing the strain on your heart and blood vessels. Further review of Resident #10's June and July 2026 medication administration records (MAR) on 07/09/26 revealed the nursing staff failed to follow Resident #10's physician order to obtain a blood pressure and pulse before administering the dose of Metoprolol each morning from June 1, 2026, through July 8, 2026. In an interview with the acting Director of Nurses (DON) on 07/09/26 at 12:20 pm, the DON was unable to produce the nursing staff were obtaining a blood pressure and a pulse from Resident #10 before administering a dose of the antihypertensive medication Metoprolol.

Based on observation and interview, it was determined that the facility failed to ensure cold foods were held at 41 degrees Fahrenheit or lower in accordance with food safety standards. This was identified during the Kitchen Task conducted as part of the Annual/Complaint Survey. This deficiency has the potential to affect all residents.The findings include:On 05/12/2026 at 12:03 PM, this surveyor observed kitchen staff begin the lunch tray line process for residents of the facility. During the observation, kitchen staff were observed obtaining food temperatures prior to beginning tray service.On 05/12/2026 at 12:09 PM, this surveyor observed that the pureed bread, which had been removed from the refrigerator and placed directly onto ice, had a temperature of 55.9 degrees Fahrenheit.On 05/12/2026 at 12:37 PM, this surveyor observed that the pureed pasta salad, which had also been removed from the walk-in refrigerator and placed directly onto ice, had a temperature of 41.5 degrees Fahrenheit.On 05/12/2026 at 12:42 PM, this surveyor observed that the cucumber salad had a temperature of 44.3 degrees Fahrenheit.On 05/12/2026 at approximately 1:00 PM, this surveyor conducted an interview with Dietary Director #7 regarding concerns that cold food items on the tray line were not being maintained at 41 degrees Fahrenheit or lower. It was discussed that food items coming directly from the walk-in refrigerator were already above the required temperature range. Dietary Director #7 acknowledged and confirmed understanding of the concern.On 05/12/2026 at approximately 2:30 PM, this surveyor conducted an interview with Administrator #1 and discussed concerns regarding the temperatures of food items being served on the tray line not meeting the required temperature of 41 degrees Fahrenheit or lower. Administrator #1 acknowledged the concerns.

Based on observation, record review and interview, it was determined that the facility failed to ensure food was stored at appropriate temperatures. This was identified during the Kitchen facility task conducted as part of the annual/complaint survey and has the ability to affect all residents. The findings include:On 05/11/2026 at 8:05 AM, this surveyor observed the thermometer inside the kitchen walk-in freezer. The thermometer read 11 degrees Fahrenheit. Pictures were taken at this time.On 05/11/2026 at 8:27 AM, this surveyor observed the reach-in refrigerator containing milk, yogurt, and juices. The thermometer inside the refrigerator read 51 degrees Fahrenheit. It was also observed that the temperature display on the outside of the refrigerator was set to 56 degrees Fahrenheit. Pictures were taken at this time.On 05/11/2026 at 2:55 PM, this surveyor conducted a dual observation with Dietary Director #7. During the observation, the reach-in refrigerator thermometer read 42 degrees Fahrenheit.On 05/11/2026 at 2:57 PM, this surveyor conducted a dual observation with Dietary Director #7 of the walk-in freezer. The thermometer inside the freezer read 10 degrees Fahrenheit. During the observation, it was discussed that the temperatures observed in both the reach-in refrigerator and walk-in freezer were not taken during periods of excessive use, and therefore were not attributed to doors being frequently opened.On 05/11/2026 at 3:01 PM, a record review of the facility's Food Storage: Cold Foods policy revealed: All perishable foods will be maintained at a temperature of 41 degrees Fahrenheit or below, except during necessary periods of preparation and service, and Freezer temperatures will be maintained at a temperature of 0 degrees or below.On 05/11/2026 at 3:02 PM, this surveyor conducted an interview with Dietary Director #7, who confirmed that the observed temperatures for both the refrigerator and freezer did not meet facility expectations or policy requirements.On 05/12/2026 at 10:23 AM, this surveyor observed that the reach-in refrigerator temperature remained at 43 degrees Fahrenheit, with the inside thermometer also reading 43 degrees Fahrenheit. It was additionally observed that all food items had been removed from the refrigerator. Pictures were taken at this time. Dietary Director #7 confirmed that the food items had been discarded.On 05/12/2026 at 10:24 AM, this surveyor observed that the thermometer inside the walk-in freezer read 9 degrees Fahrenheit. Pictures were taken at this time.On 05/12/2026 at 10:25 AM, this surveyor conducted an interview with Dietary Director #7 regarding concerns with the refrigerator and freezer temperatures not meeting policy requirements. She reported that emergency repair services were being called to repair both the walk-in freezer and the reach-in refrigerator. She further reported that, in the meantime, the reach-in refrigerator would not be used until the issue was corrected.On 05/12/2026 at approximately 2:00 PM, this surveyor conducted an interview with Administrator #1 regarding the concerns with the reach-in refrigerator and walk-in freezer temperatures. Administrator #1 acknowledged the concerns and reported that the facility was actively working to correct the issues.

Based on medical record reviews and interviews, it was determined that the facility failed to ensure medical records were complete and accurate. This was evident for 3 (Resident #1, #2 & #12) of 18 residents reviewed for accurate medical record documentation.The findings include:1. During a review of medical records for Resident #2 on 5/12/2026 at 6:55 AM it was discovered that Resident #2 had an active order that was written on 12/15/2025 to get the Resident Out of bed on Monday, Wednesday and Friday.During further review it was discovered that the order did not appear on the Medication Administration Record (MAR), Treatment Administration Record (TAR) or the Geriatric Nursing Assistants Task documentation for Resident #2.During an interview with Licensed Practical Nurse (LPN) #12 on 5/14/2026 at 7:51, she reviewed the order that stated for Resident Out of bed on Monday, Wednesday and Friday. She confirmed that the order did not show on the MAR, TAR or the GNA task for Resident #2. During an interview with the RN Unit Manager #6 on 5/14/2026 at 8:56 AM she advised the order for the Resident #2 to get Out of bed on Monday, Wednesday and Friday should show on the TAR or on the GNA Task. She confirmed that the order was not on the TAR or GNA task.During an interview with the Director of Nursing (DON) #2 on 5/14/26 at 9:12 AM she reported the order should show up on the TAR for staff to see and sign off. She was unable to locate the order for Resident Out of bed on Monday, Wednesday and Friday on the TAR for Resident #2. She advised that she wasn't sure what happened to the order, but the order must not have been entered correctly to make it appear on the TAR.2. During an observation of Resident #1 on 5/11/2026 at 10:05 AM he/she was lying in bed while on a ventilator and a tube feeding machine was at the resident's side.A gastrostomy tube (G-tube) is a medical device inserted directly through the abdomen into the stomach. It is used to provide enteral nutrition, fluids, and medications for individuals who cannot safely swallow or take in enough food by mouth. It can also drain excess gas or stomach contents.During a review of medical records for Resident #1 on 5/11/2026 at 11:46 AM it was discovered that the Resident used a Gastronomy tube for feeding and medication administration. He/she also had a dietary order for nothing by mouth.During further review of the Medication Administration Record (MAR) for Resident #1 it was discovered that the Resident had the following medications ordered to be given by mouth.An active order for an Amoxicillin tablet to be given by mouth every 12 hours. The order was started on 5/05/2026 and had been signed off as given every day.A discontinued order for Enulose Solution to give 30 milliliters by mouth that was documented as given once on 5/03/2026 and 5/04/2026.An active order to give Midodrine Tablet by mouth three times a day. The order started on 5/04/2026. The order had been signed off as given every day. A discontinued order to given Milk of Magnesia suspension by mouth that was documented as given once on 5/03/2026 and 5/04/2026.During an interview with DON #2 on 5/14/2025 at 11:25 AM she reported the medication order should have the correct administration route identified in the order. She confirmed that residents with a g-tube that have an order for nothing by mouth would get the medication by the g-tube and not by mouth. During an interview with LPN #10 on 5/14/2026 at 11:34 AM she reported that Resident #1 does not receive any medication by mouth, he/she receives medication via the g-tube. She confirmed that the Amoxicillin, Enulose Solution, Midodrine Tablet and Milk of Magnesia are all given to the Resident via G-tube.During a review of the enteral tube policy on 05/14/2026 at 2:10 PM it was revealed that, The physician's order must specify the route of administration of any medication via feeding tube. This should be stated in the directions at a minimum as per tube or via tube, but certainly the type of tube may be specified.3. During an observation of Resident #2 on 5/11/2026 at 11:18 AM he/she was lying in bed while on a ventilator and a tube feeding machine was set up at the resident's side.During a review of medical records for Resident #2 on 5/13/2026 at 6:55 AM it was discovered that the Resident used a Gastronomy tube for feeding and medication administration. He/she also had a dietary order for nothing by mouth.During further review of the Medication Administration Record (MAR) for Resident #2 it was discovered that the Resident had the following medications ordered to be given by mouth.An active order that was started on 5/30/2025 for a Baclofen tablet to be given by mouth at bedtime and was documented as completed every day from 5/01/2026 - 5/14/2026.An active order that was started on 5/30/2025 for a Finasteride tablet to be given by mouth one time a day and was documented as being completed every day from 5/01/2026 - 5/14/2026.An active order that was started on 2/26/2026 for a Saccharomyces bouladi capsule to be given by mouth two times a day and was documented as being completed every day from 5/01/2026 - 5/14/2026.During an interview with LPN #12 on 5/14/2026 at 11:14 AM she advised the nurses put the medication orders in for the Residents. She reported that Resident #2 does not get medication by mouth, he/she received medication via the g-tube. She confirmed that Resident #2 gets the Baclofen, Finasteride and Saccharomyces bouladi capsule via g-tube and not by mouth.During an interview with the DON #2 on 5/14/2025 at 11:25 AM she reported the medication order should have the correct administration route identified in the order. She confirmed that residents with a g-tube that have an order for nothing by mouth would get the medication by the g-tube and not by mouth. During a review of the enteral tube policy on 05/14/2026 at 2:10 PM it was revealed that, The physician's order must specify the route of administration of any medication via feeding tube. This should be stated in the directions at a minimum as per tube or via tube, but certainly the type of tube may be specified.4. During a review of medical records for Resident #12 on 5/13/2026 at 7:59 AM it was discovered that the Resident used a Gastronomy tube for feeding and medication administration. He/she also had a dietary order for nothing by mouth. During further review of the Medication Administration Record (MAR) for Resident #12 it was discovered that the Resident had the following medication ordered to be given by mouth.A discontinued order for Augmentin oral tablet to be given one table by mouth. This was documented as being completed every day from 5/01/2026 - 5/10/2026. During an interview with LPN #12 on 5/14/2026 at 11:14 AM she advised the nurses put in the medication orders for the Residents. She reported that Resident #12 does not get medication by mouth, he/she medication via the g-tube. She confirmed that Resident #12 would have had the Augmentin via g-tube and not by mouth.During an interview with LPN #12 on 5/14/2026 at 11:14 AM she advised the nurses put the medication orders in for the Residents. She reported that Resident #2 does not get medication by mouth, he/she received medication via the g-tube. She confirmed that Resident #2 gets the Baclofen, Finasteride and Saccharomyces bouladi capsule via g-tube and not by mouth.During an interview with DON #2 on 5/14/2025 at 11:25 AM she reported the medication order should have the correct administration route identified in the order. She confirmed that residents with a g-tube that have an order for nothing by mouth would get the medication by the g-tube and not by mouth. During a review of the enteral tube policy on 05/14/2026 at 2:10 PM it was revealed that, The physician's order must specify the route of administration of any medication via feeding tube. This should be stated in the directions at a minimum as per tube or via tube, but certainly the type of tube may be specified.

Based on observations and interviews, it was determined that facility staff failed to provide respect and dignity to residents by failing to knock on the resident's door prior to entering the resident's room to administer medications. This was evident for 2 (Resident#8 and #29) out of 3 residents observed during recertification survey process. The findings include: On 05/11/2026 at 8:10 AM during an interview, Resident #8 reported that staff do not close the door or privacy curtains during care and do not knock prior to entering the room. Resident #8 stated, This happens all the time. On 05/11/2026 at 8:20 AM surveyor observed Geriatric Nursing Assistant (GNA) #11 enter Resident #8's room without knocking on the door. Surveyor further observed that the privacy curtain was not pulled during care of the resident's roommate. During an interview, GNA #11 stated staff are expected to knock and introduce themselves prior to entering a resident's room. GNA #11 confirmed not knocking or introducing self before entering Resident #8's room. On 05/11/2026 at 10:30 AM Resident #29 reported that staff do not close the curtains during care. The resident further stated, I do not mind them seeing me, but I do not want to see my roommate when staff is performing care. On 05/12/2026 at 12:16 PM an interview was conducted with the Director of Nursing (DON) regarding expectations for resident dignity. The DON stated that staff are expected to knock on the door and introduce themselves before entering a resident's room.The DON further stated that during the provision of care, staff are expected to provide privacy by pulling the privacy curtain and ensuring the resident is appropriately covered during care.

Based on review of the facility's investigative report and administrative interview, it was determined the facility failed to report an allegation of abuse to the required entities. This was found to be evident for 1 (Resident #48) out of 2 Residents reviewed for abuse during the recertification and complaint survey. The findings include: A review of the facility's investigation file for the Facility Reported Incident (FRI) #2741835 was conducted on 05/14/2026 at 11:30 AM. During the review it was discovered that the facility failed to report an allegation of abuse to the local law enforcement and Ombudsman. During an interview conducted on 05/14/2026 11:50 AM, the Nursing Home Administration (NHA) confirmed that the investigation file was complete and that the local law enforcement and Ombudsman were not notified of the allegation of abuse. The NHA reported that the alleged perpetrator was terminated due to the number of complaints that had been received by numerous people over a period.

Based on review of the facility's investigative report and administrative interview, it was determined the facility failed to conduct a thorough investigation for an allegation of abuse. This was found to be evident for 1 (Resident #48) out of 2 Residents reviewed for abuse during the recertification and complaint survey. The findings include: A review of the facility's investigation file for the Facility Reported Incident (FRI) #2741835 was conducted on 05/14/2026 at 11:30 AM. During the review it was discovered that the facility failed to interview and obtain staff and residents statements regarding the allegation of abuse to determine if the allegation of abuse had been witnessed or if any other resident had experienced abuse by the alleged perpetrator. During an interview conducted on 05/14/2026 11:50 AM, the Nursing Home Administration (NHA) confirmed that the investigation file was complete. The NHA reported that staff and residents were not interviewed during the investigation of the allegation of abuse. The NHA also reported that the alleged perpetrator had been terminated due to the number of complaints the facility received against the alleged perpetrator.

Based on record reviews, interviews, and observations, it was determined the facility failed to appropriately code Minimum Data Set (MDS) Assessments. This was evident for 1 (Residents #1) out of 18 Residents reviewed for Accuracy MDS Assessments. The findings include:The Minimum Data Set (MDS) is a standardized, federally mandated clinical assessment tool used in the U.S to evaluate the health status, functional capabilities, and care needs of all residents in Medicare or Medicaid-certified nursing facilities. It is used to drive care planning, monitor quality, and determine Medicare/Medicaid reimbursement rates.Active diagnoses documented on the MDS assessment are attending provider-documented diagnoses in the last 60 days that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. 1. During a review of medical records conducted on 5/11/2026 at 11:46 AM, it was discovered that Resident #1 was coded on the Minimum Data Set with an Assessment Reference Date (ARD) of 4/27/2026 as having an active diagnosis of a Psychotic disorder (other than schizophrenia).Further Review of medical records revealed no active diagnosis of a Psychotic disorder for Resident #1. A review of the Medication Administration Record (MAR) showed the resident was not on any medications for a Psychotic disorder. During a phone interview with the Regional MDS Coordinator #27 on 5/14/2026 at 5:03 PM she confirmed that Resident #1 did not have an active diagnosis for a Psychotic Disorder and was not receiving any treatment for a Psychotic disorder. She reported it was a coding error.

Based on observation, interviews and record reviews it was determined that the facility failed to ensure a Resident received psychiatric services for a mental health condition. This was found to be evident for 1 (Resident # 10) out of 5 Residents reviewed for psychiatric services during the recertification and complaint survey. The findings include: Post-traumatic stress disorder (PTSD) is a mental health condition triggered by experiencing or witnessing a terrifying or life-threatening event. Symptoms like intrusive flashbacks, nightmares, severe anxiety, and hypervigilance can last for years if left untreated. However, highly effective treatments such as trauma-focused psychotherapy and medications are available. During an interview conducted on 05/11/2026 at 10:26 AM, Resident #10 reported that he/she had been diagnosed with PTSD. The Resident reported that he/she suffered from depression due to the PTSD incident. The Surveyor observed the Resident tearful and emotional as he/she discussed the PTSD incidents.A review of Resident #10 admitting diagnoses conducted on 05/11/20206 at 11:09 AM confirmed that the Resident had a diagnosis of PTSD. During a review of Resident #10's psychiatric notes conducted on 05/15/2026 at 7:15 AM, it was discovered that the Resident received routine psychiatric assessments and services. The review of the psychiatric assessments did not list PTSD as one of the treating diagnoses and it did not show services provided that assessed or treated the Resident for PTSD. During an interview conducted on 05/15/2026 at approximately 8:30 AM, the Surveyor and Director of Nursing (DON) reviewed Resident #10's psychiatric notes. The review confirmed that an assessment conducted 10/2025 listed PTSD as a diagnosis but did not include it in the assessment or treatment plan. Further review of the psychiatric notes prior to 10/2025 and after did not list PTSD as a diagnosis and was not included in the treatment plan. During an interview conducted on 05/11/2026 at approximately 11:00 AM Psychiatrist #26 confirmed the assessment notes did not list PTSD. The Psychiatrist reported that she had assessed Resident #10 and determined that the Resident's symptoms were not those of someone who suffered from PTSD. The Surveyor asked where and when did she documented the assessment. The Psychiatrist reported that she documented the assessment today (5/15/26). The Surveyor discussed the concern that the Resident was admitted [DATE] with a diagnosis of PTSD and an assessment was not documented until 05/15/2026 after the Surveyor's findings. The Psychiatrist replied that she understood the Surveyor's concern.

Based on observations and staff interview, it was determined that the facility failed to ensure medications were properly labeled and dated. This was evident for 1 of 10 medications observed in resident rooms during the recertification and complaint survey. The findings include: On 05/11/2026 at 8:07 AM, this Surveyor observed a bag of IV fluids hanging in Resident #70 room with no label or date on the bag. On 05/11/2026 at 10:00 AM, this Surveyor reviewed the facility's' Medication administration policy, Intravenous Fluid (IV) and Drug Administration policy, and Setting up a Primary Infusion policy. It was confirmed that the facility procedure is to verify the label on the IV bag with the prescriber's order. Attach label (with date, time, and nurse's initials) to administration set and IV bag. On 05/12/2026 at 12:30 PM, an interview with The Director of Nursing (DON) confirmed that all IV fluids must be labeled and have the resident's name and dates. This Surveyor showed the DON the unlabeled IV fluids in Resident #70 room and discussed concerns.

Based on record review, resident, facility staff interviews, the facility failed to provide medication administration that meets professional standards for 2 of 4 sampled residents reviewed for medication administration. (Resident #15 and Resident #16). Findings included: 1. Resident #15 was admitted to the facility on [DATE] with a diagnosis including anoxic brain damage, diabetes, anemia and protein-calorie malnutrition. A review of the physician's orders dated 11/7/25 revealed Resident #15 was prescribed thiamine HCL oral tablet 100mg , give 1 tablet via gastrostomy tube one time a day for supplement. A medication administration observation was conducted on 11/19/25 at 11:15 am with Staff Nurse #3. Staff Nurse #3 was observed to have not administered the medication thiamine HCL oral table 100mg to Resident #15 as per physician orders. Review of Medication administration record documentation for 11/19/25, indicated that thiamine HCL oral tablet 100mg medication was administered to Resident #15 on 11/19/25 at 9 am. During interview with Staff Nurse #3 on 11/19/25 at 12.17 pm, it was revealed that Resident #15 did not have any thiamine HCL oral tablet 100mg available. Staff Nurse #3 confirmed that Resident #15 did not receive thiamine HCL oral tablet 100mg at 9 am. Staff Nurse #3 indicated that she should have not documented to have administered medication. Staff Nurse #3 confirmed that she should have documented that medication was not administered. 2. Resident #16 was admitted to the facility on [DATE] with a diagnosis including protein-calorie malnutrition, and diabetes. A review of the physician's orders dated 10/28/25 revealed Resident #16 was prescribed ferrous sulfate elixir 220(44 Fe) mg/5ml , give 7ml by mouth one time a day for supplementation. A medication administration observation was conducted on 11/19/25 at 11:18 am with Staff Nurse #3. Staff Nurse #3 was observed to have not administered ferrous sulfate elixir 7ml to Resident #16 per physician orders. Review of Medication administration record documentation for 11/19/25, indicated that ferrous sulfate elixir 220(44 Fe) mg/5ml medication was administered to Resident #16 on 11/19/25 at 9 am. During interview with Staff Nurse #3 on 11/19/25 at 12.17 pm, it was revealed that Resident #16 did not have ferrous sulfate elixir 220 (44 Fe)mg/5ml. Staff Nurse #3 confirmed that Resident #16 did not receive ferrous sulfate elixir 220 (44 Fe)mg/5ml at 9 am. Staff Nurse #3 indicated that she should have not documented to have administered medication. Staff Nurse #3 confirmed that she should have documented that medication was not administered.During an interview with the Director of Nursing (DON) on 11/19/25 at 12:05 pm, she revealed that Resident #15 and Resident #16 should have received medications as per physician orders. DON further stated, that documentation should accurate on the medication administration record. DON confirmed that if medication is not administered, it should be documented as such on the medical record.

Based on record review, resident, facility and pharmacy staff interviews, the facility failed to administer medication as ordered by the physician to meet the resident's need of 2 of 4 sampled residents reviewed for pharmacy services. (Resident #15 and Resident #16). Findings included: a. Resident #15 was admitted to the facility on [DATE] with a diagnosis including anoxic brain damage, diabetes, anemia and protein-calorie malnutrition. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was cognitively impaired. A review of the physician's orders dated 11/7/25 revealed Resident #15 was prescribed thiamine HCL oral tablet 100mg , give 1 tablet via gastrostomy tube one time a day for supplement. A medication administration observation was conducted on 11/19/25 at 10:09 am with Staff Nurse #3. Staff Nurse #3 was observed to not have administered the medication thiamine HCL oral table 100mg to Resident #15 as per physician orders. During interview with Staff Nurse #3 on 11/19/25 at 10:09 am, it was revealed that Resident #15 did not have any thiamine HCL oral tablet 100mg available. Staff Nurse #3 indicated that she would have to get the medication from the over the counter stock in the facility. Staff Nurse #15 did not administer or get the medication from facility over the counter stock . b. Resident #16 was admitted to the facility on [DATE] with a diagnosis including protein-calorie malnutrition, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively impaired. A review of the physician's orders dated 10/28/25 revealed Resident #16 was prescribed ferrous sulfate elixir 220(44 Fe) mg/5ml , give 7ml by mouth one time a day for supplementation. A medication administration observation was conducted on 11/19/25 at 11:18 am with Staff Nurse #3. Staff Nurse #3 was observed to not have administered ferrous sulfate elixir 7ml to Resident #16 per physician orders. During interview with Staff Nurse #3 on 11/19/25 at 11:18 am, it was revealed that Resident #16 did not have ferrous sulfate elixir 220 (44 Fe)mg/5ml. Staff Nurse #3 indicated that she would have to reorder medication from pharmacy. Staff Nurse #3 confirmed that she had reordered Ferrous sulfate elixir 220 (44 Fe) mg/5ml on 11/19/25 with an anticipation to be delivered by pharmacy. During an interview with the Pharmacy Consultant on 11/19/25 at 4:09 pm, he revealed that Resident #15 and Resident #16 should have received their medications as per physician orders. During an interview with the Director of Nursing (DON) on 11/19/25 at 12:05 pm, she revealed that Resident #15 and Resident #16 should have received medications as per physician orders. She further stated that all nurses will be retrained on reordering medication timely.

Based on observations, record review , staff and pharmacist interviews, the facility failed to maintain a medication error rate of less than 5% as evidenced by 4 errors out of 31 opportunities observed. The medication error rate was 12%. Findings include: 1. A review of the physician's orders dated 11/7/25 revealed Resident #15 was prescribed thiamine HCL oral tablet 100mg , give 1 tablet via gastrostomy tube one time a day for supplement. A medication administration observation was conducted on 11/19/25 at 10:09 am with Staff Nurse #3. Staff Nurse #3 was observed to not have administered the medication thiamine HCL oral table 100mg to Resident #15 as per physician orders. During interview with Staff Nurse #3 on 11/19/25 at 10:09 am, it was revealed that Resident #15 did not have any thiamine HCL oral tablet 100mg available. Staff Nurse #3 indicated that she would have to get the medication from the over the counter stock in the facility. Staff Nurse #15 did not administer or get the medication from facility over the counter stock . 2. A review of the physician's orders dated 11/7/25 revealed Resident #15 was prescribed insulin lispro injection solution 100 unit/ml, inject 18 unit subcutaneously every 4 hours for diabetes. Facility provided policy and procedures on insulin pens on 11/19/25. Policy indicated that insulin pens are to be primed to each use to prevent the collection of air in the insulin reservoir. A medication administration observation was conducted on 11/19/25 at 10:09 am with Staff Nurse #3. Staff Nurse #3 was observed to not have primed the new insulin pen of insulin lispro 100unit/ml, prior to use. During interview with Staff Nurse #3 on 11/19/25 at 10:09 am, she stated that she had primed insulin lispro by ensuring to select a dose higher at than ordered ( 19 units and not the ordered 18units) to ensure that Resident #15 received his/her ordered dose. Staff Nurse #3 did not prime insulin pen. 3. A review of the physician's orders dated 11/7/25 revealed Resident #15 was prescribed vancomycin HCL oral suspension 50mg/ml , give 2.5 ml via gastrostomy tube one time a day for antibiotic prophylaxis. A medication administration observation was conducted on 11/19/25 at 10:09 am with Staff Nurse #3. Staff Nurse #3 was observed pouring the vancomycin HCL oral suspension into a medicine cup. Staff Nurse #3 was observed pouring 5 ml of vancomycin HCL oral suspension into medicine cup. Upon getting to room threshold heading to administer medication to Resident #15, Staff Nurse #3 was asked to check dosage of vancomycin in medicine cup by surveyor. Staff Nurse #3 observed to realize that she had poured 5ml of vancomycin instead of 2.5ml per physician orders. Staff Nurse #3 was observed getting a new syringe from the supply room, and using it to draw 2.5ml from the medicine cup. Medicine cup noted to have medication , and Staff nurse #3, observed discarding excess medication. During interview with Staff Nurse #3 on 11/19/25 at 10:09 am, she stated that she should have used a syringe to measure the 2.5ml of vancomycin hcl oral suspension, to ensure an accurate dosage. 4 A review of the physician's orders dated 10/28/25 revealed Resident #16 was prescribed ferrous sulfate elixir 220(44 Fe) mg/5ml , give 7ml by mouth one time a day for supplementation. A medication administration observation was conducted on 11/19/25 at 11:18 am with Staff Nurse #3. Staff Nurse #3 was observed to not have administered ferrous sulfate elixir 7ml to Resident #16 per physician orders. During interview with Staff Nurse #3 on 11/19/25 at 11:18 am, it was revealed that Resident #16 did not have ferrous sulfate elixir 220 (44 Fe)mg/5ml. Staff Nurse #3 indicated that she would have to reorder medication from pharmacy. Staff Nurse #3 confirmed that she had reordered Ferrous sulfate elixir 220 (44 Fe) mg/5ml on 11/19/25 with an anticipation to be delivered by pharmacy. During an interview with the Pharmacy Consultant on 11/19/25 at 4:09 pm, he revealed that Resident #15 and Resident #16 should have received their medications as per physician orders. During an interview with the Director of Nursing (DON) on 11/19/25 at 12:05 pm, she revealed that Resident #15 and Resident #16 should have received medications as per physician orders.

Based on observations, and staff and pharmacist interviews, the facility failed to label opened insulin pens with the patient name, physician name, date used for 4 insulin pens for 1 of 5 medication carts reviewed for medication storage ( Dogwood Unit Medication Cart #1). The findings included: The medication Cart #1 on Dogwood unit was observed on 11/19/25 at 10:09 am in the presence of Staff Nurse #3. The observation revealed 3 opened and used insulin pens of Humalog and 1 opened insulin pen of Lantus insulin that were stored together with no labels indicating patient name, physician name and date opened. The facility insulin pens policy revised 5/1/25, provided by the Director of nursing , indicated that insulin pens will be clearly labeled with the patient name, physician name, date used;a new pen must be ordered from the pharmacy. An interview with Staff Nurse #3 on 11/19/25 at 12:17 pm, stated that the insulin was delivered in individual bags that were labelled but misplaced. Staff Nurse #3 confirmed that the insulin pens had been used , and had no label. Staff Nurse #3 confirmed that one of the insulin pens did not have a cap in place. Staff Nurse #3 indicated that their was no indication when the insulin pens were opened, or who they were assigned to. Staff Nurse #3 indicated that insulin pens would be discarded. An interview with Director of Nursing on 11/19/25 at 12:05 pm indicated that nursing staff should discard any unlabeled insulin pens and notify pharmacy to reorder new insulin pens that have labels. An interview with assistant director of nursing (ADON) on 11/19/25 at 1.13 pm indicated that insulin pens are delivered from pharmacy and are place in a clear labelled bag. ADON indicated that all insulin pens must be labelled with patient name, physician name and date opened. ADON confirmed that any opened, unlabeled insulin pens, should have been discarded and not used on any resident. ADON indicated that staff nurse should notify pharmacy to reorder labeled insulin pens. ADON indicated that all nurses will be retrained on insulin pens. During an interview with the Pharmacy Consultant on 11/19/25 at 4:09 pm, he revealed that all insulin pens must be labelled with the patient name, physician name and date opened. Pharmacy consultant further stated that once insulin pen is opened , it should be labelled with the date opened. Pharmacy consultant also indicated that any opened , unlabeled insulin pens should not be used, but facility should notify pharmacy and order a new insulin pen.

Based on observation and interview it was determined the facility 1) failed to ensure a safe, clean, and comfortable environment, and 2) failed to provide maintenance services necessary to maintain a sanitary and comfortable environment. This was evident for 1) 1 floor (second floor) out of 2 floors and 2) 1 of 3 nursing units on the 2nd floor during the facility's recertification/complaint survey. The findings include: 1) On 4/7/25 at 6:57AM surveyors smelled a strong, unpleasant odor in the A wing hallway at which time the closet door was opened and surveyors observed a trash can with bagged trash which was overflowing with several trash bags on top of cardboard trash on the floor of the closet. The trash can was observed to be dirty condition with drip marks down the side of it, and the walls of the closet had a layer of black matter present and drip marks. A piece of covered respiratory equipment was observed sitting on the floor in the hallway against the wall next to the closet, approximately one foot away from the garbage on the floor. On 4/7/25 at 6:58AM the surveyor observed dirty carpeting with numerous dark circular stains present in the A wing resident hallway. On 4/7/25 at 7:32AM the surveyor observed multiple areas of damaged spots of laminate flooring within the main area on the second floor leading to the resident dining area and the nursing station. On 4/7/25 at 7:33AM the surveyor observed one resident motorized wheel chair and one motorized scooter-type of mobility equipment in unclean condition with areas of staining and debris present on them in the C wing hallway. On 4/7/25 at 8:28AM the surveyor shared concerns with the facility Director of Nursing who acknowledged understanding of the concerns. On 4/8/25 at 8:22AM the surveyor observed various carpet staining with pieces of trash present on the floor of the B wing resident hallway near where the med cart was located, brown staining and brown drip marks were observed on the wall and hand rail adjacent to the medication cart. On 4/8/25 at 2:48PM the surveyor observed the furniture drawers of Resident #56 to be missing 3 out of 4 knobs. On 4/14/25 at 8:07AM the surveyor smelled a strong, unpleasant odor in the A wing resident hallway. Upon surveyor's opening of the closet door near to the area of odor, the trash can was observed to be overflowing. At this time, the surveyor shared the concern with Director of Maintenance #20 who observed and acknowledged the concern. On 4/14/25 at 8:13AM the surveyor observed the shower room located on the facility's second floor on the A wing which revealed signage present on one of two shower stalls which read the following information: Shower is temporary out of order no hot water. At this time, the surveyor turned on the shower water, allowed it to run, and felt that the water was cold to the touch, and did not become warm or hot. On 4/14/25 at 8:18AM the surveyor conducted an interview with Director of Maintenance #20 who stated the following information regarding the shower stall which had no hot water: One and a half years ago, before I left, I put those signs up, and no, it doesn't have hot water. At this time, the surveyor shared concerns with Director of Maintenance #20 who acknowledged understanding of the concerns. On 4/14/25 at 8:19AM the surveyor conducted a dual observation of the various carpet staining on the second floor of the resident hallways with Director of Maintenance #20 and Regional Director of Nursing (RDON) #4 who observed and acknowledged understanding of the concerns. On 4/14/25 at 9:25AM the surveyor was approached by RDON #4 who reported to the surveyor that they would be addressing the carpet staining concerns of the surveyor by observing the carpeting and obtaining quotes for carpet replacement for the facility's second floor. On 4/15/25 at 11:20AM the surveyor shared concerns with the facility's Director of Nursing who acknowledged understanding of the concerns. On 4/16/25 at 7:41AM a dark stained area of carpet approximately 4 ft long by 3ft wide was observed to be present outside of room A12. 51213 2) On 4/7/25 at 7:57 AM the Director of Maintenance, Staff # 20, was asked to open the 2nd floor shower room. Staff #20 was asked how long they had worked here, and Staff # 20 replied, I have worked here for 3 years, I left, and I have been back for 2 months. Staff #20 was shown the black substance all over both vents in the 2nd floor shower room, that the door to the shower room was warped 1/4 of the way up from the floor, white paint was chipped off the door and the corner of the door had wood missing which exposed a rough edge. Broken tiles on the base of the floor and on the corner wall of the shower stall were observed to be broken, and the radiator was rusty, and the front cover was touching the floor. Staff #20 attempted to lift the front cover of the radiator to prevent it from touching the floor but was unable to. Staff # 20 was also shown the ceiling which had large pieces of paint peeling off around both light fixtures and brown marks were also observed on the ceiling around each light fixture. Staff # 20 was asked if the shower room is currently being used to bathe residents. Staff # 20 replied yes, we use this shower room to bathe the residents. Staff #20 was then asked if they agreed that these are issues that need to be fixed. Staff # 20 said yes, this shower room needs to be remodeled and repaired. On 4/16/25 at 12:35 PM the surveyor observed the 2nd floor shower room and noted that the shower door remained warped, the vents in the shower room still had a black substance all over them, the ceiling still had paint peeling around both light fixtures, the tiles at the base of the floor and on the wall of the shower stall remain broken, the radiator heater remained rusted and was still touching the floor. No changes were observed since the first observation of the 2nd floor shower room on 4/7/25, the day the survey started.

Based on observations and staff interviews, it was determined that the facility staff failed to: ensure that multi dose medications were properly labeled, and medications were properly secured and stored. This was evident in 1) medication carts and 1 of 1 medication storage rooms and 2) one (B wing) out of three nursing wings on the facility's second floor reviewed during the recertification/complaint survey. The findings include: 1) On [DATE] at 06:32 AM, when surveyors entered the facility, three medication carts on D wing were found unattended and unlocked. Geriatric Nursing Assistant (GNA) staff #40 validated the findings. On [DATE] at 05:10 PM, a Medication storage observation was conducted, accompanied by Licensed Practical Nurse (LPN) #11, and noted an unlabeled eye drops; Azelastine hcl 0.05% eye drops, prescribed for Resident #74, without labeling on the container with an open date. The surveyor also noted a plastic container in an old zip lock bag, labeled as: RX# N,d+[DATE] [DATE] oxycodone 20mg, 12 tablets, supplied by John Hopkins at [NAME], Broadway, Baltimore, with the names of the recently admitted residents at the facility. Nurse #11 acknowledged surveyors' findings and alerted the registered Nurse (RN) staff # 39, who retrieved the eye drops and the Narcotic medication oxycodone 20mg and discarded them. On [DATE] at 11:30 am, record review of the medication administration general guidelines provided by the facility, page # ,d+[DATE], item C stated Multi-use eye drops and ointments should be disposed of 28 days after initial use. On [DATE] at 12:15 PM, in an interview with LPN staff #11, it was revealed that once the eye drop pack is opened, it must be discarded after 28 days. On [DATE] at 09:27 AM, the surveyor observed an expired item in the medication storage room: Nisus NPWT Canister, supplied by Cork Medical Products, 250 ml 30' drainage tubing with clamp attached. The lot #2023112301 and expiration date were [DATE]. On [DATE] at 12:20 pm, RN staff # 39 and the Director of Nursing (DON) acknowledged the findings of unlabeled eye drops, expired items, and narcotic storage. 47200 2) On [DATE] at 8:22AM the surveyor observed one round white pill in the B wing resident hallway on the second floor of the facility. On [DATE] at 8:23AM the surveyor conducted an interview of Licensed Practical Nurse (LPN) #11 who observed the concern and stated the following: Okay, I don't know when that happened. At this time the surveyor observed LPN #11 pick the pill up and throw it away into the medication cart trash can. On [DATE] at 7:53AM the surveyor observed an unattended and unlocked medication cart on the B wing of the facility's second floor. The surveyor shared their concern with Regional Director of Nursing (RDON) #4 who observed the concern, acknowledged the concern, and after surveyor intervention, was observed locking the medication cart and attempted to round the floor looking for the staff member assigned to the cart. On [DATE] at 7:56AM the surveyor observed Registered Nurse (RN) #34 exit a resident room and return to the cart. RDON #4 was observed re-educating RN #34 on the importance of locking of the medication cart. At this time, the surveyor conducted an interview with RN #34 who acknowledged and confirmed that the facility's expectation was for the medication cart to be locked.

Based on observation and interview it was determined the facility failed to ensure: 1) ice scoops and carts were maintained in a sanitary manner, 2) maintain the dining/food service area in a sanitary manner, 3) ensure covering of food removed from the hot cart and transported through resident hallways, 4) ensure food was labeled, 5) ensure a refrigerator seal was in good repair, 6) ensure kitchen ceiling and windows were in good repair to prevent potential for contamination of food contact surfaces, and 7) ensure the kitchen floor and ceiling was maintained in a sanitary manner. These conditions have the potential to affect all residents served by the facility's kitchen services. The findings include: On 4/7/25 at 6:55AM the surveyor observed an ice cart with an ice cooler on the top tier, and the ice scoop to serve ice for resident beverages stored within a plastic bag. On 4/7/25 at 6:56AM surveyors observed the dining area on the second floor which had a trash can which was filled to the top with several pieces of trash on the floor surrounding the trash can. The dining area floor was observed to be sticky upon walking on the floor surface with visible debris present and a dirty utensil was observed on the floor. One used cup was observed sitting on the dining table and open soda cans and a dirty napkin were observed next to a medical splint sitting on the window sill next to the dining table. On 4/7/25 at 7:04AM the surveyor opened the refrigerator in the facility's kitchen which was located near the walk-in refrigerator and observed a broken seal hanging unattached along the top surface of the refrigerator opening. The refrigerator was observed to contain ready to eat food. On 4/7/25 at 7:07AM the surveyor observed the facility's kitchen walk in refrigerator which revealed a metal pan labeled sausage gravy in which there was no labeling indicating date of preparation or date of expiration. On 4/7/25 at 7:07AM the surveyor conducted an interview and dual observation of the metal pan of sausage gravy with [NAME] #36. When the surveyor inquired to [NAME] #36 as to how they know when the product would expire, they responded: I don't know, there's no date on it. The surveyor shared the concern with [NAME] #36 who acknowledged and confirmed understanding of the concern. On 4/7/25 at 7:20AM the surveyor observed the kitchen window area located above the three compartment sink which was observed being utilized. The kitchen window area was observed to have a glass pane on half of the window area, and the other half had a wooden board in place of a window which was observed to have various splintered edges hanging off, with a food cutting board resting against the window sill in front of the wooden board. A second window area was observed to have a glass pane on half of it, and a piece of bent metal covering material nailed down for the remaining half of the window. On 4/7/25 at 7:21AM the surveyor observed the kitchen floor surface which had various crumbs and other debris present, sticky areas, and a wet pooling area of water near the entrance door to the kitchen. On 4/7/25 at 7:23AM the surveyor observed the ceiling surface above the food prep line/areas which was found to have black debris present, cracked areas, and areas of peeling paint. Plastic serving pitchers were observed hanging from hooks below the area of concern. At this time the surveyor conducted a dual observation of the concern with [NAME] #36 who observed, acknowledged, and confirmed understanding of the concern. On 4/7/25 at 8:28AM the surveyor shared concerns with the facility Director of Nursing who acknowledged understanding of the concerns. On 4/7/25 at 12:14PM the surveyor observed the ice cart with the ice scoop sitting out on top of a bag in the B wing hallway. On 4/8/25 at 8:29AM the surveyor observed an ice cart in which a cooler of ice utilized for resident beverages was sitting on the top tier, and the ice scoop was sitting out laying on top of a bag on the second tier of the cart. On 4/10/25 at 3:14PM the surveyor observed the ice cart with the ice scoop sitting out on top of a bag in the B wing hallway. On 4/14/25 at 7:46AM the surveyor observed dirty dishes and dirty utensils sitting on the second tier of the ice cooler cart which held clean ice next to a sleeve of clean disposable drinking cups and the ice scoop which was situated sticking out of a plastic bag. On 4/14/25 at 7:47AM the surveyor observed the dining area trash can to be filled past the top of the trash can with trash, and pieces of trash laying on the floor surrounding the trash can. Dirty dishes were observed sitting on the counter in the dining area. At this time, the surveyor's concern was shared with the Regional Director of Nursing #4 who observed the concern and acknowledged understanding of the concern. On 4/16/25 at 7:50AM after surveyor intervention, the surveyor observed the previously identified concerning area of the kitchen ceiling to have spackling present. On 4/16/25 at 8:21AM the surveyor observed the lid covers on several plates of food during delivery were unable to consistently cover the food without falling off. On 4/16/25 at 8:27AM the surveyor shared all kitchen concerns with Food Services Director #19 who acknowledged understanding of the concerns.

Based on observation and interview it was determined the facility failed to: 1) ensure a sanitary environment, ensure appropriate personal protective equipment was utilized, and ensure appropriate infection control precautions were instituted. This was evident during the surveyor's observations for one out of two floors of the facility during the recertification survey. The facility failed to 2) maintain current documentation that all employees were free from communicable tuberculosis (TB) as it relates to infection prevention and control, and was evident for 2 (Geriatric Nursing Assistant, GNA #30 and GNA #23) of 5 employees reviewed during the recertification survey. Additionally, the facility failed to 3) ensure that the environment of the resident's 2nd floor shower room was maintained in a manner that minimized the potential spread of infection as evidenced by wet soiled linen and several liquid soap containers in the 2nd floor shower room. This was evident 3 of 3 times the 2nd floor shower room was observed during the recertification survey. The findings include: 1) On 4/7/25 at 6:54AM the surveyor observed the closet labeled fresh linen on the B wing hallway which was observed to hold linen, pieces of trash on the floor, two care basins, one of which was holding an covid test with open packaging, used medical gloves, drinking straws, and care products including packaged toothbrushes and deodorants. The second care basin was observed to contain handwritten notes of resident last names and covid test results with thermometer probe covers, medication administration cups and other care supplies. Incontinence care briefs were observed out of the packaging in disarray in care basins with a brief touching a wall which was observed to have visible staining/matter present on it. On 4/7/25 at 6:55AM the surveyor observed the storage closet located between room B5 and B7 with a rolling style chair within it with a blanket sitting on it, a care basin holding trash bags and various resident care products, an opened, uncapped tube of ointment, a personal travel beverage cup, a sleeve of drinking cups, and another care basin which had crumpled tissues and trash items in it along with packaged unused oral care swab supplies. On 4/8/25 at 8:31AM the surveyor observed that Resident #56 had a trach tube and tube feeding among other considerations, however, there was no signage to indicate precautions to direct personal protective equipment (PPE) use necessary for the resident. On 4/8/25 at 3:00PM the surveyor requested a dual observation of Resident #56 with Registered Nurse, Unit Manager (RN, UM) #26 who was observed donning PPE prior to entering the resident's room. At this time, signage for precautions was observed on the resident's door. On 4/8/25 at 3:02PM RN, UM #26 was observed with a gown and gloves on retrieving their personal phone case and cell phone from underneath their gown. The surveyor observed RN UM #26 touching the phone and case with their gloves on, prior to entering the room of Resident #56. After entering the room to assist in a dual observation of an oral care concern for the resident, RN UM #26 was asked by the surveyor if they were ready to assist the patient if necessary for the oral care observation, at which time they confirmed yes. At this time, the surveyor shared their concern with RN UM #26 who reported to the surveyor that they had forgotten to sanitize their hands after picking up their phone, and thanked the surveyor for the reminder and stated: I'll re-gown. After surveyor intervention, RN UM #26 was observed appropriately removing their ppe, performing hand sanitization, and donning new ppe to assist with the dual observation. On 4/10/25 at 10:28AM the surveyor inquired to Registered Nurse (RN) #32 during an interview as to why the resident had no boots/splints in place. RN #32 was observed holding a blood glucose monitor in their hands which they gave to another staff member, and then RN #32 entered Resident #56's room without hand sanitization, picked up the resident's bed covers to observe their lower extremities, and then exited the room with no hand hygiene observed. At this time, the surveyor shared their concern. On 4/14/25 at 7:29AM the surveyor observed the closet labeled fresh linen located on the B wing, which held linens and was observed to have a sharps container lid laying on the floor next to a packaged toothbrush, open incontinence care briefs stuffed in the corner of the closet with a used crumpled napkin sitting on top of them which was overlapping onto a care basin which held personal sized care products including toothpaste. On 4/14/25 at 7:31AM the surveyor conducted an interview and dual observation of the concern with Licensed Practical Nurse (LPN) #37. LPN #37 observed the closet with the surveyor and when the surveyor inquired as to if they felt the condition of the closet was concerning, LPN #37 stated: very. At this time the surveyor observed LPN #37 proceed to remove the sharp container lid from the closet. On 4/14/25 at 7:36AM the surveyor opened the respiratory supply room closet door on the B wing and observed gauze sponge supplies, an opened box of other respiratory supplies, a covered bottle of sterile water, and a piece of respiratory equipment stored directly on the floor's surface. Trach tubing was observed stored in an open box uncovered without any packaging and other plastic tubing was observed stored uncovered without packaging sitting directly on the shelf's surface. On 4/14/25 at 7:38AM the surveyor observed the storage closet again on the B wing which revealed the rolling style chair with a blanket on it, a sweat suit hanging with a hanger, an IV pole with a personal hat hung on it, packages of hot cocoa mix, an open uncapped tube of ointment with a dried wipe sitting against it, a care basin holding two disposable spoons (utensils) mixed in with various tubes of creams and personal sized bath toiletries, a small box containing a packaged oral care swab and partially used and opened personal sized mouthwash and shampoo along with a pair of medical gloves and gauze sponges. On 4/14/25 at 7:40AM the surveyor shared the concern and conducted a dual observation with Regional Director of Nursing (RDON) #4 who observed and acknowledged understanding of the concern. On 4/14/25 at 8:01AM the surveyor conducted an observation of a closet located between rooms A15 and A17 with Director of Maintenance #20 and Regional Director of Nursing #4 which revealed brand new back up linens in plastic packaging stored within the closet some of which were observed on the floor which were coated in a layer of black soot-type of debris. Cob webs were additionally observed within the closet which were covered with black debris. On 4/14/25 at 8:13AM the surveyor observed the shower room located on the facility's second floor on the A wing which revealed used medical gloves resting on the lay down shower chair, a pair of visibly dirty socks resting on a rolling shower chair in one of two shower stalls with a dirty wash cloth on the floor below the shower chair, used linen was observed on the shower chair, a cloth material hand splint was resting on the sharps container, a personal sized bottle of shower gel was resting on top of the sharps container, the top surface of the sharps container was observed to be visibly soiled, the trash can was observed to be overflowing with both trash and hospital gowns, and a hospital gown and other bath linens were observed sitting in the handwashing sink. At this time, the surveyor conducted a dual observation of the concerns with Maintenance Director #20 and Regional Director of Nursing #4 who observed and acknowledged the concerns. On 4/15/25 at 11:20AM the surveyor shared concerns with the facility's Director of Nursing who acknowledged understanding of the concerns. 49304 2) On 4/16/25 at 9:39 AM during a portion of the infection control task, the surveyor randomly selected five employees' files to review their immunization and TB screening records. The review revealed: 1. GNA #30 was hired on 8/28/24. Further review did not reveal any evidence that this employee was free from communicable TB. 2. GNA #23 was hired on 6/11/24. Further review revealed a chest x-ray dated 5/12/20. On the document it stated the employee has a history of a positive PPD, however, there was no further current documentation certifying this employee was free from communicable TB. On 4/11/2025 at 9:56 AM in an interview with the Assistant Director of Nursing/Infection Preventionist (ADON/IP), she verified and confirmed there was no TB clearance for GNA #30. On 4/16/25 at 11:14 AM the surveyor requested any TB related documentation for GNA #23. On 4/16/25 at around 3pm, the Nursing Home Administrator provided the survey team with TB documentation for GNA #23, however, it was the same document dated 5/12/20 observed in the employee's file. No further documentation was provided to show GNA #23 was free from communicable TB. 51213 3) During the initial tour of the facility on 4/7/2025 at 7:07 AM, the 2nd floor shower room door was unlocked, and an electronic keypad was observed outside the 2n floor shower room. The surveyor observed 2 towels, a gown and 1 blanket on the floor. These items appeared to be soiled. The towels, gown and blanket were partially on top of a clear trash bag on the floor by the sink. The shower bed with a royal blue mat was wet and had a white wet washcloth on top of the blue mat at the foot of the shower bed. The shower chair with navy blue padding had a wet towel with brown marks observed lying on the shower chair seat. What appeared to be a bed sheet was observed on the floor under the window towards the back of the shower room. Toilet tissue was also observed on the floor by the toilet. Four open bottles of soap were also observed in the 2nd floor shower room, 1 on the floor under the blue shower chair, 1 on top of the sharp container and 2 on the silver handicap railing behind the mesh green shower chair. On 4/8/25 at 10:00 AM The DON was asked to open the 2nd floor shower room. The DON entered the code on the electronic keypad. Five open bottles of liquid soap were resting on the silver handicap railing in the first shower stall. The DON was asked should each resident have their own soap to bathe with? The DON replied yes, each resident should have their own soap to bathe with. The DON then threw the 5 bottles of liquid soap in the trash. On 4/16/25 at 12:35 PM Staff #21 was asked to open the 2nd floor shower room. The surveyor observed 2 bottles of liquid soap sitting on top of the sharp container and 2 wash clothes which appeared to have been used resting on the silver handicap railing in the first shower stall. Staff #21 was asked her title and replied I am the Unit Manager and a GNA. Staff #21 was then asked, should each resident have their own personal items to bathe with, such as soap and wash clothes? Staff # 21 replied, yes, each resident should have their own personal items to bathe, and residents should not share bathing items. Staff # 21 then put on gloves and removed the 2 bottles of liquid soap and the 2 wash clothes from the 2nd floor shower room.

Based on observation and interview it was determined the facility failed to ensure adequate ventilation. This was evident on one (upstairs second floor) out of two floors during the facility's recertification survey and during investigation of MD#00213104 during the recertification/complaint survey. The findings include: On 4/14/25 at 7:51AM the surveyor observed a closet utilized for two containers for biohazard trash located between rooms C1 and C3. The ventilation cover was observed on the floor, and an uncovered ventilation area in the ceiling was present, and no air circulation within the room was able to be felt at that time. On 4/14/25 at 8:01AM the surveyor conducted an observation of a closet located between rooms A17 and A15 on the facility's second floor with the Director of Maintenance #20 and Regional Director of Nursing #4 which revealed brand new back up linens in plastic packaging stored within the closet which was observed to be coated in a layer of black soot-type of debris although the closet had no ventilation located within it. Cob webs were additionally observed within the closet which were covered with the black debris. On 4/14/25 at 8:01AM the surveyor conducted an interview with EVS Director #35 who observed the surveyor's concern and reported anything on this hallway is going to look like that, it's black soot. When the surveyor inquired as to how long the concern had existed, they stated: A couple of months. In response, Director of Maintenance #20 reported they would be getting the vents cleaned. At this time, the surveyor shared their concern with Director of Maintenance #20 and Regional Director of Nursing #4 who acknowledged the concern. On 4/14/25 at 1:06PM the surveyor conducted an interview with the facility's Director of Maintenance #20 who reported that upon their return to their job as Director of Maintenance in January of 2025, staff in the A wing of the second floor of the building had reported to them concerns on behalf of themselves as well as residents, that they were breathing black stuff in. Director of Maintenance #20 reported that in response to those concerns, they had went to the attic in order to observe the two hvac units at which time they observed that there were no filters present within the evaporator side which needed to be in place in order to filter the air that enters the resident rooms, and when they had observed the side of the hvac system in which the return air from the rooms gets pulled back through the system, there were filters which had one to two inches of dust and appeared to have not been changed/cleaned for an extended period of time. Director of Maintenance #20 explained to the surveyor that although they had ensured air filters were now present, cleaned, and in functional condition, this would not fix the problem because the debris was now present within the duct work. Director of Maintenance #20 reported to the surveyor that residents and family of residents complained because they could not leave belongings out in the resident rooms for a few days without them ending up covered again in the debris.

Based on observation and interview it was determined the facility failed to ensure a resident (#70) had access to their call device. This was evident for one out of two residents reviewed for call devices during the facility's recertification/complaint survey. The findings include: On 4/8/25 at 8:47AM the surveyor observed Resident #70 did not have their call device to call for staff assistance. Upon further surveyor observation on 4/8/25 at 8:47AM the surveyor observed Resident #70's call device resting behind a cardboard box situated on a nightstand table several feet away from the resident, out of their reach. On 4/8/25 at 8:47AM the surveyor conducted an interview with Resident #70 who reported to the surveyor that they could not reach their call device from their bed. On 4/8/25 at 8:51AM the surveyor requested a dual observation of the concern with the Assistant Director of Nursing (ADON) #3 who observed the concern and stated to Resident #70: Of course it needs to be next to you. ADON #3 was observed obtaining the resident's assigned nurse to observe the concern and asked Licensed Practical Nurse (LPN) #11 where the resident's call bell was located. LPN #11 was observed to be unable to find where the resident's call device was. ADON #3 was observed by the surveyor showing LPN #11 where the call device was, and ADON #3 asked LPN #11 to place it in reach of the resident, to which LPN #11 replied to them: S/he always calls me. At this time, the surveyor observed ADON #3 providing education to LPN #11 and instructed them again, to place the call device within the resident's reach.

Based on administrative record review, clinical record review and staff interviews, it was determined that the facility staff failed to provide adequate supervision and assistance with drinking for 1 of 3 residents reviewed for accidents during the survey (Resident #174). The facility's failure resulted in a hot water spill, causing a burn with partial thickness skin loss to Resident #174's right thigh, and was subsequently cited as actual harm. This finding was identified during investigation of facility reported incident #MD 308. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. BIMS stands for Brief Interview for Mental Status. The BIMS test is used in nursing homes to assess the cognitive function of a resident at that moment. On 4-21-2021 a review of administrative records related to the facility's investigation of MD 308 revealed, on 1-05-2021 during the 3:00 PM-11:00 PM shift, Licensed Practical Nurse (LPN) #1 provided Resident #174 with a cup of hot water at the resident ' s request. According to LPN #1's written statement, he had used the microwave for two (2) minutes to heat Resident #174's water. At approximately 8:00 PM the same evening, Resident #174 made LPN #1 aware that he/she had spilled the hot water on his/ her lap. LPN #1's statement indicated that his assessment of Resident #174's skin on 01-05-2021 did not reveal an injury. On 04-21-2021 a review of Resident #174's clinical record revealed LPN #1 did not notify the attending physician of the incident where the resident had a hot water spill, and did not report the incident to any staff. LPN #1 did not document an assessment of Resident #174's skin and/or pain in the resident's medical record. On 01-06-2021 at approximately 10:00 AM, LPN #2 observed multiple large fluid filled blisters on Resident #174's right thigh. LPN #2 notified the attending physician and the Director of Nursing (DON) about the blisters. Further review of Resident #174's clinical record revealed that on 01-06-2021 the attending physician assessed Resident #174's thigh. The physician noted scattered intact blisters to the anterior surface of the right thigh. The physician ordered intravenous hydration of Normal Saline [MEDICATION(S)] and [MEDICATION(S)] ointment to the area for 14 days. The physician also ordered prophylactic antibiotic [MEDICATION(S)] 500-125 mg three times a day for 7 days. On 01-07-2021, all of the blisters popped, so an order was received for xeroform dressing to the right thigh instead of the [MEDICATION(S)]. On 4-21-2021 a continued review of Resident #174's clinical record revealed that prior to the incident Resident #174 had a MDS with an assessment review date (ARD) of 12-23-2020. According to the MDS assessment Resident #174 was assessed as total dependent for ADLs (activities of daily living) with one-person physical assistance for eating/drinking. Resident #174 was alert and oriented to person, place and time. The resident had a history of stroke with left sided weakness. Resident #174's care plan, initiated on 12-16-2020, stated that the resident was dependent for ADL care but did not specify the number of staff needed to assist the resident with ADLs. On 12-23-2020 Resident #174 had a BIMS score of 13 out of 15, which indicates the resident was cognitively intact On 04-21-2021 Further review of Resident #174's clinical record revealed the resident had a gastrostomy tube (G-tube) and was on continuous tube feeding. According to a physician's order dated 12-31-2020, the resident was on pleasure feed (at the request of a patient or family member, a doctor will order pleasure feed to indulge a person's special request, even if they have been on a strict special diet or are designated as no intake by mouth. At this time the purpose of food is enjoyment, not proper nutrition). As a part of the pleasure feed order, the resident could have ice chips, thin water (via cup or straw), and applesauce/yogurt with staff supervision. The pleasure feed ended on 01-13-2021. On 04-21-2021 at 10:34 AM, an interview with LPN #2 revealed at approximately 10:00 AM on 01-06-2021 she noticed blisters on Resident #174's right thigh. The resident told her about the hot water spill that occurred the previous night. She notified the attending physician and got orders to treat the burn site. On 04-21-2021 at 12:43 PM, an interview with Geriatric Nursing Assistant (GNA) #4 revealed on 01-05-2021 during the 11:00 PM- 7:00 AM shift while turning Resident #174, GNA #4 noticed a boil on the Resident ' s right thigh. When she asked the resident what happened, the resident told her about the hot water spill. She reported it to Registered Nurse (RN) #3. GNA #4 said she was standing a couple of feet away from RN #3. GNA #4 said RN #3 did not say anything to her. On 04-21-2021 at 12:27 PM, in an interview, RN #3 stated he did not receive any report that Resident #174 had a hot water spill or sustained an injury. On 04-22-2021 at 10:18 AM, an interview with Nurse Practitioner confirmed that Resident #174 had multiple scattered blisters on his/her right thigh due to a burn. She was notified of the incident by nursing staff at approximately 10:00 AM on 01-06-2021. On 04-22-2021 at 10:23 AM, a telephonic interview with LPN #1 confirmed that he provided a big cup of water, that he heated up for two (2) minutes in a microwave, to Resident #174 on 01-05-2021 at approximately 8:00 PM. He left the hot water in a cup with a lid on Resident #174's bedside table. After 10 to 15 minutes, the resident called for another cup of hot water. The resident reported to LPN #1 that he/she had spilled the hot water on his/her right thigh. LPN #1 assessed the resident ' s thigh but did not see any skin discoloration and the resident denied any pain. LPN #1 did not notify the attending physician, did not report to unit supervisor, and did not document the incident in Resident #174's medical record. LPN #1 told the surveyor that Resident #174 was able to eat and drink independently. On 04-22-2021 at 12:00 PM, an interview with Resident #174's Speech Therapist revealed she evaluated the resident on 01-05-2021. She told the surveyor the resident was not allowed to have coffee. She said the resident had a physician order dated, 12/31/2020, to have ice chips, thin water (via cup or straw), and applesauce/yogurt with staff supervision. According to occupational therapy (OT) progress report for service period of 12-24-2020 through 01-06-2020, Resident #174 needed moderate assistance for personal grooming and hygiene. On 04-22-2021 at 12:26 PM, an interview with the Rehabilitation Director revealed Resident #174 was admitted to the facility with severe impairment of all extremities so the resident was dependent on staff for ADLs. During the occupational therapy service period of 12-24-2020 through 01-06-2020, the resident had improved to moderate impairment with ability to complete tasks for 15 minutes. The resident received occupational therapy on 01-04-2021 and the resident was able to do personal grooming and hygiene tasks with moderate assistance. The resident still required moderate assistance to eat or drink. On 04-22-2021 at 2:49 PM a second interview with the Rehabilitation Director revealed moderate assistance for eating and drinking meant that Resident #174 could do 50% to 74% of the tasks. Staff would still assist the resident because the resident was not able to do 100% of the task. On 04-22-2021 at 11:35 AM, an interview with the Director of Nursing revealed facility staff were not trained in the use of microwaves before the incident. She informed the surveyor all facility staff were given in-services on safe use of microwaves after the incident. No additional information was revealed.

Based on surveyor observation, review of the clinical record, and staff and responsible party interviews, it was determined that the facility staff failed to report cigarettes repeatedly observed on the floor of a resident's room and failed to provide adequate supervision for an unsafe smoker in the facility. This finding was the result of investigation of facility reported incident #MD 844. An immediate jeopardy (IJ) for resident's safety related to unsafe smoking practice was determined on 05-14-19 at 2:40 PM for resident #02. On 05-14-19 at 8:41 PM, the facility provided an IJ removal plan to the Office of Health Care Quality (OHCQ). The IJ was abated on 05-15-19 at 3PM following the facility's implementation of corrective actions to ensure the safety of the resident. The findings include: On 05-13-19 at 3:00 PM upon entry into room of resident #02 for investigation of #MD 844, surveyor observed a partially smoked cigarette on the overbed table along with two other cigarettes. The partially smoked cigarette was not lit. Surveyor also observed a cigarette lighter in full view on the floor under the bed immediately at the edge of the side of the mattress. Further observation revealed resident #02 with a nasal cannula in the nose, with the tubing attached to oxygen concentrator near the bedside. The surveyor also observed an oxygen cylinder (E-tank) approximately 10 feet from the bedside with a stack of numerous newspapers sitting on the floor next to the oxygen cylinder. The cylinder gauge read 2000 PSI (pounds per square inch). (The maximum PSI for an E-tank is 2200 PSI, indicating this cylinder was almost full.) On 05-13-19 at 3:40 PM, the director of nursing and administrator accompanied the surveyor into resident #02's room to confirm the presence of the cigarettes and lighter. The director of nursing removed the lighter from the room into the hallway and verified that it was working properly as one attempt resulted in the presence of a flame. Resident #02 asked to see the lighter and then stated yes, that's my cigarette lighter. Review of the facility smoking policy with a revision date of 07-24-18 revealed patients will not be allowed to maintain their own lighter, lighter fluid or matches. On 05-13-19 at 3:45 PM, interview with the director of nursing revealed that all smoking materials were to be kept by the nursing staff in the cart at the nurse's station. Neither the administrator nor the director of nursing could explain the presence of smoking materials in resident #02's room. The director of nursing stated resident #02 was significantly more confused than previously. On 05-13-19 at 3:50 PM, further observation of resident #02's room by the surveyor revealed a carton of cigarettes in a bag in a basin by the sink across from the bed. The director of nursing removed all smoking materials from the resident's room. Review of the clinical record revealed that the resident was admitted with [DIAGNOSES REDACTED]. Review of a care plan initiated on 04-17-18 for resident #02 revealed that the resident was to have supervised smoking only. The care plan also stated facility staff was to ensure that there was no oxygen use in smoking areas and that facility staff were to monitor resident #02 ' s compliance with the facility smoking policy. Further review of the clinical record revealed a care plan evaluation note dated 12-17-18 in which the nurse documented observation of unsafe smoking by resident #02. The resident was being supervised at the time of the observation, but chose to ignore the staff's request to remove the plastic gloves being worn while smoking. On 02-28-19, resident #02 was again counseled about safe smoking practices, however, the resident refused to sign the smoking assessment form which was updated at the time because of the resident's history of sharing cigarettes. On 03-07-19, resident #02 was transferred to the hospital for evaluation of increased mental status changes and abnormal labs. The director of nursing stated the resident did not resume supervised smoking upon readmission to the facility from the hospital on 03-09-19 because of a decline in overall physical condition which left the resident primarily bed bound. The director of nursing was unaware that resident #02 had any cigarettes until surveyor's observation on 05-13-19 On 05-14-19 at 9:00 AM, interview with the director of nursing and facility administrator revealed that administrative staff determined that resident #02 purchased cigarettes when transported out for a medical appointment by an independent transportation company on 05-09-19. On 05-14-19 at 1:00 PM, interview of charge nurse staff #1 revealed that, on 05-13-19 as of 10:00 AM, based on earlier observation, resident #2 did not have cigarettes at the bedside. When asked how resident #02 could have obtained the cigarettes observed by the surveyor after the initial observation, staff #1 replied that resident #02 can transfer in and out of bed without staff assistance at times. Surveyor attempt to interview resident #02 was unsuccessful as the resident became angry when facility staff removed smoking material from the room. The resident did state that the charge nurse, staff #1, had been the only person in the room prior to surveyor's initial observation of the smoking materials at the bedside. On 05-14-19 at 2:00 PM during an interview, staff #2 informed the surveyor that he/she had observed cigarettes on the floor in resident #02's room on several occasions in the four months that he/she had been cleaning the resident's room. Staff #2 also stated that he/she swept some whole cigarettes, some broken, and some cigarette butts from off the floor and beneath the bed. Staff #2 also stated that he/she had not seen any cigarette butts for about two weeks on the floor. Staff #2 stated he/she did not alert anyone to the finding of cigarettes on the floor of the resident #02's room. On 05-14-19 at 2:10 PM, a follow up interview with the director of nursing confirmed staff #2 had not alerted anyone of the findings. A review of staff #2's personnel file revealed that the facility's smoking policy was not included in the orientation checklist. On 05-14-19 at 2:40 PM, the facility administrator and director of nursing were notified of the immediate jeopardy citation. On 05-14-19 at 8:41 PM the facility's IJ removal plan included review of the facility smoking policy and the need to report violations immediately with 100% of facility staff, revision of resident #02's physician's orders [REDACTED]. The plan also included audits of all resident rooms to verify the absence of smoking materials in any resident rooms, and development of an audit tool to monitor the smoking area for compliance. Smoking assessments were to be completed on all new admissions effective immediately. Letters were to be mailed to all family members/responsible parties reinforcing facility smoking policy, and letters to transportation vendors notifying them that they are prohibited from taking residents to any location other than the designated appointments that had been approved were also included in the removal plan. On 05-15-19 at 3:00 PM, the administrator and director of nursing were notified that surveyors had verified that the removal plan had been fully implemented, and the immediate jeopardy citation was abated.

Based on surveyor review of the clinical record and facility staff interview, it was determined that the facility failed to provide adequate assessment, planning, and supervision to ensure the safety of resident #60. This finding was evident in 1 (#60) of 4 residents reviewed for accidents. The findings include: On [DATE], surveyor review of the clinical record for resident #60 revealed the resident was admitted to the facility with a [MEDICAL CONDITION]. A [MEDICAL CONDITION] (trach) is an opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube. A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. Breathing is done through the [MEDICAL CONDITION] rather than through the nose and mouth. Review of the hospital discharge paperwork revealed a social work progress note, written on [DATE], that documented resident #60 has required either a mitt or wrist restraint as he/she has intermittently pulled at his/her trach. Review of the hospital discharge summary revealed that, on exam, resident #60 was [MEDICAL CONDITION], PERRL (pupils equal, round, responsive to light), does not follow commands, spontaneous movement in LUE (left upper extremity), purposeful. The resident was discharged to rehabilitation facility with orders for physical therapy, occupational therapy, and speech therapy. In addition, the discharge summary documented that resident #60 has had a sitter to avoid picking and pulling out lines. Sitter to continue in rehab. Review of a care plan meeting notel written on [DATE]l revealed that resident #60 was improving with bed mobility and seating on the side of the bed. The note also documented that the resident had a private care giver provided by an acute care hospital. Review of a nursing note, written on [DATE], revealed that resident #60 had tried to pull [MEDICAL CONDITION] and that was observed many times. There was no evidence of an assessment, evaluation, re-evaluation, or an analysis of risks of resident #60's identified behavior of pulling at the trach. Nor was there evidence that the facility considered or attempted interventions other than the sitter. In addition, there was no care plan in place to address the behavior or the plan for the sitter. (Refer to F656) Further review of the clinical record revealed a transfer note, written on [DATE], that documented resident #60 pulled out the trach. In addition, a nursing progress note for resident #60 was written on [DATE] (as a late entry for [DATE]) which noted that, around 5:30 AM on [DATE], the resident removed [MEDICAL CONDITION] was found unresponsive. The nurse called for a code and 911, replaced the trach, and CPR (cardiopulmonary resuscitation that included the use of an automatic defibrillator) was initiated . EMS (emergency medical system) transported the resident to the emergency room . Further review of resident #60's clinical record revealed a hospital discharge summary, written on [DATE],7 that documented discharge [DIAGNOSES REDACTED]. Cerebral anoxia is when the brain stops getting oxygen which can cause brain damage and death. Cardiac and respiratory arrest can lead to cerebral anoxia. The discharge summary further revealed that the resident was on a ventilator and was terminal. On [DATE] at 1:25 PM, surveyor interview with the administrator revealed that the administrator was aware of the transfer of resident #60 to the hospital after [MEDICAL CONDITION] pulled out, however, was not aware of any of the details of the events, and did not know if there was any investigation or internal review. On [DATE] at 1:35 PM, surveyor interview revealed that the social worker was aware that staff reported that resident #60 had pulled [MEDICAL CONDITION] while the sitter was in the room, and that the nurse had performed CPR. The social worker was unaware of any investigation or review of the events on [DATE] by the agency that employed the sitter. On [DATE] at 2:20 PM, surveyor interview with staff nurse #1 revealed that the nurse responded when the facility Geriatric Nursing Assistant (GNA) called for help for resident #60. Upon entering the room, staff nurse #1 saw that the resident had pulled out [MEDICAL CONDITION] the sitter was beside the resident. Staff nurse #1 stated that the sitter said they had seen was [MEDICAL CONDITION] the hands of resident #60. Staff nurse #1 did not know how long [MEDICAL CONDITION] been out, and explained the GNA had been doing rounds, so it was between 5:30 AM and 6 AM that the incident occurred. The last time resident #60 was checked by staff nurse #1 was around 4:10 AM. On [DATE] at 7:15 AM, surveyor interview with the staff #3 (GNA) revealed that staff #3 was doing their last rounds of the shift starting with resident #60. When staff #3 went into the room, the resident'[MEDICAL CONDITION] detached and laying on the chest, so staff #3 called for the nurse. Staff #3 stated that the sitter was sitting in the chair and had not reacted to the situation. Staff #3 was not able to say what the sitter was doing, as staff #3's focus was on the resident. On [DATE] at 8:35 AM, surveyor interview of the sitter (a certified nursing assistant CNA) revealed that the sitter had worked with resident #60 for a few weeks and was responsible to watch the resident who pulled at tubes. The sitter stated that the resident pulled at the tube on the neck frequently. When the resident pulled at the trach, the sitter would tell the resident no then call staff for help if needed. On [DATE] before 6 AM, the sitter was sitting with resident #60 when staff #3 came into check the resident. Staff #3 ran out to get the nurse and the sitter put on the call light even though the nurse was already summoned by staff #3. The sitter could not say when the resident had pulled out the trach. In addition, the sitter could not explain how the resident was able to pull out [MEDICAL CONDITION] why the sitter had not identified or intervened with the problem before staff #3 had entered the room. On [DATE] at 9:45 AM, surveyor interview with the Director of Nursing revealed that according to the administrator at the staffing agency, they provide a hands on and a hands off sitter. The sitter that was provided for resident #60 was a hands off sitter and that meant the sitter could not physically touch the resident. On [DATE] at 3 PM, surveyor interview with the Director of Nursing revealed the agency would provide sitters with a detailed report on the resident and the reason why they were sitting/watching. Once the sitters arrived to the facility, the floor nurse would give report to the sitter. In addition, the staffing agency disclosed that, when a CNA (Certified Nursing Assistant) instead of a GNA was sent to a nursing facility, approval was required from someone in administration at the facility. The Director of Nursing was not employed by the facility at that time and the administrator could not recall anything about the approval. The facility could not verify that the sitter had training regarding emergency procedures or resident abuse/neglect. On [DATE] at 3:30 PM, surveyor interview with the Respiratory Therapy Manager revealed that the facility had previously taken care of residents that pull at the trachs and had used mittens to deter the behavior. If a Respiratory Therapist (RT) noted that a resident was at risk for pulling out the trachd the RT would notify the nurse to get an order for [REDACTED].

Based on surveyor observations and staff interviews, it was determined that the facility failed to ensure proper food preparation practices and to store, prepare and serve food under safe conditions. This finding was evident in the facility's kitchen during the kitchen/ food service observation. The findings include: 1. On 8-15-16, at 11:40 AM, surveyor observation during the tray line service for lunch, revealed that the facility failed to ensure proper food preparation practices for the prevention of food borne illness. This deficient practice placed all 13 residents on pureed diets at risk for serious harm of a potential food borne illness due to improper cooling of potentially hazardous food. Therefore, an immediate jeopardy to the residents' health was determined on 8-15-16 at 12:15 PM. The immediate jeopardy was abated on 8-15-16 at 8:05 PM following the facility's implementation of corrective actions to ensure the health and safety of all residents. On 8-15-16 at 11:40 AM, the surveyor and County Environmental Health Sanitarian (EHS) observation of the tray line service revealed that the pureed ham sandwich temperature was 82 degrees F. Residents who require a modified consistency diet may be at risk for developing food borne illness because of the increased number of food handling steps required when preparing pureed and other modified consistency foods. Although almost any food can be contaminated, certain foods are considered more hazardous than others and are called potentially hazardous foods (PHF). When hot pureed, ground, or diced food fall into the danger zone (below 135 degrees F), the mechanically altered food must be reheated to 165 degrees F for 15 seconds. When cooling PHF's, internal temperatures should be cooled from 135 degrees to 70 degrees F within 2 hours and from 70 degrees F to 41 degrees F or less within an additional 4 hours. The EHS informed the cook that the pureed sandwich temperature was in the danger zone for PHF, (between 41 degrees F and 135 degrees F) and could not be served. The cook then described the process used to prepare the pureed ham sandwich: the pureed bread was prepared at 9:50 AM and then put into the refrigerator to cool. At around 11:30 AM, she made a tray of pureed sandwiches which consisted of a layer of the pureed bread, followed by a layer of the pureed ham, followed by another layer of the pureed bread. She then cut individual servings of the sandwiches and placed them in a tray on the cooling table. There is no evidence that the pureed bread had been cooled to a safe temperature within the specified timeframe. The EHS again stated that 82 degrees F was in the danger zone and the pureed sandwiches were unsafe for consumption. The cook told the surveyor that she disagreed with the EHS's method of taking the temperature and did not stop the staff from transporting the pureed meal trays to the units. At 12:00 PM, the surveyor and EHS left the kitchen to discuss their concerns with the survey team leader. The 3 other surveyors, who were assigned to the meal observation, recovered the pureed ham sandwiches from the tray carts and/or from residents. No residents were known to eat the pureed ham sandwiches. An alternate meal of chicken and vegetables was prepared for the residents who required a pureed diet. On 8-15-16, at 5 PM, surveyor interview with the administrator revealed that the kitchen staff did not inform her of the problem until after the tray carts had been delivered to the units. 2. On 8-15-16 at 8:30 AM, this surveyor's initial observation of the kitchen revealed that the reach-in refrigerator thermometer read 60 degrees F. Three boxes of butter were observed inside the refrigerator. Interview of the cook revealed that the refrigerator had conked out on Saturday and although she had told an employee to put the boxes of butter into the walk in refrigerator, he had not done so. The kitchen staff was aware of the malfunctioning refrigerator and the cook (staff #4) reported that the maintenance manager would be looking at it later that day. a. The kitchen had insufficient ventilation/air conditioning as demonstrated by a room temperature of 86 degrees F. Observation revealed one window air conditioning unit in the main area and another unit in the walk through area leading to the dry storage room. b. Observation revealed an unlabeled/undated pitcher of beverage in the walk-in refrigerator. c. Observation revealed foods stored in cardboard boxes in the dry food storage room. Additionally, shelves were observed to be in disrepair with chipped paint and dirty. d. Observation revealed several ants in a cardboard box that held white cake mix and a bowl of cheerios was left open to air. e. Observation revealed that the ceiling near the food prep area was in disrepair with chipped paint and the floor behind the stove and oven was dirty, grimy and littered with trash. In addition, wall surfaces throughout the kitchen were dirty and greasy. The window mounted box fan blades were dusty and the ice chest seal was loose, preventing a tight seal. f. Observation revealed dead insects in the ceiling light cover between the walk through area of the kitchen and dry storage room. The facility failed to store, prepare and serve food under sanitary conditions.

Based on review of the medical record, observation, and interviews with staff and the ombudsman, it was determined that the facility staff failed to apply bilateral arm splints correctly, failed to monitor the condition of the skin under the splints, and failed to provide accurate and timely documentation of skin impairment for resident #3. This finding is considered to be harm done. The findings included: On 04-18-13, record review revealed that resident #3 incurred multiple fractures and a [MEDICAL CONDITION] as a result of a motor vehicle accident. The resident appears to be sleeping frequently but will open their eyes if roused. Staff reported that the resident can follow simple commands approximately 50% of the time. Due to the neurological injury, the resident has muscle spasms causing his arms and legs to flex (bend). To maintain function of the joints and prevent contractures (a fixed loss of motion in a joint), the physician ordered splints for both wrists, the left elbow, and AFO (ankle foot orthotic - like a brace) boots for both feet when out of bed and multipodus boots (a protective orthotic or boot that corrects foot misalignments and minimizes the chance of skin breakdown) for both feet when in bed. The resident's feet are plantar flexed which means that the foot and toes are dropped down toward the bed. Staff reported that the resident is only up out of bed for 2 hours per day and that the AFO boots are on the resident only for those two hours. a. The following addresses the upper extremities. On 04-17-13 at 12:45 PM, interview with the local ombudsman revealed that "she was told" that the GNA's (geriatric nursing assistants) failed to apply the splints for both arms correctly which caused two pressure sores to develop - one on the left elbow and one on the left wrist. On 04-18-13 at 3 PM, observation of the resident revealed that the resident was lying on an air mattress with no splints on. A healing pressure sore was observed on the inside of the medial left wrist and the posterior left elbow. Record review revealed an order on 02-26-13 that the wrist splints were to be applied to both wrists for 5 to 7 hours daily. Review of the TARs (treatment administration record) for February, March, and April 2013 revealed that the splints were applied at 11 AM and removed at 5 PM. The resident also had a left arm extension elbow splint to straighten the left elbow. On 04-19-13 at 9: 30 AM, interview with the OT (occupational therapist) revealed that he was involved when the splints were ordered and then discharged the resident to nursing after training the staff on their use. He stated that the director of therapy services and the representative from the company who made the splints gave a "whole day" inservice to the facility day staff who were supposed to train the evening staff. He said he did "periodic checks" on the resident. Further interview with the OT revealed that on 04-05-13, the OT said that "someone" (he couldn't remember if it was staff, family, or visitor) asked him to check the wrist splints. He observed that the right wrist splint was on the left wrist and the left on the right wrist. This misplaced splint pushed the left elbow splint up on the arm which left the left elbow unprotected. This combination resulted in a blister on the left wrist and elbow which opened to stage II pressure sores. A stage II pressure ulcer is a partial thickness skin loss. The ulcer is superficial and presents clinically as a abrasion, blister, or shallow crater. The OT stated that the splints were sometimes left on all night also although interviews with staff did not substantiate this. Review of the TARs revealed that the nurses were documenting that the splints were being removed at 5 PM. The OT wrote an order on 04-05-13 to discontinue the wrist splints "until the evening staff were educated on maintenance of orthotics". On 04-19-13 at 9:20 AM, interview with the Assistant Director of Nursing (ADON) for the resident's unit revealed that she was not aware that the wrist splints were not being applied correctly. Additionally, she later stated that the left elbow "skin tear" started as a blister, indicating that it was a pressure sore. When asked about training for the evening staff, she said she knew that the evening staff "needed to be inserviced" related to the boots but had received training on the arm splints. Review of the skin sheets revealed that the left elbow pressure sore was identified on 04-07-13 and described as a skin tear. The left wrist skin sheet started on 04-8-13 and it was described as a blister. Review of the nursing notes revealed that a change in condition documenting the new onset/change in skin condition was written on 04-07-13, two days after they were noted by the OT and this documentation only noted a skin tear on the left elbow. The facility provided an incident report dated 04-08-13 which documented that the resident had a skin tear on the left elbow and a blister on the left inner wrist. an order for [REDACTED]. The director of therapy provided an inservice of splinting and contracture management completed on 02-25-13. b. The following relates to the pressure sores on the bilateral feet. Record review revealed that the resident was admitted with multipodus boots for both feet which were to be worn when in bed. Staff reported that the resident is in bed except for 2 hours when he is up in the chair. The resident is followed by a consultant orthopedic physician. Review of this consultant's orders written on the 02-18-13 follow up visit revealed he wanted PT (physical therapy) for "aggressive ROM (range of motion) of the bilateral ankles and knees" and bilateral bracing with AFO boots to keep the feet "out of equinas (sic)". Equinus is a condition in which the upward bending motion of the ankle is limited. Someone with equinus lacks the flexibility to bring the top of the foot up toward the front of the leg. On 03-01-13, an order was written to discontinue the AFO's when out of bed because new AFOs which were "more appropriate" were ordered and then PT would re-assess when the new boots arrived. Review of the PT (physical therapy notes) revealed that the initial evaluation related to the new AFO boots was on 03-07-13. The PT documented that the reason for the referral was due to the AFO's to be worn when out of bed and the assess the resident's tolerance and educate nursing staff on donning and doffing the boots. This schedule became wearing them for the two hours the resident was up out of bed but no actual times were specified or recorded. The resident was discharged from PT services on 03-14-13. On 04-10-13, the PT contacted the resident's attending physician to discontinue the AFOs when out of bed and the multipodus boots while in bed due to skin breakdown and poor tolerance". Review of the pressure sore skin sheets revealed one for the plantar (bottom) surface of both feet. The length of the left sore was 1 cm. (centimeter) by 5 cm. and the right was 3 cm. by 1 cm. One centimeter is approximately a half inch and five centimeters is approximately two inches. Both areas were described as deep purple in color and intact. The deep purple color indicates a deep tissue injury under the skin. Observation of the resident on 04-18-13 at 3 PM revealed deep tissue injuries were noted on the right lateral metatarsal (over the bones below the toes) area of the right foot, a bruised area on the right great toe and healed areas on the lateral left foot metatarsal area. On 04-19-13 at 9:40 AM, interview with the PT who worked with the resident revealed that the resident should have had "time off" without the boots on and indicated, as did the director of therapy, that nursing should have obtained an order for [REDACTED]. No evidence was identified in the record of a time the AFO boots were applied and removed or when the resident was gotten up to the chair and returned to bed. Staff stated they were on only when the resident was up in the chair. Record review revealed no physician orders for routine skin checks by licensed staff and no evidence from the nursing notes of skin assessments until the pressure sores were identified. A care plan was developed on admission for risk of skin breakdown according to staff, The original care plan was not available because the care plan had been changed on 04-10-13 to actual skin breakdown. The interventions included: evaluate for localized skin problems, monitor skin integrity every shift and as necessary. No care plan addressing the multiple splints was identified.