Every finding on record at Fairmont Rehabilitation Hospital

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in food handling, storage, and preparation areas for 53 residents who received meals from the kitchen when:1. Debris was present inside the clean utensils drawer;2. Mold was found inside a bag of cherries stored in the refrigerator;3. Cereal container lids were found loose;4. An opened box of iced tea bags in the dry goods area contained a plastic bag with a hole;5. Four spice containers were observed with lids that were open and could not be closed;6. Two large spice containers with screw-top lids were not tightly sealed;7. The casserole scalloped potatoes box was not properly sealed;8. Inconsistent food labeling was observed, including multiple opened liquid seasonings and sweetener that lacked open-by-dates; 9. Wet snack containers were found stacked in a cabinet;10. The food preparation table was found with debris and dust accumulation;11. One cutting board was in use in the kitchen, limiting the ability to properly clean and sanitize between tasks;12. The oven/range was found with significant grease buildup;13. The wall surface directly above the manual dishwashing sink in the kitchen was cracked and chipped; and14. Two pieces of fish were found thawing improperly in a bowl of still water. These failures have the potential to result in cross-contamination and foodborne illness for 53 residents.Findings:1. During a concurrent observation and interview on 5/4/26 at 8:20 AM with the Certified Dietary Manager (CDM), the CDM stated the utensils drawer was last cleaned on 4/30/26. The CDM further stated that the debris found inside the drawer may have originated from the wooden surface above the drawer and indicated there was a risk of cross-contamination. During an interview on 5/6/26 at 11:09 AM with the Registered Dietician (RD), the RD stated the utensils drawer needed repair because it could lead to food contamination During a review of the facility's policy titled, SANITATION, dated 2023, the policy indicated, .All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seam, cracks and chipped areas.2. During a concurrent observation and interview on 5/4/26 at 8:20 AM with the CDM, the CDM was shown a bag of cherries in the refrigerator that contained visible mold. The bag was not labeled with a use-by-date. The CDM stated she would discard the bag because it posed a risk for contamination.During an interview on 5/6/26 at 11:09 AM with the RD, the RD stated that mold inside the cherries bag could cause food poisoning.During a review of the facility's policy titled, LABELING AND DATING OF FOODS dated 2023, the policy indicated, .All food items in the storeroom, refrigerator, and freezer need to be labeled and dated based on established procedures. it further requires that .the individual opening or preparing a food shall be responsible for date marking. and that foods .stored cold greater than 24 hours will be marked with a Use By date. The Use-by date will incorporate the open date.According to the FDA Food Code (2022), Chapter 3, 3-501.18, indicated, .Ready-to-Eat, Time/Temperature Control for Safety Food.shall be discarded if it.is in a container or package that does not bear a date or day. (https://www.fda.gov/food/fda-food-code/food-code-2022)According to the FDA Food Code (2022), Chapter 3, 3-701.11, indicated, .A food that is unsafe, adulterated or not honestly presented.shall be discarded (https://www.fda.gov/food/fda-food-code/food-code-2022)3. During a concurrent observation and interview on 5/4/26 at 8:20 AM with the CDM, the CDM was shown cereal containers with loose lids. The CDM stated that loose lids created a risk for pests to enter the cereal.During an interview on 5/6/26 at 11:09 AM with the RD, the RD stated that containers must have a tight-fitting lid to prevent pests from entering and contaminating food.4. During a concurrent observation and interview on 5/4/26 at 8:20 AM with the CDM, the CDM was shown an improperly closed box in the dry goods area containing multiple plastic bags of iced tea, one of which had a hole. The CDM stated that pests could enter through the hole.During an interview on 5/6/26 at 11:09 AM with the RD, the RD stated that a plastic bag of iced tea with a hole poses a risk of food contamination. 5. During a concurrent observation and interview on 5/4/26 at 8:20 AM with the CDM, the CDM was shown four spice containers with lids that were open. The CDM attempted to close the lids but was unsuccessful and stated that the containers would be discarded because pests could enter the spices. During an interview on 5/6/26 at 11:09 AM with the RD, the RD stated that containers should be tightly closed to prevent food contamination. 6. During a concurrent observation and interview on 5/4/26 at 8:20 AM with the CDM, the CDM was shown two large spice containers with screw-top lids that were not tightly sealed. The CDM stated that pests could enter through the loosely sealed lids.During an interview on 5/6/26 at 11:09 AM with the RD, the RD stated that containers with screw-top lids should be tightly closed because it can cause food contamination. 7. During a concurrent observation and interview on 5/4/26 at 8:20 AM with the CDM, the CDM was shown a casserole scalloped potatoes box that was not properly sealed. The top cardboard flap showed signs of previous opening. The CDM stated that they use tape to re-seal the box and acknowledged that improperly re-sealed boxes create a risk for pests to enter.During an interview on 5/6/26 at 11:09 AM with the RD, the RD stated that a casserole scalloped potatoes box should be fully sealed because it posed a risk for food contamination. 8. During a concurrent observation and interview on 5/4/26 at 8:20 AM with the CDM, the CDM stated that only the pancake/waffle syrup had a received-by-date. The CDM further stated that the other liquid seasonings and sweeteners did not have received-by dates, opened-by dates, or use-by dates. The CDM explained that because staff came from different facilities, they followed their own individual labeling practices, with some applying opened-by date and others not applying any.During a follow up interview on 5/5/26 at 12:50 PM with the CDM, the CDM stated that opened-by date should have been placed on the liquid seasoning and sweeteners because these items can spoil after opening before the expiration date.During an interview on 5/6/26 at 11:09 AM with the RD, the RD stated that due to this practice the liquid seasonings and sweeteners could have been expired without the kitchen's knowledge and could cause food poisoning.During a follow up interview on 5/6/26 at 3:05 PM with the RD, the RD reviewed the facility policy titled Labelling and Dating dated 2023. The RD acknowledged that there was no consistent methodology on labeling of food and stated she also understood the importance of use-by-date and would ensure the kitchen implements it.During a review of the facility's policy titled, GENERAL RECEIVING OF DELIVERY OF FOOD AND SUPPLIES dated 2023, the policy indicated, .label all items with the delivery date or use-by date.During a review of the facility's policy titled, LABELING AND DATING OF FOODS dated 2023, the policy indicated, .All food items in the storeroom, refrigerator, and freezer need to be labeled and dated based on established procedures for either food safety or product rotation.the individual opening or preparing a food shall be responsible for date marking at the time of processing and/or storage.For foods that are commercially processed, ready to eat and intended to be stored cold greater than 24 hours will be marked with a Use By date. The Use By date will incorporate the open date for TCS (Time/temperature control for food safety) food.9. During a concurrent observation and interview on 5/4/26 at 8:20 AM with the CDM, the CDM was shown snack containers stacked inside a cabinet that were wet. The CDM stated that stacking wet containers posed a risk for contamination.During an interview on 5/6/26 at 11:09 AM with the RD, the RD stated that containers stacked in a cabinet while wet could grow bacteria and cause food contamination and/or food poisoning.According to the FDA Food Code (2022), Chapter 4, 4-901.11, .After cleaning and sanitizing, equipment and utensils shall be air-dried. https://www.fda.gov/food/fda-food-code/food-code-202210. During a concurrent observation and interview on 5/4/26 at 8:20 AM with the CDM, the CDM was shown the food preparation table with debris and dust on one side. The CDM stated that the debris and dust presented a risk for food contamination.During an interview on 5/6/26 at 11:09 AM with the RD, the RD stated that anything that comes in contact with food must be clean because it can cause food contamination.According to the FDA Food Code (2022), Chapter 4, 4-601.11, indicated, .Equipment food-contact surfaces and utensils shall be clean to sight and touch. Non-food contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue, and other debris. (https://www.fda.gov/food/fda-food-code/food-code-2022)During a review of the facility's policy titled, SANITATION, dated 2023, the policy indicated, .All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open sea, cracks and chipped areas.11. During a concurrent observation and interview on 5/4/26 at 8:20 AM with the CDM, the CDM stated that the kitchen uses only one cutting board for all tasks and washes it continuously throughout the day. The CDM noted they have brand new cutting boards in stock and readily available.During a follow up interview on 5/5/26 at 12:50 PM with the CDM, the CDM reiterated that the facility uses the same cutting board for meat/poultry, vegetables, and ready to eat foods. The CDM explained that staff wash and sanitize the cutting board after each use, run it through the dish machine, and air dry it before re-use. The CDM further stated there is no cleaning log for the cutting board because it is in continuous use. The CDM acknowledged this practice can present a risk for cross contamination and foodborne illness.During an interview on 5/6/26 at 11:09 AM with the RD, the RD stated the use of a single cutting board could cause cross-contamination.During an interview on 5/7/26 at 10:02 AM with the Assistant Supervisor (AS), the AS stated that the facility now uses two cutting boards after taking a new one out on 5/6/26. The AS confirmed that using only one cutting board increases the risk for food contamination.During a review of the facility's policy titled, FOOD PREPARATION, dated 2023, the policy indicated, .Keep raw and cooked foods separate. Use separate cleaned and sanitized cutting boards.During a review of the facility's policy titled, SANITATION, dated 2023, the policy indicated, .Separate chopping boards are to be used for preparing meats and vegetables. 12. During a concurrent observation and interview on 5/4/26 at 8:20 AM with the CDM, the CDM observed the oven/range with significant grease buildup on non-food contact surfaces, including inside the recessed oval opening on the side of the range adjacent to the cooking surface, around the control knobs and surrounding area, and on the exterior sides. The CDM stated she would contact the Maintenance Director to have it cleaned because it was a fire hazard.During an interview on 5/5/26 at 11:03 AM with the Maintenance Director (MAT), the MAT stated that he believed the kitchen staff performed deep cleaning of the oven and that removing grease was part of their responsibility. The MAT further stated that the excessive grease buildup was his fault and that it posed a risk for fire.During an interview on 5/6/26 at 11:09 AM with the RD, the RD stated an oven/range with grease buildup is a risk for fire.During a review of the facility's policy titled, SANITATION, dated 2023, the policy indicated, .All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seam, cracks and chipped areas.During a review of the facility's document titled, RANGES AND OVENS, dated 2023, the document details cleaning procedures for ranges, including removing encrusted grease and material from range surfaces, burners, and drip pans.According to the FDA Food Code (2022), Chapter 4, 4-601.11(C), indicated, .Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. (https://www.fda.gov/food/fda-food-code/food-code-2022) 13. During a concurrent observation and interview on 5/4/26 at 8:20 AM with the CDM, the CDM was shown the wall surface directly above the manual dishwashing sink. The wall showed multiple areas of cracked and chipped paint with visible peeling, flaking, and raised sections throughout the area where the pot & pan wash procedure poster and hand hygiene policy sign were posted. The CDM stated that she will have their Maintenance Director (MAT) fix the wall.During an interview on 5/5/26 at 11:03 AM, with the Maintenance Director (MAT), the MAT stated that he had attempted to smooth the wall on 5/4/26 after it was reported by the CDM. The MAT stated he would fix it again because peeling debris from the cracked and chipped wall posed both fire safety risk and a food safety risk, as particles could enter the food.During an interview on 5/6/26 at 11:09 AM with the RD, the RD stated she was not aware of any incidents involving paint particles in the food area but acknowledged that peeling debris from the wall could contaminate the food.During a review of the facility's document titled, WALLS, CEILINGS, AND LIGHT FIXTURES, dated 2023, the document indicated, .Walls and ceilings must be free of chipped and/or peeling paint. 14. During a concurrent observation and interview on 5/7/26 at 10:02 AM with the AS, the AS was shown two pieces of fish soaking in a bowl of still water on the left side of the manual dish washing sink. The AS stated the fish were being thawed due to a same-morning request to substitute fish for the proposed lunch menu. The AS explained that the facility's procedure for thawing frozen items requires running water, but this was not followed. The AS acknowledged that she had accidentally pushed the bowl to the side of the sink and turned the faucet off, resulting in improper thawing that could cause food contamination. During a review of the facility's policy titled, THAWING OF MEATS, dated 2023, the policy indicated, .Thawing meat properly can be done in these four ways: 1. In a refrigerator at 41F or colder. 2. In a microwave if foods are to be cooked immediately.3. Submerge under running, potable water at a temperature of 70F or lower, with a pressure sufficient to flush away loose particles.4. Foods can be thawed as part of the cooking process. This works well for frozen vegetables and ground meat.

Based on observation, interview, and record review, the facility failed to promote, maintain, and protect the dignity and privacy for one of eighteen sampled residents (Resident 5) when: 1. Certified Nursing Assistant (CNA) 1 did not fully close the privacy curtain during a bed bath, resulting in Resident 5's body being exposed and visible from the hallway; and, 2. Resident 5's nephrostomy (a thin, flexible tube is inserted through the skin of your lower back directly into your kidney to drain urine) drainage bag (urinary bag) was not covered with a dignity bag (privacy bag). These deficient practices resulted in unnecessary exposure of Resident 5 during care and had the potential for loss of privacy and dignity, and increased psychosocial distress (embarrassment, anxiety and feelings of humiliation). Findings: During a review of Resident 5's clinical record titled, FACE SHEET, dated 5/6/26, the record indicated Resident 5 with diagnoses that included, but were not limited to, hydronephrosis with renal and ureteral calculous obstruction ( kidney swelling secondary to kidney stones blocking urine flow) During a review of Resident 5's Minimum Data Set (MDS, an assessment tool) dated 4/30/26 it was indicated that Resident 5 required moderate assistance (a person performs less than half of the effort for each activity while staff provide the remaining assistance) with the bathing task. 1. During a concurrent observation and interview on 5/5/26 at 9:08 AM with Certified Nursing Assistant (CNA) 1, the privacy curtain around Resident 5 was not fully closed during her bed bath leaving Resident 5's body exposed and visible from the hallway. According to CNA 1, the risk of not fully closing the curtain was that Resident 5 was exposed for others to see from the hallway. During an interview on 5/6/26 at 8:48 AM with CNA 1, CNA 1 stated that she did not realize the privacy curtain for Resident 5 was not fully closed during Resident 5's bed bath until after the concurrent observation and interview conducted on 5/5/26 at 9:08 AM. During an interview on 5/5/26 at 9:12 AM with CNA 2, CNA 2 stated that during a bed bath, staff have to ensure that curtains are closed from both sides and that there are no openings that would allow others to see the resident from the hallway because if the curtain was not properly closed, the resident may be exposed, and their dignity may be compromised. During an interview on 5/5/26 at 9:27 AM with the Director of Nursing (DON), the DON stated it was a dignity issue if a resident was exposed during a bed bath due to the privacy curtains not being fully closed. During a review of the facility's undated policy titled, Dignity, the policy indicated .Staff promote, maintain and protect Resident privacy, including bodily privacy during assistance with personal care. 2. During a concurrent observation and interview on 5/5/26 at 1:25 PM with Licensed Nurse (LN) 1, LN 1 confirmed that Resident 5's nephrostomy bag did not have a dignity cover and that it posed a risk to Resident 5's privacy. During an interview on 5/5/26 at 1:48 PM with the Infection Preventionist (IP), the IP stated that it was important to provide a nephrostomy bag privacy cover to protect Resident 5's dignity and privacy. During an interview on 5/5/26 at 1:55 PM with the DON, the DON stated that Resident 5's nephrostomy bag should have a cover to protect her dignity and privacy. During a review of the facility's undated policy titled, Dignity, the policy indicated that .Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist resident; for example: a. helping the resident keep a urinary catheter bag covered.

Based on observation, interview, and record review, the facility failed to accommodate the needs of 1 of 18 sampled residents (Resident 68) when Resident 68's call light (devices used to contact staff for assistance) was not within his reach.This failure placed Resident 68 at increased risk for unmet care needs, delayed staff response, falls, and increased the potential for accidents or injury.Findings:During a review of Resident 68's clinical record titled, Face Sheet, dated 5/6/26, the record indicated that Resident 68 had diagnoses that included, but were not limited to, need for assistance with personal care, hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke, a sudden lack of oxygen to the brain) affecting the right dominant side, muscle weakness, aphasia (a language disorder caused by brain damage most commonly from a stroke that impairs the ability to speak, write, and understand language), and dysphagia (difficulty swallowing, indicating a disruption in the process of moving food or liquid from the mouth to the stomach).A review of Resident 68's undated clinical record titled, Care Plan Report, indicated .Focus: At risk for fall related to muscle weakness .The interventions include: Be sure the call light is within reach and encourage to use it to call for assistance as needed.During a concurrent observation and interview on 5/4/26 at 10:34 AM with Certified Nurse Assistant (CNA) 3, Resident 68's call light was observed. CNA 3 confirmed that Resident 68's call light was off to the left side of the bed. CNA 3 stated that Resident 68's call light should have been placed on his bed or his overbed table and not off the bed. CNA 3 also stated that if Resident 68 needed to call for help, he would have been unable to do so by having his call light off the bed and out of reach.During an interview on 5/4/26 at 12:01 PM with Family Member (FM) 1, FM 1 stated that it was hard for Resident 68 to move his body and that he was not verbal. FM 1 also stated that Resident 68 was right-handed and should have his call light close to his right hand as much as possible.During an interview on 5/4/26 at 2:20 PM with the Infection Preventionist, the IP stated that the call lights should be close to residents or within their reach if they are unable to speak their needs. The IP also stated that if a resident needed something, they would not be able to make their needs be known or get the care they needed by having the call light out of reach.During an interview on 5/5/26 at 3:03 PM with the Director of Staff Development (DSD), the DSD stated that her expectation was for the staff members to place the call light within the reach of the residents. The DSD also stated that residents may get neglected or not have their needs met if the call light was not within reach. The DSD further stated that a resident may not get the help they require in an emergency situation if they are not able to use their call light.During an interview on 5/6/26 at 10:55 AM with the Director of Nursing (DON), the DON stated that her expectation was for the staff members to place the call light within reach for the residents after care had been provided. The DON also stated that having call lights close to the residents and easy for them to use would prevent accidents from occurring.During a review of the facility's undated policy and procedure (P&P) titled, Accommodation of Needs, the P&P indicated, .Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and wellbeing . Staff will arrange .personal items so that they are in easy reach of the resident.During a review of the facility's undated P&P titled, Answering the Call Light, the P&P indicated, .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .Some residents may not be able to use their call light .

Based on observation, interview, and record review, the facility failed to act upon the concerns brought forth from the Resident Council (a group of residents that meet and discuss concerns monthly) when Resident Council concerns of call lights not being answered timely, call lights being wrapped around the bed frame, staff speaking another language, and staff not fully completing Activities of Daily Living (ADL- these are the fundamental, routine self-care tasks individuals perform daily such as eating, bathing, dressing, toileting, and moving around) care before leaving the room were not addressed by the facility in a timely manner.This failure resulted in residents declining to attend the Resident Council meeting scheduled on 3/24/26 and feeling that issues brought forth in Resident Council meetings were not being addressed. Findings: During a review of Resident 23's clinical record titled, Face Sheet, dated 5/7/26, the record indicated that Resident 23 was admitted to the facility in 2025 with diagnoses which included muscle weakness, type 2 diabetes mellitus (a chronic metabolic disorder, affecting over 90% of diabetics, where the body resists insulin or fails to produce enough, leading to high blood sugar), and essential hypertension ( high blood pressure - a chronic condition where the force of blood against artery walls is consistently too high, generally defined as 130/80 mm Hg or higher). During a review of Resident 53's clinical record titled, Face Sheet, dated 5/7/26, the record indicted that Resident 53 was admitted to the facility in 2025 with diagnoses which included major depressive disorder (persistent, severe sadness, low mood, and loss of interest in activities), cardiogenic shock (a life-threatening medical emergency where the heart suddenly cannot pump enough blood to meet the body's oxygen needs, often resulting from a severe heart attack), and hypovolemic shock (a life-threatening medical emergency caused by the loss of more than 20% [one-fifth] of the body's blood or fluid supply, preventing the heart from pumping sufficient blood to the body). During a review of Resident 56's clinical record titled, Face Sheet, dated 5/7/26, the record indicted that Resident 56 was admitted to the facility in 2024 with diagnoses which included hemiplegia and hemiparesis (neurological conditions causing one-sided body impairment due to brain injury, often from stroke, tumor, or trauma), functional quadriplegia (the complete inability to move all four limbs, generally due to extreme physical frailty or severe disability rather than structural damage to the spinal cord or brain), major depressive disorder, and dysphagia (difficulty swallowing, often caused by nerve damage, muscular issues, or blockages). During an interview on 5/5/26 at 1:45 PM with the Activities Assistant (AA), the AA stated that a lot of residents had refused to attend the Resident Council meeting on 5/5/26. The AA confirmed that only 4 residents out of all the residents that she had asked attended the Resident Council meeting on 5/5/26. During a concurrent interview and record review on 5/7/26 at 10:37 AM with the Activities Director (AD), the AD stated the facility had Resident Council meetings once a month where residents were able to discuss their concerns. The AD also stated that she documented and notified the Director of Staff Development (DSD) about issues that were brought forth by the residents during Resident Council meetings. The AD further stated that at the Resident Council meeting held on 1/27/26, residents were concerned that new staff members were not introducing themselves to the residents, call lights were being wrapped around the residents' bed rails, and residents' likes and dislikes were not being honored in the kitchen. The AD expressed that the staff were asked not to wrap the call light around the residents' bed rails. The AD stated that at the 2/24/26 Resident Council meeting, residents had brought issues about long wait time for staff members to answer residents call light during the morning and noc shift (overnight shift), some staff members were not communicating with residents when staff members were going on a break, staff members were not introducing themselves to residents when entering residents room, staff members were not asking residents if residents needed anything else before leaving residents room, staff members only checked bed A and not bed B while in residents room, staff spoke another language other then English and residents likes and dislikes were not honored by kitchen staff. The AD also stated that previous residents who had attended the Resident Council meetings in the past refused to attend the Resident Council meeting on 3/24/26. The AD further stated that the residents said they did not feel there had been any changes made to the concerns that were brought up in the previous Resident Council meetings. During an interview and record review on 5/7/26 at 11:03 AM with the DSD, the DSD stated she was not aware that residents had declined to attend the Resident Council meeting on 3/24/26. The DSD also stated that she would have addressed residents' concerns if the residents' concerns were communicated better with her. The DSD further stated that the facility needed better internal communication between staff members and the DSD to address resident council issues faster. During an interview on 5/7/26 at 11:09 AM with the AA, the AA stated she went around and invited all the residents to attend Resident Council meeting on 3/24/26. The AA also stated that the residents said nothing had changed since the last Resident Council meeting and that they declined to attend the Resident Council meeting on 3/24/26. The AA further stated that it was important for residents' concerns to be addressed in a timely manner, so residents did not feel sad thinking that nothing had been done about their concerns. During an interview on 5/7/26 at 11:57 AM with Resident 56, Resident 56 stated she was invited to attend the Resident Council meeting on 3/24/26. Resident 56 also stated some of the concerns brought during the 1/27/26 and 2/24/26 Resident Council meetings were still not being addressed by the facility. Resident 56 further stated when she asked staff to help with ADL care, the staff members left her room and staff members did not come back to finish what she asked staff members to do. Resident 56 expressed staff members still leave her room without asking if she needed anything else. During an interview on 5/7/26 at 12:15 PM with Resident 53, Resident 53 stated a few staff members still wrapped her call light around the bed rail which made it hard for her to reach the call light. Resident 53 stated some staff members spoke another language other than English and she could not understand what staff members were talking about. Resident 53 further stated sometimes she had to wait for more than twenty minutes before a staff member answered her call light. During an interview on 5/7/26 at 12:20 PM with Resident 23, Resident 23 stated some staff members still did not knock on her room door before entering the room. Resident 23 also stated some staff members helped her with ADL care and then left Resident her room without asking if she needed any more help. During a review of a facility document titled Resident Council Meeting/Minutes, dated 1/27/26, the document indicated .Residents are expressing a long wait time for call lights for all shifts. Residents would like better communication with the staff to staff and staff to resident. When they are going to do a shower or going on break. Resident expressing that when assisted back to bed the staff/therapy are not giving them the call light so its within reach when resident needs it. Informed resident that the call light code should not be wrapped around the bed or other equipment. Staff are not communicating with the resident when they are done, staff just leave and resident is asking for another task. Some residents are expressing that when staff answer the call lights they are only checking on A bed not both beds in the room. Staff still speaking another language on the floor and in (resident) rooms . During a review of a facility document titled Resident Council Meeting/Minutes, dated 2/24/26, the document indicated .Residents are expressing a long wait time for call lights for AM and NOC shifts. Residents expressing that there is still no communication with the staff to staff and staff to resident, only with certain staff .Resident expressing that when assisted back to bed the staff are not giving them the call light so its in within reach when resident needs it. Staff are not communicating with the resident when they are done, staff just leave and resident is asking for another task. Some residents are expressing that when staff answer the call lights they are only checking on A bed not both beds in the room .Staff still speaking another language on the floor and in pt rooms . During a review of facility document titled Resident Council Meeting/Minutes, dated 3/24/26, the document indicated .When (AA) was inviting residents to join resident council, (AA) said they all declined. (AD) went around with (ombudsman - an independent, neutral official appointed to investigate and resolve complaints, usually against government agencies, employers, or corporations) room to room to talk to the residents. Residents that talked to us expressed that they chose not to attend due to feeling that nothing is being done or changed. (AD) apologized and explained that it does take some time to get policies in place and/or train staff. Some residents talked about call light wait times and (AD) explained that staff do the best they can and that [AD] will ask all staff to be on the floor more to help, during meals and shift change when the wait times are longer . During a review of an undated facility policy and procedure (P&P) titled RESIDENT COUNCIL, the P&P indicated, .It is the policy of this facility to assist residents in establishing and maintaining a Resident Council and to provide an opportunity for residents to express their concerns, contribute ideas, and make recommendations regarding the operation of the facility.The AD or [social services director] assures that all Resident Council meeting concerns are addressed and resolved, when possible . During a review of an undated facility policy titled Resident Rights, the P&P indicated, .Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to .voice grievances to the facility .have the facility respond to his or her grievances .

Based on observation, interview, and record review, the facility failed to implement a fall intervention for 1 of 18 sampled residents (Resident 8), when fall mat was not placed at Resident 8's bedside. This failure had the potential for Resident 8 to sustain further falls with injury. Findings:A review of Resident 8's admission Record indicated Resident 8 was admitted to the facility in 2025 with diagnoses which included chronic obstructive pulmonary disease (a progressive, treatable, but generally irreversible lung condition that restricts airflow, making it hard to breathe), schizophrenia (a chronic and severe brain disorder that affects how a person thinks, feels, and acts, often causing them to struggle with distinguishing reality from fantasy), and anxiety disorder (serious, treatable mental health conditions characterized by excessive, persistent fear or worry that interferes with daily life).A review of Resident 8's Minimum Data Set (MDS - an assessment tool), dated 1/12/26, Resident 8 scored 0 out of 15 in a Brief Interview for Mental Status (BIMS) which indicated she had severe cognitive impairment (the individual gives no correct answers, is entirely unable to recall the prompted information, or provides incoherent/nonsensical responses to questions).A review of Resident 8's progress note dated 2/21/26 indicated, Writer and CNA [Certified Nursing Assistant] both heard yelling for help. Upon entering room, [Resident 8] was found on the left side of the bed, both hands clinging onto the bed rail, both knees on the ground in sitting position. [Resident 8] unable to give description to what she was wanting to do nor where she was trying to go. Writer and CNA helped resident back to bed. Upon assessment, no visible injuries at this time. Able to perform [range of motion]; no facial pain expressions observed.Review of Resident 8's Interdisciplinary Notes, dated 2/24/26, indicated, . Staff heard a call for help coming from [Resident 8's] room. Upon entering the room, [Resident 8] was found on the left side of the bed on the floor in a sitting position while holding on to her handrail. [Resident 8] is currently on hospice care. Interventions: -Therapy to perform post fall assessment and continue with current care plan.Fall mats at bedside.Review of Resident 1's Care Plan, initiated on 7/11/25, indicated, Focus.At risk for falls .Goal .Will not sustain serious injury., Interventions initiated on 2/24/26, indicated, .Fall mats at bedside.During a concurrent observation, interview, and record review with Licensed Nurse (LN) 6 in Resident 8 's room on 5/6/26, at 11:25 a.m., LN 6 confirmed there was no fall mat found found at Resident 8 ' s bedside. LN 6 stated Resident 8 had a fall on 2/21/26 and a post fall intervention was initiated on 2/24/26 which indicated Resident 8 should have a fall mat at bedside. LN 6 stated Resident 8 was a fall risk and a fall mat at Resident 8's bedside should have been in place to prevent Resident 8 from injuries.During a concurrent observation and interview with the Director of Staff Development (DSD) in Resident 8's room on 5/6/26, at 11:30 a.m., the DSD confirmed Resident 8 did not have a fall mat at her bedside. The DSD stated the intervention of fall mat should have been followed for safety for Resident 8.During a concurrent interview and record review with the Director of Nursing (DON) on 5/6/26, at 3:09 p.m., Resident 8's fall risk care plan, initiated on 7/11/25, was reviewed. the DON stated the intervention for Resident 8 to have fall mat at Resident 8's bedside was initiated on 2/24/26 and the fall mat intervention was active as of 5/6/26. The DON stated Resident 8 should have had a fall mat at her bedside.Review of an undated facility policy titled, Falls and Fall Risk, Managing, indicated, .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.the staff may choose to prioritize interventions.Review of an undated facility policy titled, Care Plans, Comprehensive Person-Centered, indicated, A comprehensive, a person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on interview and record review, the facility failed to maintain accurate and complete records for one of eighteen sampled residents (Resident 5) when, Resident 5's allergy to Levaquin (an antibiotic medication used to kill bacteria causing illness) was not updated in Resident 5's allergy profile, Resident 5 was ordered and administered Levaquin, and there was no documentation regarding communication with the ordering provider regarding the allergy, no documentation of an IDT (interdisciplinary team; a group of healthcare professionals) meeting discussing the medication allergy, or monitoring of any adverse reactions to the medication. This deficient practice had the potential to place Resident 5 at risk for adverse reactions and the care and services provided would not be known across all disciplines to assist in making medical decisions for Resident 5. Findings:During a review of Resident 5's clinical record titled, Face Sheet, dated 5/7/26, the record indicated the resident was admitted to the facility in 2026, with diagnosis of, but not limited to, urinary tract infection (UTI, a common bacterial infection in the bladder or urethra, causing pain, burning, and frequent, urgent urination).During a review of Resident 5's Progress notes dated 4/27/26, the progress notes indicated that Resident 5's allergy list included an allergy to Levaquin (a powerful antibiotic used to treat serious bacterial infections), however, there was no documented physician clarification addressing the listed allergy prior to administration of the medication to Resident 5.During a review of Resident 5's Discharge summary, dated [DATE], the summary indicated that Resident 5's documented Levaquin allergy was on Resident 5's allergy profile, but it did not appear she had one. However, the allergy continued to remain active in Resident 5's facility medical record and was not updated in the allergy profile.During a review of Resident 5's Medication Administration Record (MAR, the official, legal document used in healthcare settings to track all medications given to a patient), dated 04/2026 and 05/2026, the MAR indicated that Resident 5 was administered Levaquin, however there was no documented evidence that Resident 5 was monitored for adverse reactions or side effects following administration of Levaquin despite the listed allergy.During a concurrent interview and record review on 5/6/26 at 4:02 PM with Licensed Nurse (LN) 3, LN 3 confirmed Resident 5's allergy list included an allergy to Levaquin. LN 3 also confirmed that Resident 5 received Levaquin 500 mg (a unit of measurement) on 4/27/26, 4/28/26, 4/29/26, 4/30/26, 5/1/26, 5/2/26 and 5/3/26. LN 3 was unable to provide documentation confirming clarification of the allergy status, and monitoring for adverse effects after administration of Levaquin.During a concurrent interview and record review on 5/7/26 at 9:46 AM, with the Infection Preventionist (IP), Resident 5's progress notes were reviewed. The IP confirmed Resident 5's allergies included an allergy to Levaquin. The IP also confirmed that Resident 5 received Levaquin after her admission on [DATE]. The IP stated that the physician was notified of Resident 5' allergy to Levaquin, however it was not documented. The IP stated that they had an Interdisciplinary Team meeting (a coordinated group of healthcare professionals from different disciplines who work collaboratively to plan, deliver, and evaluate patient care) to discuss Resident 5's Levaquin allergy, but it was not documented either. The IP also stated that it should have been documented to avoid potential harm to Resident 5.During a concurrent interview and record review on 5/07/26 at 12:29 PM, with the Director of Nursing (DON), Resident 5's MAR, dated April 2026, was reviewed. The DON confirmed that there was no documented evidence that Resident 5 was monitored for adverse reactions or side effects following administration of Levaquin. The DON stated that a nurse had contacted the physician prior to the administration of Levaquin, however she could not find documentation that the physician was contacted to clarify the order. The DON verified that monitoring of adverse effects was not documented on the MAR. The DON confirmed that there should be specific instructions for monitoring adverse effects. The DON further stated that if missed, it could have led to possible adverse reactions.During an interview on 5/7/26 at 11:47 AM with the Pharmacist, the Pharmacist confirmed that Resident 5's allergy profile listed Levaquin as an allergy and confirmed Resident 5 had received the medication. The Pharmacist further confirmed staff should document physician clarifications, monitor, and document for side effects or adverse effects following the administration of medications. The Pharmacist stated failure to do so had the potential to harm the residents.Review of an undated facility policy titled, Charting and Documentation, indicated, .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.The following information is to be documented in the resident medical record.Medications administered.Treatments or services performed.Documentation in the medical record will be objective .complete, and accurate.

Based on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 53 residents when Resident 67's urinal (portable, handheld containers designed for men with limited mobility to urinate while in bed or seated) was not labeled with identifying information.This failure had the potential to spread infection and cause health problems to the residents in the facility.Findings:During a review of Resident 67's clinical record titled, Face Sheet, dated 5/6/26, the record indicated that Resident 67 had diagnoses that included, but were not limited to, need for assistance with personal care, hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting right dominant side (a type of ischemic stroke, accounting for about 80% of all strokes, caused by blocked blood flow to the brain, leading to tissue death [necrosis]).During a concurrent observation and interview on 5/4/26 at 10:33 AM with Certified Nurse Assistant (CNA) 3, Resident 67's urinal was observed. CNA 3 confirmed that Resident 67's urinal was not labeled with identifying information and should have been labeled. CNA 3 stated that it was an infection control issue by not labeling Resident 67's urinal and possibly another resident could have accidentally used it.During an interview on 5/4/26 at 2:20 PM with the IP, the IP stated that her expectation was for the staff members to label the urinals for each individual resident by either placing a room number or resident initials on them. The IP also stated that if urinals were not labeled, the staff would not know who it belongs to. The IP further stated that the spread of infections such as Multidrug-resistant organisms (MDROs- Bacteria and other germs resistant to three or more classes of antimicrobial agents, making infections difficult to treat) could occur if urinals were not properly labeled.During an interview on 5/5/26 at 3:03 PM with the Director of Staff Development (DSD), the DSD stated that her expectation was for each resident that used a urinal to have labels and individual identifiers on them. The DSD also stated that by labeling the urinal, the staff would know who it belonged to and it would prevent cross-contamination and infection control issues from arising.During an interview on 5/6/26 at 10:55 AM with the DON, the DON stated that her expectation was for the staff to label urinals before giving them to the residents. The DON also stated that she did not want the residents to mix urinals, especially when they were sharing the same restroom. The DON further stated that it was a cross-contamination risk by not labeling urinals accordingly. During a review of the facility's undated Policy and Procedure (P&P) titled, Infection Prevention and Control Program, the P&P indicated, .Decrease the risk of infection to residents and personnel .During a review of the facility's undated P&P titled, Equipment Labeling Policy, the P&P indicated, . To ensure all equipment is properly labeled for identification, safety, maintenance tracking, and regulatory compliance within the long-term care environment .All equipment must be clearly labeled with durable, legible identifiers. Equipment without proper labeling must not be used until corrected .Staff must check equipment labeling before use .

Based on observation, interview, and record review, the facility failed to ensure an accurate assessment of the Minimum Data Set (MDS- a comprehensive assessment and screening tool) for 1 of 18 sampled residents (Resident 6), when Resident 6's oxygen therapy section was documented inaccurately.This failure had the potential to result in an inaccurate reflection of Resident 6's health status and the risk for confusion in Resident 6's plan of care.Findings:A review of Resident 6's admission RECORD, indicated Resident 6 was admitted to the facility in 2025 with diagnoses which included pleural effusion (a collection of fluid around the lungs).A review of Resident 6's MDS Section O (Special Treatments, Procedures, and Programs- a specific category to document high-intensity care, therapies, and services a resident receives), dated 1/23/26, indicated that Resident 6 was not on oxygen therapy.A review of Resident 6's MDS Section O, dated 4/29/26, indicated that Resident 6 was not on oxygen therapy.Review of Resident 6's Care Plan, initiated on 11/13/25, indicated, Focus. [Resident 6] had acute respiratory distress .Goal .Respiratory symptoms will show signs of improvement., Interventions Initiated on 2/24/26, indicated, .Administer medications as ordered. Elevate [head of bed] due to shortness of breath when lying flat. Monitor for shortness of breath.Oxygen as ordered.During an observation on 5/4/26, at 12:17 p.m., in Resident 6's room, Resident 6 was on supplemental oxygen via nasal cannula at 2.5 LPM.During a concurrent observation, interview and record review on 5/6/26, at 3:52 p.m., with Licensed Nurse (LN) 3, Resident 6's electronic medical record (EMR) was reviewed. LN 3 confirmed Resident 6 was receiving 2.5 LPM oxygen via nasal canula. LN 3 stated Resident 6's supplemental oxygen order indicated to administer between 2 to 3 LPM of oxygen to keep Resident 6's oxygen saturation above 90% (percentage of oxygen-carrying hemoglobin in your red blood cells compared to the amount that is unbound. It indicates how effectively your blood is delivering oxygen to your body's cells, with a normal, healthy range usually between 95% and 100%). LN 3 stated Resident 6 had received supplemental oxygen via nasal cannula since November of 2025.During a concurrent interview, and record review on 5/7/26, at 7:53 a.m., with LN 7, Resident 6's EMR was reviewed. LN 7 stated the MDS section for oxygen therapy for 1/23/26, and 4/29/26 was documented incorrectly for Resident 6. LN 7 further stated a resident's MDS assessment was done upon admission to the facility, and every ninety days. LN 7 stated during the MDS assessment she would look at a resident's doctors' orders to check if a resident had an order for supplemental oxygen, and how much oxygen was being administered to that specific resident. LN 7 further stated Resident 6 had a doctor's order to administer supplemental oxygen between 2L/min to 3L/min to maintain oxygen saturation above 90%. LN 7 stated Resident 6's MDS assessment should have been correctly documented indicating Resident 6 received oxygen therapy. During an interview on 5/6/26, at 4:14 p.m., with the Director of Nursing (DON), the DON stated the MDS staff could have looked at Resident 6's doctor's order, documentation of oxygen use, and asked the LN if Resident 6 was receiving supplemental oxygen. The DON further stated checking the vital signs documentation could have indicated if a resident received oxygen therapy. The DON stated there was a risk to the accuracy of the document when Resident 6's oxygen therapy assessment was not documented accurately.Review of an undated facility policy titled, Charting and Documentation, indicated, .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.The following information is to be documented in the resident medical record.Medications administered.Treatments or services performed.Documentation in the medical record will be objective.complete, and accurate.

Based on interview, and record review, the facility failed to submit a summary of investigation for an alleged resident to resident altercation to the Department within five (5) working days, as required, for one of three sampled residents (Resident 1).This failure placed Resident 1 at risk for further resident to resident altercations.Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to thefacility with diagnoses including unspecified dementia (ongoing problems with memory and thinking), chronic kidney disease (long term kidney damage), other symptoms and signs involving cognitive (the brain's mental processes of acquiring knowledge, understanding, and thinking) functions and awareness.Review of Resident 5's admission RECORD, indicated Resident 5 was admitted to thefacility with diagnoses including orthopedic aftercare (care and recovery support after bone, joint, or muscle surgery or injury), displaced intertrochanteric fracture of right femur (broken upper thigh bone near the hip), history of falling, abnormalities of gait and mobility, type 2 diabetes mellitus (high blood sugar levels) and depression (mood disorder).Review of the document titled, Report of Suspected Dependent Adult/Elder Abuse, completed and submitted to the Department on 11/8/25 by the Social Services Director (SSD), indicated that on 11/8/25 at 6 AM, Resident 1 was involved in an incident in which the former roommate, Resident 5, blocked the bathroom door while Resident 1 was inside the bathroom, preventing Resident 1 from exiting the bathroom. Review of Resident 1's care plan, initiated on 11/8/25, in the section titled, Focus, indicated, .[Resident 1] At risk for psychosocial and mood changes related an incident of being locked in the bathroom by another resident.Review of Resident 5's care plan, initiated on 11/8/25, in the section titled, Focus, indicated, .[Resident 5].At risk for psychosocial and mood changes related to locking in a resident in the bathroom.During an interview on 1/9/26, at 9:49 AM, with the SSD, the SSD stated that he completed the 5-day investigation for the reportable resident-to-resident altercation involving Resident 1 and Resident 5 but did not submit the 5-day investigation report to the Department. During an interview on 1/13/26, at 1:44 PM, with the Director of Nursing (DON), the DON stated that the 5-day investigation summary for the reportable resident-to-resident altercation involving Resident1 and Resident 5 was not submitted to the Department and that there was no documentation or confirmation indicating that it was submitted. The DON further stated that she was aware the 5-day investigation summary was required to be submitted to the Department within five working days and that failure to submit the report indicated the investigation was not completed.Review of an undated facility policy and procedure (P&P) titled, Abuse Investigation and Reporting, indicated, .The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written repost of the findings of the investigation within five (5) working days of the occurrence of the incident.

Based on interview, and record review, the facility failed to develop and implement a comprehensive care plan (written plan that guides staff on daily care and safety based on the resident's needs) for one of three sampled residents (Resident 1) to address Resident 1's frequent and extended use of a shared bathroom, which delayed other residents' access to the bathroom.This failure resulted in dissatisfaction among those residents and placed Resident 1 at potential risk for further altercations with other residents.Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including unspecified dementia (ongoing problems with memory and thinking), chronic kidney disease (long term kidney damage), other symptoms and signs involving cognitive (the brain's mental processes of acquiring knowledge, understanding, and thinking) functions and awareness. Review of the document titled, Report of Suspected Dependent Adult/Elder Abuse, completed and submitted to the Department on 11/8/25 by the Social Service Director (SSD), indicated that on 11/8/25 at 6 AM, Resident 1 was involved in an incident in which the former roommate, Resident 5, blocked the bathroom door while Resident 1 was inside the bathroom, preventing Resident 1 from exiting the bathroom. Review of Resident 1's .Brief Interview For Mental Status (BIMS) Evaluation, (BIMS, a short set of simple questions staff ask a resident to check how well they are thinking and remembering) dated 12/4/25, indicated that Resident 1 had moderate cognitive impairment (noticeable problems with memory and thinking, but able to perform some activities independently).During an interview on 1/9/26, at 11:26 AM, with Resident 2, Resident 2 stated she could not access the bathroom in a timely manner because Resident 1 was frequently in the bathroom for extended periods. Resident 2 further stated that Resident 1 was causing a problem with bathroom access and that it was not fair she could not access the bathroom when needed. During an interview on 1/9/26, at 11:35 AM, with Resident 3, Resident 3 stated that Resident 1 was confused and was not aware of how frequently she used the shared bathroom, which made it difficult for other residents to access the bathroom when needed. During an interview on 1/9/26, at 11:55 AM, with Resident 4, Resident 4 stated that Resident 1 used the bathroom frequently and stayed in the bathroom for extended periods. Resident 3 further stated she had to hold her urine and call a nurse to intervene and assist Resident 1 to complete bathroom use in a timely manner before she could access the bathroom. During an interview on 1/9/26, at 12:19 PM, with Certified Nurse Assistant (CNA) 1, CNA 1 stated that Resident 1 required staff supervision to prevent prolonged bathroom used. CNA 1 stated that Resident 1 would go to the bathroom without using the call light for assistance and would remove her personal alarm which made it difficult for staff to be aware when Resident 1 was already in the bathroom. CNA 1 further stated that Resident 1 previously experienced a conflict with Resident 5 related to bathroom use. During an interview on 1/9/26, at 12:51 PM, with Licensed Nurse (LN) 1, LN 1 stated that Resident 1 was forgetful and could not remember the timing of her bathroom use, which caused Resident 1 to use the bathroom frequently and remain in the bathroom for extended periods. LN 1 further stated that other residents who could not access the bathroom in a timely manner due to Resident 1's bathroom use had to use the shower room for toileting. During a concurrent interview and record review on 1/9/26, at 1:30 PM, with LN 2, Resident 1's care plans were reviewed. LN 2 stated that Resident 1 had previously been involved in a resident-to resident altercation with Resident 5 related to bathroom use because Resident 1 had frequent bathroom use. LN 2 further stated that Resident 1 did not have a care plan to address or prevent conflict related to Resident 1's bathroom use, which placed Resident 1 at risk for repeated resident-to resident altercations.During a concurrent interview and record review on 1/9/26, at 2:07 PM, with the Minimum Data Set Coordinator (MDS), Resident 1's care plans were reviewed. The MDS stated that Resident 1 did not have a care plan addressing the prior resident-to-resident altercation with Resident 5, including identification of the root cause or individualized interventions, which placed Resident 1 at risk for repeated resident-to resident altercations. The MDS further stated that individualized care plans were necessary because interventions were not the same for every resident. During an interview on 1/12/26, at 1:14 PM, with the Director of Nursing (DON), the DON stated that when nursing staff identified a problem with a resident's care, nursing staff were expected to initiate a care plan. The DON stated that care plans were required to be individualized, address resident needs, and include specific goals and interventions. The DON further stated that without a care plan specific to a resident's need, staff would be unable to provide the expected services to meet resident needs.Review of an undated facility policy and procedure titled, Care Plans, Comprehensive Person-Centered, indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.incorporate identified problem areas.When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers .Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change.

Based on observation, interview, and record review, the facility failed to implement a comprehensive water safety management program based on nationally accepted standards to minimize the risk of Legionella (a serious lung infection) and other opportunistic waterborne pathogens (a microorganism [bacteria] that exists in water sources or plumbing [pipes required for the water supply, heating and sanitation in a building] systems that can cause serious illness in people over [AGE] years of age and have weakened immune systems) for a census of 54 when: a. The facility did not complete and document a facility-wide assessment of potential Legionella growth areas to include flow chart, b. The facility did not implement adequate control measures, c. The facility did not establish sufficient monitoring protocols; and, d. The facility did not create an intervention plan for when control limits are not met. These failures put the residents and staff at risk of potential Legionella and other opportunistic waterborne pathogen exposure, threatening their health and well-being. Findings: During a joint interview on 7/2/25, at 9:30 AM, with the Director of Nursing (DON) and the Administrator (ADM), the DON stated the facility was notified by a local general acute care hospital (GACH) on 5/6/25 that a resident who was sent to them from the facility tested positive for Legionella pneumophila (a severe form of pneumonia -a lung infection caused by Legionella bacteria). The DON further stated the facility contacted the local Public Health Department (PHD) for guidance on how to handle the results. The DON explained the PHD told them to test residents with respiratory symptoms (signs that like runny nose, cough, and difficulty breathing that indicate a problem with your breathing or lungs) and to test their water for Legionella. The DON stated they tested all the residents in the facility with respiratory symptoms and the roommate of the resident who tested positive. The DON further stated all results were negative. The ADM explained the PHD asked the facility to test their water and when they did, the PHD stated the sample was inadequate and needed to be done by a company certified to collect water samples. The DON explained the PHD also wanted the facility to be contracted with a company to provide certified testing and facility water maintenance in case of a positive result. The ADM stated they did not have a contracted provider at the time and requested a list of certified companies from the PHD. The ADM explained they contacted a company who came out on 7/1/25 and collected 15 different water samples from different sources and sent them to the lab for processing. The DON added the results would be available in 10-14 days. During a concurrent interview and record review on 7/2/25, at 9:37 AM, with the Infection Preventionist (IP), the facility policy and procedure (P&P) titled, Water Safety Management Program (Legionella), revised on 12/2023, was reviewed. The IP stated the P&P was based on the Centers for Disease and Prevention's (CDC) Legionella Toolkit (an actionable, detailed guide to assist facilities in developing a water safety program). The IP further stated the local PHDs, Public Health Officer (PHO) told her the facility's P&P for water safety management was not detailed enough because it lacked a full facility water supply system analysis, graphs that included the inlets and outlets of the water sources, and locations of all the water sources inside and outside of the building. The IP confirmed the P&P did not include a certified testing company contract and how to handle the water supply in the building in case of water borne pathogen outbreak. The IP further explained the PHO recommended the facility conduct a full risk assessment. When asked if the facility had previously conducted a facility risk assessment; the IP stated, I don't think so. During a concurrent observation (tour of facility's water sources) and interview on 7/2/25, at 12:25 PM, the Maintenance Director (MTD) showed the boiler room and explained the two water storage tanks held 103 gallons of water each, and they supplied all the water to the building. The cooling tower was observed outside of the facility near the boiler room. The MTD showed the shower rooms that the residents use in the facility. The MTD stated he was in the process of replacing the showerheads and the eye washing station with specialized filters on the recommendation of the certified water management company. The MTD stated preventative maintenance was important to prevent downtime and for the residents' health and safety. The MTD explained the special filters on the showerheads and eye wash station help filter opportunistic pathogens like Legionella from the water. The MTD stated it was important to test the water to prevent lung infections like pneumonia which can harm the residents and cause death. The MTD was not able to explain the facility's process for decontaminating the building water systems if necessary. The MTD confirmed they did not have an outside source contracted to decontaminate the water system, prior to notification of a positive Legionella resident on 5/6/25. During a follow-up interview on 7/2/25, at 3:46 PM, the DON stated her expectation for a water safety management plan was to have one in place. The DON further stated the facility did have one in place but confirmed it was not as detailed as the PHD stated it should be and it needed to include a flow chart of the water in and out of the building, where it goes, and to which water outlets, and added it needed to have their water system mapped out. The DON confirmed they did not have their water system mapped out with points of possible Legionella risk documented. The DON explained Legionella could grow and spread in water pipes and can be inhaled via steam, like in the showers. The DON further explained it was important to have a detailed water safety management program and plan in place to prevent the residents from getting Legionella pneumonia. The DON stated the risk to the residents was respiratory distress and even death. During an interview on 7/3/25, at 11:51 AM, with the local PHO, the PHO confirmed she asked the facility to develop a water management plan. The PHO stated the facility did not have a plan or policy in place based on nationally accepted standards to minimize the risk of Legionella contamination. The PHO further stated when she reviewed the Water Safety Management Program (Legionella) P&P, she stated their plan was just a copy and paste of the CDC toolkit on how to develop and implement a water safety plan with some added text. The PHO explained the CDC's Toolkit was designed to be used as a tool to help facilities develop a water safety program, not to be used as one. The PHO added the facility did not have a diagram of their water system with a flow chart of the inlets and outlets of water as it moved through pipes in the buildings and where each source of water comes from. The PHO further explained that the facility needed to have all this information as part of their water management program, and it had to be mapped out with an action plan, including who they would contact and work with to chlorinate and flush lines in case of a Legionella outbreak. A review of the facility's P&P titled, Water Safety Management Program (Legionella), revised 12/2024, indicated, .It is the policy of this facility to provide facility maintenance protocol guidelines for plant operations related to water safety management to ensure the reduction in potential for growth of Legionella .This policy will follow and reference recommended guidelines .by the Centers for Disease Control and Prevention (CDC) for program implementation referenced . A review of the CDC's online guide titled, Overview of Water Management Programs, published March 15, 2024, indicated, .Key Points .Many buildings need a water management program (WMP) for their building water system .WMPs identify hazardous conditions and outline steps to minimize the health impact of waterborne pathogens .Developing and maintaining a WMP is a multi-step process that requires continuous review .Seven steps of a Legionella WMP are to: 1. Establish a WMP team 2. Describe the building water systems 3. Identify areas where Legionella could grow and spread 4. Decide where to apply and how to monitor control measures 5. Establish interventions when control limits aren't met 6. Ensure the program runs as designed and is effective 7. Document and communicate all activities .the principle of effective water management include: Ensuring adequate disinfection .Maintaining devices to prevent .Sediment, Scale, Corrosion, Biofilm .Maintaining water temperatures to limit Legionella growth, preventing water stagnation .Once established, WMPs require regular monitoring of key areas for potentially hazardous conditions. The programs use predetermined responses to respond when control measures aren't met .Each program has to be tailored for each building at a particular point in time .In some settings, the entire building needs a WMP: Hospitals and long-term care facilities . https://www.cdc.gov/control-legionella/php/wmp/index.html

Based on observation, interview, and record review, the facility failed to ensure an environment free of accidents or hazards for one of four residents (Resident 2) when Resident 2, who was at high risk for falls, fell when she was left in the bathroom unattended on 8/5/24. This failure had the potential to result in Resident 2 sustaining injury including fractures (broken bones) and decreased well-being.Findings:A review of Resident 2's admission RECORD, indicated that Resident 2 was admitted to the facility in 2024 with diagnoses which included surgical repair of left hip fracture.A review of Resident 2's Care Plan Report, dated 7/27/24, indicated .Focus.At risk for falls.Goal.Will not sustain serious injury.Interventions.Anticipate and meet needs.A review of Resident 2's Progress Notes, dated 8/5/24, indicated, .writer was called by attending CNA (Certified Nursing Assistant) to pull up resident @ 0600 [6AM].upon entering room, resident was found sitting down inside the bathroom.resident transferred back to wc [wheelchair] by 3 person assist.resident stated that she needed to use the bathroom and received help doing so, but attending CNA had left her unattended while using the bathroom.informed attending CNA to be with resident at all times while using the bathroom.A review of Resident 2's Fall Risk Evaluation, dated 7/24/24, indicated .Score: 12.Category: High Risk. A. Mental Status: Alert/Oriented x 3 (time, place, person) .B. History of Falls. 3 or more falls in past 3 months.C. Elimination Status.Requires regular assist with elimination.A review of Resident 2's MDS (Minimum Data Set, a comprehensive care assessment tool) - Section GG-Functional Abilities and Goals, dated 8/1/24, indicated, Self-Care.Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided.Toileting/hygiene: The ability to maintain perineal hygiene, adjust clothes before or after voiding or having a bowel movement.02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort.Toilet transfer: the ability to get on or off a toilet or commode.01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.During a phone interview on 6/19/25, at 10:14 a.m., with the Responsible Party (RP) of Resident 2, the RP stated that she was concerned about the care Resident 2 received at the facility. The RP further stated Resident 2 was assisted to the bathroom and left alone by staff, resulting in a fall. The RP stated that she was notified by phone after the fall. The RP further stated that Resident 2 was not injured.During an interview on 6/20/25, at 12:20 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated the facility's fall protocol for residents at risk for falls was to have the call light within reach, bed in low position with wheels locked, wheelchair locks on when a resident was not mobile in the wheelchair, ambulate (walk) with assistance with gait belt if needed, stand outside the bathroom door to give the resident privacy and wait to assist the resident when done.During an interview on 6/20/25, at 12:21 p.m., with Licensed Nurse (LN) 1, LN 1 stated residents were assessed for fall risk on admission, quarterly, and after a fall incident. LN 1 stated that when residents who were at risk for falls were assisted to the bathroom; the CNAs stayed with the residents. LN 1 further stated the CNAs stayed outside the bathroom door so that the residents could have privacy. LN 1 stated the residents were instructed to call for assistance when they were finished using the bathroom.During a phone interview on 6/20/25, at 3:50 p.m., CNA 2 stated that she remembered Resident 2. CNA 2 confirmed that she remembered taking Resident 2 to the bathroom on 8/5/24. CNA 2 further confirmed that she left Resident 2's room after she helped her to the bathroom. During a phone interview on 6/20/25, at 3:55 p.m., with LN 2, LN 2 stated she remembered Resident 2. LN 2 further stated that CNA 2 assisted Resident 2 to the bathroom, then CNA 2 left Resident 2's room while Resident 2 was still in the bathroom. LN 2 confirmed that Resident 2 fell in the bathroom. LN 2 stated that she advised CNA 2 to remain with the residents with high risk for falls while they used the bathroom. LN 2 stated that staff waited outside the bathroom door so that they could give the residents privacy but be close by to assist the residents after they were finished. LN 2 stated that Resident 2 had a high fall risk and had fallen before.During a concurrent interview and record review on 6/20/25, at 3:30 p.m., with the Director of Nursing (DON), Resident 2's Electronic Medical Record (EMR) was reviewed. The DON stated residents were assessed for fall risk upon admission to the facility, quarterly, and after a fall incident. The DON further stated that if a resident that was assessed to be at high risk for falls was assisted to the bathroom, the resident was instructed to use the call light for assistance when finished. The DON explained that the staff usually waited outside the bathroom door to give the resident privacy. The DON acknowledged that leaving a resident at risk for falls in the bathroom and not waiting outside the bathroom door to assist the resident could increase the resident's risk of falling. The DON stated that Resident 2 was instructed to use the call light when she was finished in the bathroom on 8/5/24. The DON confirmed that the CNA did not wait outside the bathroom door while Resident 2 was in the bathroom. The DON further confirmed that the facility policy was not followed. A review of an undated facility policy and procedure (P&P) titled, Resident Examination and Assessment, indicated, .Purpose.The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan.9. Activity level: a. able to perform ADLs (Activities of daily living, tasks of everyday life including eating, dressing, bathing, or showering, and using the bathroom); and b. degree of assistance required. A review of an undated P&P titled, Fall Risk Assessment, indicated, .The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others will seek to identify and document risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information.Policy Interpretation and Implementation.1. Upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days.7. The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including.mobility.activities of daily living (ADL) capabilities.continence [control or lack of control of the bowel and bladder]. A review of an undated facility P&P titled, Fall, indicated, .General Guidelines.1. Falls area leading cause of morbidity and mortality [death] among the elderly in nursing homes.4. Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly.

Based on observation, interview, and record review, the facility failed to ensure dietary staff served the correct meal portions for two of four sampled residents (Resident 2 and Resident 3) when, 1. Resident 2 did not receive their prescribed small portion diet during the lunch meal on 5/7/25. 2. Resident 3 did not receive their prescribed small portion diet during the lunch meal on 5/7/25. This failure had the potential to contribute to unplanned weight gain which could negatively impact the health and wellbeing of Resident 2 and Resident 3. Findings: 1. During a review of Resident 2 ' s ADMISSION RECORD, the document indicated Resident 2 was admitted to the facility in early 2020. A review of Resident 2 ' s BIMS [Brief Interview for Mental Status; a screening tool used to assess for cognitive impairment], dated 3/18/25, indicated Resident 2 had a BIMS score of 15 (a score of 13 to 15 points suggested that cognition was intact). A review of Resident 2 ' s Order Listing Report, dated 1/19/24, indicated, .NAS [No Added Salt] diet .***Small Portions on all meals*** . A review of Resident 2 ' s Care Plan Report (a report that indicated Resident 2's problems, goals, and interventions), dated 7/2/24, indicated, .Goal .160-170 lbs. [pounds - unit of measurement] . Will comply with recommended diet for weight reduction daily .Will not develop complications related to obesity, including skin breakdown, ineffective breathing pattern .impaired mobility .Intervention/Tasks .Assist with developing a support system to aid in wt. [weight] loss efforts . A review of Resident 2 ' s Weight Summary, indicated, .5/5/2025 .213 Lbs [pounds] . During a concurrent observation, interview, and record review in Resident 2 ' s room, on 5/7/25, at 12:17 p.m., Resident 2 ' s meal tray was compared with Resident 4 ' s meal tray . Resident 2 ' s diet card indicated, .Small Portions . Resident 2 stated the plate did not look like it contained small portions, it looked like a lot of food. Resident 4 ' s diet card did not indicate small portions and appeared to contain the same amount of food as Resident 2 ' s tray. 2.A review of Resident 3 ' s ADMISSION RECORD, the record indicated Resident 3 was admitted to the facility with a diagnoses of major depressive disorder ( a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 3 ' s BIMS, dated 3/5/25, indicated a score of 15. During an interview on 5/7/25, at 11:03 a.m., Resident 3 stated she requested small portions, but her plate was always full of food. A review of Resident 3 ' s Order Listing Report, dated 4/3/24, indicated, REGULAR diet .**SMALL PORTIONS** . A review of Resident 3 ' s Care Plan Report, dated 1/12/25, indicated, .Goal .will comply with recommended diet for weight reduction .Weight goal 145-155 lbs . Intervention/Tasks .Assist with developing a support system to aid in wt loss efforts .small portions as resident requested . A review of Resident 3 ' s Weight Summary, indicated, .2/2/2023 .159.0 Lbs . + 5.0 % [plus 5 percent weight gain] change .1/4/2023 .149.0 Lbs . During a concurrent observation, interview, and record review in Resident 2 ' s room, on 5/7/25, at 12:20 p.m., Resident 3 ' s meal tray was observed with a full serving of food. Resident 3's diet card indicated, .1/2 [half] portion only . Resident 3 stated she was never given small portions. Resident 3 further stated she declined to have her weight assessed because it depressed her when she did not lose weight. During a concurrent interview and record review on 5/7/25, at 12:35 p.m., [NAME] 2 viewed photos of Resident 2, Resident 3, and Resident 4 ' s lunch meal trays and confirmed the portion size was the same for all three. [NAME] 2 stated when she served the food, another staff member called out the portion size. [NAME] 2 further stated staff must not have called out the correct portion size for Resident 2 and Resident 3 ' s meals. During an interview on 5/7/25, at 12:39 p.m., the Food and Nutrition Services (FNS) director stated it was her expectation that the correct food portions would be served to Resident 2 and Resident 3. The FNS further stated too much food could be overwhelming and could interfere with Resident 2 and Resident 3 ' s weight loss goals. The FNS stated unintentional weight gain could have a negative health effect. A review of a facility document titled Job Description, dated 2023, indicated, .POSITION: FNS Director .Ability to follow prepared menus and portion control guidelines .Ability to train staff how to properly prepare and serve food .Check trays to ensure diets are served as ordered . A review of a facility policy and procedure titled, PORTION SIZES, dated 2023, indicated, .Various portion sizes of the food served will be available to better meet the needs of the residents .The small and large portion servings will be served as printed on the cook ' s spreadsheet for every meal .1/2 size portions are to be given to those residents who request smaller portions than the small portion diet provides .The food server is to give the 1/2 size portion of the diet for the food on the main plate-entree, vegetable , and starch .

Based on observation, interview, and record review, the facility failed to ensure safe food storage and production in accordance with professional standards of food safety for the 56 residents who received prepared food from the kitchen when: 1. Open food packages (one bag of bran cereal, one bag of biscuit mix, and a five-gallon storage bin with about two-gallons of rice) were not labeled with a use by date; and, 2. Wet plate covers were stacked together. These failures had the potential to expose residents to food borne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). Findings: During a concurrent observation and interview on [DATE], at 8:47 a.m., in the kitchen accompanied by the Dietary Manager (DM), the following findings were observed: 1. a. An opened clear plastic bag containing bran cereal was not labeled with a use by date. The DM stated the bag should have been labeled with a use by date. 1.b. A five-gallon storage bin with about two-gallons of rice was not labeled with a use by date. The DM confirmed the rice was not in the original packaging and there was no use by date. 1.c. An opened clear plastic bag containing biscuit mix was not labeled with a use by date. The DM further stated it should have been labeled with a use by date once the box was opened by kitchen staff. The DM explained the risk was not knowing how old the food was. 2. During an observation on [DATE], at 1:01 p.m., the Dietary Aid (DA) was observed pulling two clean loads of plate covers out of the dishwasher and stacked the wet plate covers on the table countertop. During an interview on [DATE], at 1:33 p.m., with the DA, the DA stated dishes should be dried before being stacked and put away. The DA further stated the plate covers were stacked wet upside down to make more room for more washed dishes. During an interview on [DATE], at 2:38 p.m., the DM stated staff should wait until dishes were air dried before putting them away. The DM confirmed that plate covers were stacked while wet and stated it posed a risk of contaminating the food and causing bacterial growth. The DM further stated when food was transferred from its original container or package to another bag or bin for storage, it should be labeled with the name of the product, date it was opened, and a use by date. The DM stated the risk for staff not putting a use by date was the product being used passed its used by date therefore affecting the products quality and nutritional value. The DM added this could have posed a risk to the residents of receiving food that was of low quality, nutritional value, and taste. The DM confirmed wet, stacked plate covers could have caused sickness to the residents. During an interview on [DATE], at 4:18 p.m., the Director of Nursing (DON) stated staff should not be stacking and overlapping dishes before drying. The DON added if dishes were still wet it could grow bacteria in the moist warm environment which can cause illness to the residents. The DON further stated staff should put an open date, expiration date, and name of the food item if it was removed from the original package and stored in another container or package. The DON further stated staff could have used expired food which could have caused illness in the residents of the facility. During a review of an undated facility policy titled, DISHWASHING, the policy indicated, . Dishes are to be air dried in racks before stacking and storing . Review of the facility policy titled, LABELING AND DATING OF FOODS, dated 2023, indicated, .All food items in the storeroom need to be labeled and dated .The Use By date signifies the date in which food must be consumed or discarded .

Based on observation, interview, and record review, the facility failed to ensure safe use of facility owned smart phones (also known as cell phones) for communication with medical providers regarding resident's Protected Health Information (or PHI, refers to any individually identifiable health information about a resident) with a census of 56 residents. This unsafe practice could compromise residents' private medical information and violate residents' health information privacy and confidentiality. Findings: During a concurrent inspection of the facility's Station 2 medication storage areas and interview with Licensed Nurse (LN) 7, on 1/13/25, at 10:26 AM, a smart phone marked with Nurse Station 2, 209-3 . [phone number]) was noticed sitting unattended next to a computer at the station. LN 7 stated the phone was used to communicate with medical providers. When LN 7 unlocked the screen, the review of text messages communicated with different doctors and nursing staff, indicated the staff sent resident's health updates including their name, medical condition, or photos of laboratory test results, and the providers responded back with orders for medications or medical tests. The review of the photo section of the smart phone, indicated the smart phone stored 3,166 items including pictures of body parts, laboratory tests, and resident's demographic information such as names, date of birth, and medical diagnosis. Further review of the select text format communication via smart phone with medical doctors were as follow: 1.Text communication with Medical Doctor 5 (MD) via smart phone: Text to MD 5 On Saturday 12/28/24 : good evening Doctor sorry to bother. I hope its not that late yet, I just want to let you know your patient [Resident 9] is back in the facility .with the following diagnosis. A copy of demographic information with a list of diagnosis was attached. MD 5's response: Ok Thx [thanks] . Text to MD 5 on Sunday 12/29/24, at 10:39 AM: Good morning [MD 5] .your [Resident 14] fell facing the floor while trying to unlocked his WC [Wheel chair] & sustained ABRASIONS to his forehead and bilateral knees. TX [treatment] nurse does the first aide tx [treatment] to affected areas. Can we req [request] Xray [creates pictures of the inside of your body] please. Thank you MD 5's response (no time stamp): Ok to do facial Xray. Do knees look swollen enough for Xray Nurses' response: It doesn't look like it Dr. but can we have the order to make please Dr thank you MD 5's response (no time stamp): Yes Ok Knee X-ray Text to MD 5 on Sunday 12/19/24 at 3:01 PM: Hi Dr [doctor] your [Resident 9] . req [request] an order for Pepcid PRN [as needed] for reflux please advise thank you. MD 5's response (no time stamp): Ok to give Pepcid . PRN reflux Text to MD 5 on Sunday 12/29/24, at 10:53 PM: Doc here's the X-ray results for Resident 14 Two pages of knee and facial x-ray results dated 12/29/24 was attached. MD 5 response on Monday 12/30/24 at 7:47 AM: no acute finding. Ok to start amoxicillin [an antibiotic .for 10days for sinusitis [infection of sinus, or areas connected to nose] 2.Text Communication with Medical Doctor 6 (MD) via smart phone: Text to MD 6 with a copy of urine test on 1/7/25: Patient [Resident 43] UA results [UA is Urinalysis- test of urine for infection] obtained. UA collection r/t [related to] to foul smelling urine. MD 6's text on 1/7/25: Can you please give her Rocephin [an antibiotic] . daily for 3 days .Please call the family we are treating it . Text to MD 6 on 1/9/25 at 10:13 AM; Good morning, Doc, your [Resident 43's] family is concerned about resident has episodes of head dropping when up in WC [Wheelchair]. Please advise thanks you. MD 6's response: I am not sure how to help that. Are they suggesting we not put her in the wheelchair. Nurse's response: They are actually request her to be up in WC every meal . MD 6's response: I have no idea how to stop her from flexing her head forward unless you use a band, and I don't think you should do that Nurse's response at 1/9/25 at 1:26 PM: Unfortunately we cannot. Also, on weekends they want her up multiple times a day which I don't think is beneficial for the patient. She is always sleepy. The family is more concerned about her multiple and frequent head dropping even at rest. MD 6's response: Spoke with her son. Please Stop Seroquel [mood altering drug]. You can use Xanax [anxiety pill] . once at night if agitated you can use it PRN 90 pills one refill Nurse's response on 1/9/25, at 4:24 PM: Noted thank you During a concurrent record review and interview with LN 5 and LN 1 on 1/14/25, at 11:45 AM, Resident 47's medical record was reviewed. LN 5 could not find the electronic or paper version of the chest x-ray (imaging test that used a small amount of radiation to create pictures of the organs and structures in the chest) taken prior to starting intravenous (or IV, Into Vein) antibiotics on Resident 47. LN 5 stated the result of the chest X-ray was communicated to MD 4. LN 1 stated Resident 47's results was texted to MD 4 via the facility's smart phone. LN 1 located the smart phone sitting at station 2 desk, marked as 209 . (phone number) Nurse Station 2 on the back. LN 1 was able to find the text communication with a picture of the Xray result in the smart phone addressed to MD 4 on 1/11/25 at 5:18 PM. The communication in addition to a copy of the X-ray results, included Resident 47's name and comments on his weight loss, allergy, and the name of the prescribed antibiotic. The following summary of random text communication between nursing staff and MD 4 from 1/11/25 to 1/12/25 as follows: 1. Text communication with MD 4 Nursing text to MD 4, 1/11/25 at 5:18 PM: Results for Chest X-ray for [Resident 47] Nursing Text to MD 4 on 1/11/25 at 5:36 PM: Quoted earlier text to MD 4 requesting prescription for an opioid drug called Norco for Resident 410 F/U [follow up] Pharmacy stating E-script [electronic prescription] still hasn't been received for [Resident 410] Nursing Text to MD 4, on 1/11/54, at 9:35 PM: Doc, May we have follow-up CXR [chest xray] for [Resident 8] She still have persistent cough. May we also order Tessalon Perls [Tessalon [NAME], or Benzonatate, is cough medicine in pill form] for her? MD 4's response on 1/11/25 at 9:46 PM: Ok CXr 1 tab q 6 hrs prn [every 6 hours as needed] Nurse's response on 1/11/25 at 10:18 PM: [Resident 47] also has wt loss [weight loss] of 16.2 lbs [pounds] x 3 weeks, started on Med pass 2.0 [a nutritional supplement] .TID [three times daily] MD 4's response on 1/11/25, at 10:30 PM: [NAME] [thank you] Quoted chest xray results for Resident 47 and asked allergy? MD's response on 1/11/25 at 11:33 PM: Levaquin [an antibiotic] . daily x7 days; Flagyl [antimicrobial antibiotic X7 days . Nurse's response on 1/11/25, at 11:38 PM: He is on full liquid diet because of the consistent emesis [vomiting] and diarrhea. He's failed his barium swallow [a test that assess if resident can swallow solid food safely] as well . MD 4 later changed the antibiotic to IV form. Text from nurse to MD 4, on 1/12/25, at 8:56 AM: Good morning, Dr your [Resident 410] been complaining of pain 10/10 [pain severity 1 out of 10 with 10 being the most severe] but his Norco .was not delivered yet. Can you please give us a script because he was saying that he will file a complaint already for not getting it thank you MD 4's response on 1/12/25: Please call the Pharmacy Nurse's text to MD 4, on 1/12/25, at 11:45 AM: Hi Doc. RD [Registered Dietitian] had recommendations for your patients The text included the names of three residents with request to prescribe vitamin supplements and fluid restriction (restricting amount of fluid resident can take). Md 4's response on 1/12/25: ok During a concurrent interview with Licensed Nurse 7 (LN 7) and review of text message documentation between nursing staff and MD 7, on 1/13/25, at 11:49 AM, the smart phone text message with MD 7 were as follow: Nurse text message to MD 7 on 1/5/25 at 2 PM: Text Message RCS (Rich Communication Services, a type of text communication) Sun [DATE] at 2:00 PM (in green color text); Hi doctor your [Resident 409]. She is currently on a routine regimen for lorazepam [anxiety pill and controlled medication] 1-tab 2x/day. Patient and son .would like her PRN tramadol [pain medication] to be on the same regimen as lorazepam if possible. Please advise. Thank you No response from MD Nurse Text message to MD 7 on 1/18/25 at 6:49 AM: Good Morning Doc, These are [Resident 409's] lab results. Please advise sent in green color text as SMS (or Short Message Service) and included pages of test results. During review of text messages between the Director of Nursing (DON) and nursing staff at facility's Station 1, on 1/13/25, at 11:42 AM, accompanied by LN 7, the smart phone text message with DON were as follow: Text from nurse to DON on 1/13/25: Hi [DON's first name], have been trying to get E-script from [MD 4] since this morning & [Resident 410] keeps asking for his Norco [pain medication] but pharmacy keeps saying E-script isn't in yet DON's response: Is this a new admit? Give me Dx [Diagnosis] and DOB [Date of birth] please Nurse's response: [Resident 410], DX: cellulitis of LLE [skin infection of left lower extremity; leg] [DOB] DON's response: When did this patient came in and from what hospital? Nurse response: came in yesterday from [redacted hospital name] DON response okay just texted him LN 7 stated the nursing staff were allowed to text the doctors with resident information and medical request via the facility provided smart phone. In an interview with the DON, in her office, on 1/15/25, at 4:52 PM, the DON stated the medical providers wanted text messages and it was easier for them to address and responsed to the requests. The DON stated the orders from text messages were written as a telephone order. The DON stated the smart phone had a 7-digit code to open it. The DON stated the facility did not have a special software for secure messaging. The DON stated the facility can use the messaging option from its computer system and it was not an easy option for the doctors to access or use. The DON was not sure about the details of the facility's policy on use of smart phones with confidential health information of the residents. In a concurrent interview with facility's Administrator (Admin), in his office, on 1/16/25, at 2:20 PM, and review of the facility's policy on use of smart phones, the Admin stated the facility provided the smart phone for each nursing station to help with communication. The Admin stated the use should be limited to situations such as urgent change in condition of a resident. The Admin stated he was not sure if anyone in management were monitoring the smart phone use, or the messages or pictures communicated. The Admin stated he had not looked at the policy recently on how smart phones should be handled. The Admin stated the health care information was vulnerable to hacking (unauthorized access to a computer system or smart phones) and no one was immune to it. Review of the facility's policy titled Use of facility-Designated Cell Phone (or Smart Phone) for Physician Communication, with revision date of 4/24, the policy indicated, .To establish guideline for the use of facility designated cell phones for text-based communication with physicians while ensuring compliance with HIPAA (Health Insurance Portability and Accountability Act; [federal law that protects patients' health information]) requirements and safeguarding the privacy and security of patient information. The policy in the scope section indicated, .This policy applies to all employees' contractors and affiliated healthcare providers . The policy further indicated, .The use of facility designated cell phones for texting physician is permitted only when the following guidelines are adhered to. All text-based communication involving protected health information (PHI) must occur through iMessage the facility approved secure messaging application to ensure compliance with HIPAA regulations. The policy on Content Guidelines section indicated, .Limit text messages to the minimum necessary information required for effective communication. Avoid including highly sensitive details in text messages. If extensive information is required, communicate via a secure phone call or in person discussion. The policy on Storage and Retention section indicated, .PHI (or Private Health Information) should not be stored on facility designated cell phones beyond what is necessary for the communication .Any messages containing PHI must be deleted from the device once the information is transferred to the EHR or the purpose of the message is fulfilled . The facility owned smart phone or cell phone stored 3,166 items including pictures of body part, documents containing resident name, and test results. Review of an online article posted by The HIPPA Journal titled Is iMessage HIPAA Compliant?, dated 9/30/24, last accessed on 1/28/25, indicated, .iMessage is not HIPAA compliant and should not be used to communicate Protected Health Information (PHI) .[Smart phone brand] does not have any control over how devices are configured, so does not take any responsibility for the privacy and security of PHI however it is created, received, stored, or transmitted by [Smart phone brand] devices. [smart phone brand] will not enter into Business Associate Agreements with covered entities and business associates and specifically states in its terms of service .the fact that [smart phone brand] will not take responsibility for the privacy and security of PHI - and will not enter into a Business Associate Agreement with covered entities and business associates - means it is not possible to use iMessages to communicate PHI . (https://www.hipaajournal.com/is-imessage-hipaa-compliant/#:~:text=iMessage%20is%20not%20HIPAA%20compliant,in%20its%20Terms%20of%20Servicethe)

Based on interview, observation, and record review, the facility failed to ensure safe medication storage practices in the medication room (a locked room used to store medications and supplies) and one out of six medication carts (a mobile cart stored medication and supplies for immediate use), and medication refrigerator when: 1. Medication Cart 2 in Station 2 stored undated inhalation medication called Ipratropium/Albuterol (or DuoNeb, an inhalation solution used to treat breathing problems); 2. Medication Closet 1 in Station 1, in the active storage areas, stored expired test tubes (A blood test tube is a sterile, vacuum-sealed tube used to collect and store blood samples for medical testing); and 3. Medication refrigerator in Station 2 contained an opened and undated vial of Aplisol (or Tuberculin Purified Protein Derivative [PPD] a testing agent used to diagnose Tuberculosis or [TB], a serious lung disease) and an expired container of Golytely liquid (a solution used to prepare the colon for medical procedures) bottle for a resident that never used it. These failed practices could contribute to unsafe and spoiled medication use in the facility. Findings: 1. During a concurrent observation and interview with Licensed Nurse (LN) 3, on [DATE], at 9:35 a.m., in the facility's Station 2 unit, the Medication Cart 2 stored an inhalation medication called DuoNeb out of its foiled wrap and was undated. The product label on the foil box indicated .Protect from light. Unit-dose vials should remain stored in the protective foil pouch at all times. Once removed from the foil pouch, the individual vials should be used within one week . The packets did not have resident name, date, and time it was opened. LN 2 acknowledged the findings. 2. During a concurrent observation and interview LN 6, on [DATE], at 10:04 a.m., the facility's medication room (closet) 1 at Station 1, stored one unopened package of blue top test tube. It was observed the expiration on the test tubes was [DATE]. LN 6 acknowledged the finding. 3. During a concurrent observation and interview with LN 7, on [DATE], at 11:19 a.m., in facility's Station 2 unit, the Medication Refrigerator stored one vial of Aplisol. The manufacture specification on the packaging indicated, .Once entered [opened], vial should be discarded after 30 days . It was observed the vial was opened and undated. LN 7 acknowledged the finding. During a concurrent observation and interview with LN 7, on [DATE], at 11:19 a.m., in facility's Station 2 unit, the Medication Refrigerator stored one expired and unused container of Golytely liquid bottle for a resident that never used it. The label on the container was dated [DATE]. The manufacturer label on the container indicated Throw away (discard) unused Golytely solution within 48 hours (2 days). LN 7 confirmed the finding. During an interview on [DATE], at 4:19 p.m., the Director of Nurses (DON) stated the vials with the blue top stored in medication room Closet 1 in Station 1 were used for labs to test blood for coumadin levels in residents. The DON stated they were sent to the facility by the laboratory and explained they were sent the wrong test tubes. The DON stated the risk for the residents if the expired test tubes were to be used during blood collection, would be they might not work, and the test results might not be accurate. The DON stated in terms of the Tuberculin, the expectation was for the nurse to write the date the medication was opened on the vial and stated the medication was only good for a certain number of days after opening. The DON stated the risk to the resident would be the Tuberculin would not be effective. The DON stated in regard to the inhaler solution DuoNeb, the medication was packaged in foil, and when first opened, the medication must be dated by the LN. The DON stated the risk to the resident if this was not done was the medication might not be as effective. Review of a facility policy and procedure (P&P) titled, Storage of Medications, undated, indicated, .The facility stores all drugs and biologicals in a safe, secure, and orderly manner .Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications .Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .

Based on observation, interview, and record review, the facility failed to ensure safety of bed side medication storage and use for 1 out of 10 residents (Resident 24) observed for medication administration based on facility's policy and medical doctor's orders. This failed practice resulted in unauthorize use of medications without a doctor's order in the facility, unsafe handling, and storage of medications in a room shared with another resident. Findings: During a medication administration observation for Resident 24, at facility's station 2 hallway, accompanied by Licensed Nurse (LN) 3, on 1/13/25, at 9:35 AM, LN 3 administered the morning medications and later at 9:56 AM measured the Blood Pressure (BP) and gave the two blood pressure medications. Resident 24 was sitting in a wheelchair and was hard of hearing. Further observation, inside Resident 24's room, there were three medications with no labels stored on top of Resident 24's bed-side table During a concurrent observation and interview with LN 3, in Resident 24's room, on 1/13/25, at 1:22 PM, the bed side unlabeled medications were brought to the attention of LN 3. The medications at bed side included an inhaler called Foracort 200 (a brand name for combination of two drugs for treatment of the asthma) indicating 100 out of total 120 puffs had been already used, a nose spray called Aller-FLO (or Fluticasone, a medication spray into the nose), and a second nose spray called Saline Nasal Mist (a nose spray with salt solution to moisturizer the nasal lining). LN 3 stated she did not notice the medications were stored at Resident 24's bedside and had to check if there was an order from the doctor to use the medications. LN 3 stated it was not safe to keep resident medications at the bed side without proper assessment. During a concurrent interview and record review on 1/13/25, at 1:35 PM, with LN 3, Resident 24's Medication Administration Record (MAR), dated 1/25, was reviewed. LN 3 confirmed Resident 24's MAR record did not contain any orders for the 3 medications stored at Resident 24's bedside. During an interview with Resident 24, in her room, on 1/14/25, at 8:35 AM, Resident 24 stated the medication at her bedside were her own and was prescribed by her allergy doctor and had been using them for years. Resident 24 did not know if the facility was aware of her use since she was admitted in November of 2024 and no one from the facility had explained to her the process of her using her own inhaler at the facility. During an interview on 1/15/25, at 4:52 PM, the Director of Nursing (DON) stated the residents could use their own medications with a doctor's order, and an assessment of safe storage and the resident's mental status. The DON stated the risk of having medication at bed side and self-use could pose safety risk and/or medication interaction and use by another resident. Review of the facility's policy titled Nursing Administration: Continuum of Care, dated 2/23, in section 10 titled Nurse Assistant Procedure, indicated, .If the resident brought in any medication, give them to the charge nurse . Review of the facility's undated policy titled Self-Administration of Medications, the policy indicated, .Residents have the right to self-administer medications if the interdisciplinary team (team of health care professionals caring for the resident) has determined that it is clinically appropriate and safe for the residents to do so . Section 8 of the policy indicated, .Self-administered medications are stored in a safe and secure place, which is not accessible by other residents . Section 9 of the policy indicated, .Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party . Review of the facility's undated policy titled Medications brought to the facility by the Resident/Family, the policy indicated, .The facility shall ordinarily not permit residents and families to bring medications into the facility . The policy further indicated, .Resident and families must report to the nursing staff any medications that they want to bring or have brought into the facility .

Based on observation, interview, and record review the facility failed to ensure safe cleaning and sanitization of shared glucometer (a device used to measure blood sugar) in-between resident care for two residents out of nine residents observed for medication administration (Resident 39 and Resident 10) based on facility's policy and manufacturer specifications. This failure had potential to spread infection among residents and compromise resident's well-being. Findings: During a medication administration observation with Licensed Nurse 2 (LN 2), at Station 2 hallway, on 1/14/25, at 12:08 PM, LN 2 with gloved hand took the glucometer and supplies in the Resident 39's room to measure the blood sugar. LN 2 placed the glucometer on the bedside table then poked Resident 39's right middle finger with a lancet (small, sharp needles used to obtain a small amount of blood from the finger for blood sugar testing) to get the blood and soaked the test strip (a plastic strip contains chemicals to help with blood sugar measurement) with blood to measure the blood sugar. LN 2 used one Sani-Cloth-Bleach wipe (brand name for a wipe with chemicals to disinfect and kill germs on the surfaces) quickly (less than 10 seconds) to clean the glucometer outer surface once out of the Resident 39's room. During the subsequent medication administration observation, with LN 2, at Station 2 hallway, on 1/14/25, at 12:18 PM, LN 2 with gloved hand took the same glucometer used on previous resident and supplies into the Resident 10's room to measure the blood sugar. Resident 10 had a lunch tray in front of her while sitting on a wheelchair and was eating her food. LN 2 placed the glucometer on the bedside table then poked Resident 10's right thumb finger with lancet to get the blood and soaked the test strip with blood to measure the blood sugar. LN 2 was not able to get a result from the glucometer machine and stated she had to repeat the test. LN 2 went back to cart with new supplies and this time after putting the glucometer on bedside table, she poked Resident 10's index finger to get blood for testing. LN 2 then used one Sani-Cloth-Bleach wipe quickly (less than 10 seconds) to clean the glucometer outer surface once out of the Resident 10's room and placed it in a plastic cup. In an interview with LN 2 on 1/14/25, at 2:11 PM, LN 2 stated she stated she used one wipe to clean the glucometer. LN 2 stated the wipe bottle indicated 4 minutes wet time (the time for surface of glucometer remained wet to kill possible bugs on the surface) to disinfect and then allow to dry. In an interview with Infection Prevention nurse (IP), on 1/15/24 3:01 PM, the IP stated the nursing staff were educated to clean and disinfect the shared glucometer in-between resident use. The IP stated she had trained the nursing staff during the staff meetings and the last time was in November of 2024. The IP stated for new nurses the facility's DSD (Director of Staff Development) had been doing the initial orientation and training on infection control and glucometer care in addition to following a senior nurse. The IP stated the cleaning and sanitization of shared glucometer was a two-step process to use one wipe to clean and remove surface contaminations and then a second wipe used to sanitize and keep the outer surface wet so you can see the wetness with eye for minimum of 4 minutes per Sani-Wipe instruction to kill the germs that could not be seen with eye. During a concurrent interview with IP on 1/15/25, at 3:05 PM, and review of facility's disinfecting wipe document, titled General Guidelines For Use, the document indicated Use a wipe to remove visible soil prior to disinfecting . Unfold a clean wipe and thoroughly wet surface . Allow surface to remain visibly wet for Four (4) minutes. In an interview with Director of Nursing (DON), in her office, on 1/15/25, at 4:19 PM, the DON stated the facility used bleach wipes and it needed to stay wet for 4 minutes to kill germs. The DON stated it was important to clean the share devices per instruction to prevent spread of the infections. The DON did not provide further detail on how the process of cleaning and sanitization should be done by the nursing staff. Review of the facility's policy, titled 483.80 Infection Control, dated 3/2024, the policy indicated It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases (infections that spread easily) and conditions. The policy on section 2 indicated . Patient care equipment: . It is preferred dedicated or disposable patient care equipment be used. If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient. Review of the facility provided instruction sheet by manufacturer of Assure Platinum glucometer (a brand name by ARKRAY, the manufacturer of glucometer), titled ARKRAY Technical Brief: Cleaning and Disinfecting the Assure Platinum Blood Glucose Monitoring System , dated 9/2024, the documents under Cleaning and Disinfecting FAQ (Frequently Asked Questions) indicated Can cleaning and disinfecting be accomplished with one wipe? No, Each time the cleaning and disinfecting procedure is performed, two wipes are needed. One wipe to clean the meter and the second wipe to disinfect the meter. What will happen if a blood glucose meter is not clean and disinfected after use? . It is important that long term care facility establish a program for infection control . Program include addressing the cleaning and disinfecting of blood glucose meters along with other equipment and environmental surfaces . It is also important to provide education on infection control and the proper use of products. A review of the Center for Disease Control (A federal agency responsible for the health and safety of people) guideline, titled Considerations for Blood Glucose Monitoring and Insulin Administration, last accessed on 1/24/25 via https://www.cdc.gov/injection-safety/hcp/infection-control/index.html, the guideline indicated Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings, germs and infections can spread if preventive measures are not in place. The guideline further indicated Dedicated meters should be cleaned and disinfected per the manufacturer's instructions and, at a minimum, anytime the device is reassigned to a different person . If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per the manufacturer's instructions, to prevent the spread of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected, it should not be shared. Review of the facility's undated policy, titled Glucometer Cleaning/Disinfecting, the one-page policy indicated It is the policy of this facility to ensure the glucometers are cleaned and disinfected accurately. The Procedures section indicated After each use with gloves on glucometer will be cleaned/disinfected with PDI Sani-Cloth Germicidal Disposable Bleach Wipes (brand name of wipes used at the facility). Ensure there is no dried blood spot on the glucometer. Lay the glucometer flat on a paper towel and leave open to air for four minutes until it is ready to use.

Based on observation, interview, and record review, the facility failed to ensure the prescription medication delivery manifests (delivery manifest, also known as a shipping manifest, is a legal document that listed all items being transported in a shipment) which included narcotic controlled medications (medication with risk of abuse including opioids) were signed by licensed staff upon delivery from the provider pharmacy for a census of 56 residents. This failed practice may contribute to unsafe medication handling and risk of drug diversion (unlawful use or abuse of medication). Findings: During a medication area inspection, at facility's Station 1, on 1/13/25, at 10:36 AM, accompanied by Licensed Nurse (LN) 6, a binder which contained the delivery sheets for prescription and narcotic medications delivery, were not consistently signed by nursing staff upon receipt from the provider pharmacy delivery driver. The individual sheets titled Packing Slip, at the bottom on each page, indicated .By signing below you acknowledge that you have received this pharmacy shipment. Please fax the signed packing slip to the pharmacy .Please notify the pharmacy within 24 hours of any discrepancy .Signature . Date . LN 6 stated they signed the paper from from the delivery driver, but was not sure why some sheets were signed, and the majority of the sheets were not signed. In an interview with Director of Nursing (DON), in her office, on 1/14/25, at 2:23 PM, the DON stated the staff signed a copy of the delivery sheet for the driver and were not required to sign the facility copy. Review of the facility's undated policy titled Controlled Substances, the policy indicated, .The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Section 8 of the policy indicated, .Controlled substances are reconciled upon receipt . Section 9 of the policy indicated, .Upon receipt: the Nurse receiving the medication and the individual delivering the medication verify the name, dose, and quantity of each controlled substance being delivered. Both individuals sign the controlled substance record of receipt . Review of the facility's undated policy titled Accepting Delivery of Medications, the policy indicated, .All staff shall follow a consistent procedure in accepting medications .Before signing to accept the delivery, the nurse must reconcile the medication in the package with the delivery ticket/order receipt . Section 4 of the policy indicated, .A Nurse shall sign the delivery ticket, indicating review and acceptance of the delivery, and shall keep copy of the delivery ticket. Both the receiving nurse and the delivery agent must sign any notation about errors .

Based on interview, observation, and record review, the facility failed to ensure the safe use of psychotropic medications (mind altering drugs) for one of five residents (Resident 44) selected for unnecessary medication use when: 1. Resident 44's documented diagnosis of bipolar disorder (a chronic mood disorder which causes intense shifts in mood, energy levels and behavior) in the medical record for use of aripiprazole (a drug used to treat mental health issues) was not reflected in the medical doctor's progress notes, History and Physical (H&P), and previous hospitalization record; and 2. Resident 44's mental health consult and mental health medication adjustments were not carried out, nor communicated to the primary Medical Doctor (MD) 1, the Director of Nursing (DON), the licensed nursing (LN) staff, and the Resident Representative (RP, individual responsible for maing healthcare decisions on behalf of resident). These failures could contribute to unsafe use of mind-altering medications and the inaccurate diagnosis could lead to unnecessary use of medications with adverse consequences. Findings: 1. Review of Resident 44's electronic medical record, titled ADMISSION RECORD, indicated, Resident 44 was admitted to the facility with diagnosis including but not limited to: Parkinson's disease (a movement disorder of the nervous system which worsens over time), dementia (a brain disorder which causes memory loss, confusion, problems with language, and changes in behavior), encephalopathy (a change in brain function due to injury or disease), psychosis (disruptions to a person's thoughts and perceptions that make it difficult for them to recognize what is real and what is not), anxiety disorder (excessive fear or worry about a specific situation), major depressive disorder (affects how you feel, think and behave and can lead to a variety of emotional and physical problems), and bipolar disorder (mental health condition which causes extreme mood swings). Review of Resident 44's electronic medical record, titled Medication Administration Record (MAR, where nurses document what and when ordered medications were administered), dated 9/24 and 1/25, indicated the following orders for mind altering medication as follow: ARIPiprazole Oral Tablet 2 MG [a psychotropic mind-altering medication, MG is milligram, a unit of measure] Give 1 tablet by mouth at bedtime related to BIPOLAR DISORDER .; Start date 8/28/24 . Mirtazapine Oral Tablet 15 MG [a drug used to treat depression] Give 1 tablet by mouth at bedtime for M/B [manifested by] POOR FOOD ORAL INTAKE related to MAJOR DEPRESSIVE DISORDER; Start Date 8/28/24 . Sertraline HCl Oral Tablet 50 MG [drug used to treat depression] Give 1 tablet by mouth in the morning related to MAJOR DEPRESSIVE DISORDER, . m/b verbalization of sadness; Start date 8/28/24 . The September 2024 MAR document indicated the medications listed above were ordered on 8/27/24 and the 1/2025 MAR indicated aripiprazole order start date changed to 9/30/24. Review of Resident 44's Physician Physical and History, dated 8/29/24, written by MD 1, the record indicated the past medical history for Parkinson disease, depression, and high blood pressure among others. The record further indicated, .The resident .Has the capacity to understand and make decisions [checked] . MD 1's H&P did not include diagnosis of bipolar disorder for the use of the mind-altering drug aripiprazole. Phone call and message left for MD 1, on 1/16/25, at 12:32 p.m., during the Department visit was not answered or returned. During a review of Resident 44's medical record, titled History and Physical (H&P), from Hospital A, dated 8/22/24, written by MD 8, the record indicated Parkinson's disease, anxiety, and depression as the only mental health diagnosis. MD 8 did not include a diagnosis of bipolar disorder as current or past medical history. Review of Resident 44's paper chart titled Physician Progress Notes, written by MD 3 who admitted the resident at a previous facility for one day, dated 8/26/24, the record under medication list indicated, .Medications .aripiprazole 2 mg tablet .Give 1 tablet by mouth at bedtime for Bipolar/Depression/Psychosis . The Resident 44's record under Assessment and Plan (final diagnosis and plan for care moving forward) indicated, Parkinson disease, hypertension (high blood pressure), anxiety, and depression as the main diagnosis. The Assessment and Plan section further indicated, .Major Depressive Disorder, recurrent .continue mirtazapine 45 mg [antidepressant, mg stands for milligram] and aripiprazole 2 mg [mood altering drug] at bedtime. Assess mood daily using standard scale . The MD 3's assessment did not include a diagnosis of bipolar disorder for use of aripiprazole. During a concurrent interview and record review on 1/16/25, at 10:40 a.m., Resident 44's medical record was reviewed with the MDS Coordinator (MDS stands for Minimum Data Set, which is a federally mandated tool used in skilled nursing facilities for comprehensive assessment of a resident's health, diagnosis, and care needs; MDS coordinator is a nurse that compile data for transmitting to the federal government). The MDS Coordinator stated she used admission records including doctor's H&P, previous hospitalization , and MD's progress notes to input the diagnosis in the MDS database. The MDS Coordinator stated she did not have access to any mental health visit or progress notes as the social services staff were protecting them. The MDS Coordinator acknowledged the bipolar diagnosis, which was documented in the MDS records, was not listed, or addressed by MD 1's H&P, hospital's records, and the previous facility's assessment of Resident 44's final diagnosis. Review of Resident 44's Psychiatric Visit Progress Report, dated 9/10/24, written by the telehealth (a way to receive healthcare remotely using technology like the internet, computers, and video conferencing) Nurse Practitioner (NP), the Assessment section indicated the following: .Diagnostic Impression: DEMENTIA .Per Facility Records .ANXIETY DISORDER .Per Facility Records .MAJOR DEPRESSIVE DISORDER .Per Facility Records .PSYCHOSIS .Per Facility Records .BIPOLAR DISORDER .Per Facility Records . Further review of Resident 44's Psychiatric Visit Progress Report did not include independent mental health diagnosis and the NP used the facility provided records to obtain patients history and diagnosis. During an observation and interview on 1/16/25, at 11:49 a.m., Resident 44 was observed sitting in her wheelchair in her room. Resident 44 stated she had been living at the facility for five months. Resident 44 stated her mental health diagnosis' included Parkinson disease and memory loss. When asked if she had a psychiatrist (a medical doctor who specializes in mental health and can diagnose and treat), Resident 44 stated she did but had not seen him for three or four months. When asked if she had ever been diagnosed with bipolar disorder, Resident 44 stated no. During a phone interview with NP on 1/16/25, at 12:38 p.m., the NP stated she used the facility documents to obtain the patients history and diagnosis. The NP stated the bipolar diagnosis was a core psychiatric diagnosis which required a comprehensive review of resident's history and other clinical factors. The NP stated she would have referred the patient out to a neuropsychiatrist (a medical professional who treats mental disorders and conditions that are caused by psychiatric factors) for further examination. The NP stated clinically her expectation was that the facility did their due process and based their diagnosis on the patient's clinical record. During a phone interview, with MD 2, on 1/17/25, at 12:07 p.m., MD 2 stated Resident 44 was a patient of his and he was her psychiatrist for the last few years. MD 2 stated he had a visit with Resident 44 on 10/21/24 and stated she was diagnosed with major depressive disorder and anxiety. MD 2 stated he had never diagnosed Resident 44 with bipolar disorder. MD 2 stated it was best practice for a patient not to have two separate psychiatrists treating them at the same time. MD 2 stated this was due to the risk of adjusting a patient's medications and the psychiatrists not being aware of what the other doctor was prescribing or treating the patient with. MD 2 stated a patient having two separate psychiatrists treating them could have the potential for the psychiatrists to contradict each other and lead to problems with their doses of medications, including increases and decreases of medication doses. In a phone interview with Resident 44's Representative (RP), on 1/21/25, at 11 AM, the RP stated her mother (Resident 44) was never diagnosed with Bipolar or Psychosis mental health diagnosis. 2. Review of Resident 44's electronic medical record titled Medication Administration Record, dated 9/24 and 1/25, indicated the following orders for mind altering medication as follow: ARIPiprazole Oral Tablet 2 MG .Give 1 tablet by mouth at bedtime related to BIPOLAR DISORDER .; Start date 8/28/24. Mirtazapine Oral Tablet 15 MG .Give 1 tablet by mouth at bedtime for M/B POOR FOOD ORAL INTAKE related to MAJOR DEPRESSIVE DISORDER; Start Date 8/28/24. Sertraline HCl Oral Tablet 50 MG .Give 1 tablet by mouth in the morning related to MAJOR DEPRESSIVE DISORDER . m/b verbalization of sadness; Start date 8/28/24. Further review of the record indicated these medications had continued up to 1/16/25. During a concurrent interview and record review on 1/16/25, at 10:40 a.m., with the MDS coordinator and the SSD (Social Services Director), in the SSD's office, the SSD stated the facility used psychiatric (mental health) services through telehealth. The SSD stated the mental health progress notes written by telehealth doctors were emailed to the SSD and the facility's Administrator (ADM). The SSD stated the mental health progress notes and records did not go into the resident's medical record chart (paper or electronic) due to confidentiality of mental health records. The SSD stated if the mental health progress notes and consults contained medication orders or required actions by the attending physician, the SSD would provide them with a copy of the mental health consult. The SSD stated the clinical staff, medical records, MDS Coordinator, and Licensed Nurses (LN) did not have access to these records, and they needed to contact him to look at the records if needed. The SSD stated he was available every day around the clock to provide the document which resided in his email. The SSD acknowledged records not being in the resident's electronic or paper chart could have posed a barrier to the attending physician's timely care and accessibility of the health record to front line licensed staff providing care. During a concurrent interview, with the MDS Coordinator and the SSD, on 1/16/25, at 10:57 a.m., and record review of Resident 44's mental health consult, dated 9/10/24, in the SSD's office, the SSD printed the mental health consult from his email. The SSD confirmed the psychiatric consult notes for Resident 44 were not documented or stored in the electronic or paper medical chart. During review of Resident 44's psychiatric consult notes, written by NP, it was confirmed the psychiatric progress notes listed two recommendations of reducing Mirtazapine 15 mg to 7.5 mg and reducing Sertraline 100 mg to 50 mg. The SSD confirmed and acknowledged the NP's recommendations were not carried out or reflected in the resident's medical record including, Resident 44's progress notes or the MAR. The SSD confirmed the mental health consult was not shared with medical doctor or the Director of Nursing. The MDS Coordinator stated she did not have access to resident's psychiatric progress notes unless she asked the SSD to see them. The SSD stated he only provided the mental health progress notes for the Licensed Nurses or doctor to review if there were new orders or an action needed to be taken. The SSD acknowledged if the records were not in the resident's chart it could affect the continuity of care. The SSD acknowledged the risk to the resident if the information was not shared with the LN or attending physician was new orders would not be carried out and information was not shared. Further review of Resident 44's medical record, the SSD confirmed Resident 44 had a primary psychiatrist (MD 2) and was seen by him on 9/23/24. The SSD stated he had never contacted MD 2 and did not inform the telehealth psychiatric provider that Resident 44 was under MD 2's care. The SSD stated coordination of care among health care providers would have helped optimized care for Resident 44. During a concurrent interview and record review on 1/16/25, at 11:37 a.m., with the Medical Record Director (MRD) and Medical Record Assistant (MRA), the MRD stated since 2023 all medical records were uploaded into the resident's electronic health record (EHR). The MRD stated psychiatric consults stayed with the social worker due to confidentiality reasons and medical records does not get a copy. During an interview on 1/16/25, at 1:24 p.m., LN 4 stated she had heard about residents receiving psychiatric telehealth in the facility. LN 4 stated she had not seen progress notes in any residents' chart. LN 4 stated doctors ask the LNs about their patients psychiatric or mental health status regularly. LN 4 stated it would be helpful to know what the doctor's plan was for residents, residents medication use, and having the (mental) health progress notes would be helpful. During a concurrent interview with DON and record review, on 1/16/25, at 1:35 p.m., the DON stated the facility used telehealth mental health services for residents needing psychiatric care. The DON stated patients were welcomed to use their own mental health provider because they would know the resident's history and know what medications they were taking. The DON stated if a resident had an order for a psychiatric consult the SSD would communicate with telehealth services, and once the resident was seen, an email containing the telehealth progress notes was sent to the SSD. The DON stated the SSD will then forward the emails to her. The DON stated if the psychiatric progress notes contained orders the SSD would give it to the admissions Case Manager (CM), who was a LN, and the CM would inform the Attending Physician (AP). The DON stated the AP will notify the resident representative (RR) and put the psychiatric progress note in the resident's medical record. The DON stated it was her expectation the SSD was printing the psychiatric progress notes to be uploaded into the resident's electronic health record by medical records. The DON stated it was her understanding psychiatric progress notes were being uploaded to the electronic medical record and stated it was important for LN's to have access to these records. The DON stated all the attending physician and LN's should have access to psychiatric progress notes which would provide awareness of the residents condition. The DON stated having access to all medical records was important for continuity of care. The DON confirmed she did not receive Resident 44's psychiatric progress note, dated 9/10/24, from the telehealth mental health provider and the SSD did not forward the email with telehealth consult notes to her. The DON stated the SSD should not be reviewing psychiatric physician progress notes or making clinical decisions regarding residents. The DON stated the SSD had no clinical license and the CM should be doing this. The DON stated confidentiality of mental health documents applies to all medical documents and stated keeping the mental health documents out of the resident's chart would be a failure to disseminate information to the clinical team. The DON stated Resident 44's bipolar diagnosis was based on her transfer from another assisted living facility and her expectation was for the diagnosis to be verified by the attending physician. Review of the facility's policy titled Content of Medical Records, dated 2/23, the policy indicated, .List of content of the medical record .Current Diagnosis, Statement that the patient was informed of his/her medical condition, Physician Progress Notes .Consultation Reports . Review of the facility's policy titled Medication (Drug) Regimen Review (MRR), dated 12/24, indicated, . Definitions . Definitions are provided to clarify terminology related to pharmaceutical services and management of each resident's medication regimen for effectiveness and safety . Irregularity refers to the use of medication that is inconsistent with accepted standards of practice for providing pharmaceutical services, not supported by medical evidence, and/or that impedes or interferes with the intended outcomes of pharmaceutical services. An irregularity also includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, and excessive doses, and/or in the presence of adverse consequences as well as the identification of conditions that may warrant initiation of medication therapy .Unnecessary drug is defined as medications ordered .In excessive dosage .Without adequate indications for its use . Review of the facility's document, titled Job Description Social Services Manager, dated 11/2021, indicated, .Maintain a quality working relationship with the medical profession and other health related facilities and organizations .Delegate authority, responsibility, and accountability to other responsible department personal . Coordinate social services activities with other departments as necessary .Assure that social service progress notes are informative and descriptive of the services provided and of the resident's response to the service .Qualifications .Must have, as a minimum, a bachelor's degree in social work or a bachelor's degree in a human services field including but not limited to sociology, special education, rehabilitation counseling, and psychology . Review of the facility's document, titled Job Description Licensed Vocational Nurse/Licensed Practical Nurse, dated 12/17/21, indicated, . the primary purpose of your job position is to provide primary care to specific residents under the medical direction and supervision of the resident's attending physicians or the Medical Director of the facility, with an emphasis on assessment, illness prevention and health care management. You will assist in modifying the treatment regimen to meet the physical and psychosocial needs of the resident, in accordance with established medical practices and the requirements of the state and the policies and goals of this facility .Consult with the physician concerning resident evaluation and assist the Director of Nursing Services in planning and developing the nursing services to be performed for the resident .Initiate requests for consultation or referral. Respond to requests from the resident physician or nursing staff .Examine the resident and his her records and charts to distinguish between normal and abnormal findings in order to recognize early stages of serious physical, emotional or mental problems . Determine when to refer the resident to a physician for evaluation, supervision, or directions Prepare and administer medications as ordered by the physician . Review medication cards for completeness of information, accuracy and the transcription of the physicians order . Chart all communications with the resident's attending physician regarding the resident, the resident's treatment or the response that treatment .