Every finding on record at Franklin Oaks Nursing and Rehabilitation Center

Based on observation and staff interviews, the facility failed to protect private health information for 32 of 147 residents (Resident #106, #143, #4, #82, #100, #130, #137, #56, #103, #124, #29, #17, #123, #18, #99, #77, #41, #116, #134, #73, #147, #35, #126, #115, #145, #27, #23, #132, #50, #111, #16, and #34), when staff left confidential medical information in a clear cylinder shaped plastic container, accessible to the public on an unattended medication cart in hall 300. The findings included: A continuous observation of an unattended medication cart on hall 300 was made on 8/11/26 at 9:31 AM to 9:45 AM. On top of the medication cart was a clear plastic cylinder shaped container which contained empty pill pouches from the previous medication pass. Each pouch had confidential information printed on it including; resident name, medication name and dose. This information was visible through the clear container. Visitors, residents and staff were present in the hallway during the observation. The pouches in a clear plastic cylinder container were for Resident #106, #143, #4, #82, #100, #130, #137, #56, #103, #124, #29, #17, #123, #18, #99, #77, #41, #116, #134, #73, #147, #35, #126, #115, #145, #27, #23, #132, #50, #111, #16, and #34. During an interview on 8/11/26 at 10:20 AM with MA #2 she stated that she forgot to put away the plastic container and shred the used pill pouches that hold resident medications before she left for a smoking break. MA #2 further stated that she is trained in how to secure and dispose of the pill pouches which had resident information. In an interview with the Unit Manager (UM#3) on 8/11/26 at 10:23 AM, she stated that the error was an oversight on the part of the MA #2, and that they would figure out the best way to discard the pill pouches after medication pass. An interview was conducted on 8/12/26 at 11:19 AM with the Director of Nursing (DON). The DON indicated that it was the first time the error had occurred, and that nurses and Medication Aides are expected to dispose of the pill pouches safely by shredding them after passing out medications. The DON further revealed that they had acquired new containers since 8/11/26 that have a lid and key and are not clear. The DON further stated that the facility is working on providing in-service education to all nursing staff. During an interview on 8/14/26 at 12:12 PM with the facility Administrator, she indicated MA #2 should not have left the medical records information visible while she went for a smoking break. The Administrator further stated private health information should never be left on the medication cart unattended where it was visible to the public.

Based on observations and staff interviews, the facility failed to provide privacy curtains wide enough for visual privacy to protect a resident from view of others during activities of daily living. The deficient practice affected 4 of 12 residents reviewed for privacy curtain. (Resident #42, Resident #51, Resident # 62, and Resident #69) The findings included:1.Resident #42 was admitted to the facility on [DATE].The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #42 had severe cognitive impairment.On 8/12/26 at 9:56 AM an observation was conducted of urinary catheter care for Resident #42. Resident # 42's bed was closest to the door of the room. Nurse #5 went to pull the privacy curtain for Resident #42, and the privacy curtain did not go completely around Bed A. There was approximately 15 feet of insufficient privacy curtain. This would not allow full visual privacy when the resident was receiving care or when the resident desired privacy. The room was occupied and the curtain for Bed B was wide enough.An interview was conducted with Nurse #5 on 8/12/26 at 10:02 AM. Nurse #5 stated she was unaware of a missing privacy curtain and indicated that housekeeping was responsible for hanging the privacy curtains.An interview was conducted with the Housekeeping Manager on 8/12/26 at 10:30 AM. The Housekeeping Manager verified that his department was responsible for hanging privacy curtains. He stated upon visualization that sometimes the floor technician put up the wrong size curtains. The Housekeeping Manager stated he would have the curtains changed in the affected rooms.During an interview with the Administrator on 8/14/26 at 4:18 PM, she stated full visual privacy curtains should be in every resident's room to provide privacy when care is provided.2. Resident #69 was admitted to the facility on [DATE].The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #69 was cognitively intact.On 8/12/26 at 10:04 AM an observation was conducted with the Housekeeping Manager of Resident # 69's privacy curtain. The Housekeeping Manager went to pull the privacy curtain for Resident #69, and the privacy curtain did not go completely around Bed A. There was approximately 15 feet of insufficient privacy curtain. This would not allow full visual privacy when the resident was receiving care or when the resident desired privacy. The room was occupied and the curtain for Bed B was wide enough.An interview was conducted with Resident #69 on 8/12/26 at 10:05 AM. Resident #69 stated that the missing privacy curtain had been like that for a couple of months but did not recall mentioning the missing curtain to staff. Resident # 69 stated she did utilize the privacy curtain when resting in bed.An interview was conducted with the Housekeeping Manager on 8/12/26 at 10:30 AM. The Housekeeping Manager verified that his department was responsible for hanging privacy curtains. He stated upon visualization that sometimes the floor technician put up the wrong size curtains. The Housekeeping Manager stated he would have the curtains changed in the affected rooms.During an interview with the Administrator on 8/14/26 at 4:18 PM, she stated full visual privacy curtains should be in every resident's room to provide privacy when care is provided.3. Resident #62 was admitted to the facility on [DATE].The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #62 was cognitively intact.On 8/12/26 at 10:06 AM an observation was conducted with the Housekeeping Manager of Resident # 62's privacy curtain. The Housekeeping Manager went to pull the privacy curtain for Resident #62, and the privacy curtain did not go completely around Bed A. There was approximately 15 feet of insufficient privacy curtain. This would not allow full visual privacy when the resident was receiving care or when the resident desired privacy. The room was occupied and the curtain for Bed B was wide enough.An interview was conducted with Resident #62 on 8/12/26 at 10:09 AM. Resident #62 stated she had noticed that the curtain did not go all the way around the bed but denied reporting this to the staff. Resident #62 was unable to give a timeframe of how long the privacy curtain had been like that. Resident #62 stated she does used the privacy curtain during personal care.An interview was conducted with the Housekeeping Manager on 8/12/26 at 10:30 AM. The Housekeeping Manager verified that his department was responsible for hanging privacy curtains. He stated upon visualization that sometimes the floor technician put up the wrong size curtains. The Housekeeping Manager stated he would have the curtains changed in the affected rooms.During an interview with the Administrator on 8/14/26 at 4:18 PM, she stated full visual privacy curtains should be in every resident's room to provide privacy when care is provided.4. Resident #51 was admitted to the facility on [DATE].The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #51 had moderate cognitive impairment.On 8/12/26 at 10:04 AM an observation was conducted with the Housekeeping Manager of Resident # 62's privacy curtain. The Housekeeping Manager went to pull the privacy curtain for Resident #62, and the privacy curtain did not go completely around Bed A. There was approximately 15 feet of insufficient privacy curtain. This would not allow full visual privacy when the resident was receiving care or when the resident desired privacy. The room was occupied and the curtain for Bed B was wide enough.An interview was conducted with Nurse Aide #4 on 8/12/26 at 10:15AM. NA#4 stated that she was not aware the privacy curtain was missing in Resident #62's room. NA #4 stated that she usually reported to the housekeeping staff when privacy curtains were missing in resident rooms.An interview was conducted with the Housekeeping Manager on 8/12/26 at 10:30 AM. The Housekeeping Manager verified that his department was responsible for hanging privacy curtains. He stated upon visualization that sometimes the floor technician put up the wrong size curtains. The Housekeeping Manager stated he would have the curtains changed in the affected rooms.During an interview with the Administrator on 8/14/26 at 4:18 PM, she stated full visual privacy curtains should be in every resident's room to provide privacy when care is provided.

Based on observations, record review, resident, and staff interviews, the facility failed to maintain an effective pest control program as evidenced by the presence of flies in the conference room, kitchen area, and on 2 of 4 halls (200 and 300 hall) reviewed for pest control. The findings included:Pest control summary of services from the pest control company were reviewed for the following dates of 6/2/25; 7/1/25; 8/5/25; 9/1/25; 10/1/25;11/3/25; 12/5/24; 1/2/26; 2/11/25; 3/6/26; 4/3/26; 5/1/26; 6/18/26; and 6/25/26. Summary of services documented on the above dates included spots treated in the foundation, perimeter, porches, patios, kitchen, dining area, bathrooms, drain areas, laundry room drain areas, closets/storage, doorways-target pests ants, roaches, spiders, and drain Gnats. The pest control summary services showed that no flies were treated.PEST CONTROL AGREEMENT: DATED 5/26/2026Contractor will provide structural perimeter pest control at the above address: coverage includes treatment (s) for the following pests: Ants, carpet beetles, centipedes, cockroaches, pantry pests, crickets, earwigs, mice, hornets, millipedes, silverfish, snow bugs, pill bugs, paper wasps and yellow jackets. a. During a tour of the kitchen on 8/10/26 at 10:23 AM with the Certified Dietary Manager (CDM) two flies were observed flying around the dish rack and landing on the trash can by the exit door. The CDM stated that the food truck delivery came in earlier and they had to leave the doors leading to the kitchen from outside open, and that's when the flies made their way in. The CDM further stated that there have been flies in the facility for a couple of weeks. b. An observation was conducted in rooms 201, 221, and in the 200 hallways on 8/10/26 at 10:44 AM. The observation showed two flies, flying around the resident rooms and out to the 200 hallways. An interview with Resident #31 revealed she sees flies in and out of her room all day and that it was annoying to her.c. An observation on 8/13/26 at 12:31 PM revealed flies, flying down the 300 hall and landing and taking off from the medication cart. d. During an observation on 8/13/26 at 2:01 PM in room [ROOM NUMBER], approximately four flies were observed flying between the room window and the bed. e. An observation in the conference room of flies on the following dates and times:8/10/26 at 10:03 AM, 11:02 AM, 11:08 AM, 1:12 PM, 3:44 PM,8/11/26 at 8:22 AM, 12:09 PM, 4:14 PM and 4:49 PM,8/12/26 at 7:58 AM, 10:24 AM, 2:22 PM and 5:05 PM,8/13/26 at 8:10 AM, 11:02 AM and 2:09 PM, and 4:23 PM,8/14/26 at 8:22 AM and 12:23 PM.During a telephone conversation with the Pest Control Technician on 8/12/26 at 11:08 AM he stated that he only started providing fly treatment to the facility on 8/11/26. He revealed that he treated the exterior of building for flies, treated inside kitchen area for drain flies, treated inside doors for flies, and will be putting new fly lights, and treating drains and around trash cans every week until wintertime comes.During a resident council meeting on 8/12/26 at 2:00 PM the resident council members reported that the problem of flies in the facility was ongoing. The residents reported that the Administrator informed them that the facility had acquired a new pest control vendor.In an interview on 8/12/26 at 3:18 PM with Housekeeper #1 she stated that the presence of the flies has been an ongoing problem in the facility. She stated that she was going to report to the maintenance staff but had not done so. On 8/13/26 at 8:32 AM an interview was completed with the Maintenance Director who stated that the facility has experienced a surge of flies for a couple of weeks and that the pest control technician had been in the building on 8/11/26 to treat the problem. He further stated that the pest control technician installed fly traps, air curtains and traps on the trees have been installed to address the problem. An interview was conducted with the Administrator on 8/13/26 at 11:01 AM who revealed the fly's problem had been ongoing for a couple of weeks and that the facility had contracted a new pest control vendor since 5/26/26. The Administrator revealed that a Pest Control Technician provided treatment for the fly's on 8/11/26.

Based on record review, observations, staff, resident, and plumber interviews, the facility failed to maintain safe hot water temperatures to avoid putting residents at risk (Residents #12, #131, #102, #21, #29, and #78). The facility also failed to remove fall mats from the bedside when residents (Resident #11, #110, and #85) were out of bed creating the potential for a preventable accident. These deficient practices affected 9 of 11 residents reviewed for accident/hazards. The findings included:a. Resident #12 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease.A significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was moderately cognitively impaired, was coded as having no impairments to his extremities, and was coded as requiring partial assistance from staff to complete activities of daily (adls).During an observation on 8/10/26 at 10:48 AM the hot water was turned on in Resident #12's sink and was found to be very hot to touch. At 11:33 AM the Maintenance Director checked the hot water in Resident #12's room sink with his calibrated thermometer, and it registered 119.8 F.An interview conducted with Resident #12 on 8/10/26 at 11:34 AM revealed he used his room sink to wash his hands. Resident #12 stated he did not feel the water was too hot.b. Resident #131 was admitted to the facility on [DATE] with diagnoses that included dementia and diabetes.An annual MDS assessment dated [DATE] revealed Resident #131 was severely cognitively impaired, was coded as having no impairments to his extremities, and was coded as requiring setup assistance from staff to complete adls.During an observation on 8/10/25 at 11:36 AM the hot water was turned on in Resident #131's sink and was found to be very hot to touch. At 11:37 AM the Maintenance Director checked the hot water in Resident #131's room sink with his calibrated thermometer, and it registered 118.6 F.An interview was conducted with Resident #131 on 8/10/26 at 11:39 AM. Resident #131 revealed when his room sink's hot water was too hot to wash his face or hands. Resident #131 stated he had not verbalized this to staff.c. Resident #102 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and dementia.A quarterly MDS assessment dated [DATE] revealed Resident #102 was moderately cognitively impaired, was coded as having no impairments to her extremities, and was coded as requiring partial to moderate assistance from staff to complete adls.During an observation on 8/10/25 at 11:40 AM the hot water was turned on in Resident #102's sink and was found to be very hot to touch. At 11:41 AM the Maintenance Director checked the hot water in Resident #102's room sink with his calibrated thermometer, and it registered 119.3 F.d. Resident #21 was admitted to the facility on [DATE] with diagnoses that included heart failure and diabetes.A quarterly MDS dated [DATE] revealed Resident #21 was severely cognitively impaired, was coded as having no impairment to her extremities, and was coded as requiring supervision from staff to complete her adls.During an observation on 8/10/25 at 11:40 AM the hot water was turned on in Resident #21's sink and was found to be very hot to touch. At 12:01 PM the Maintenance Director checked the hot water in Resident #21's room sink with his calibrated thermometer, and it registered 118.2 F.An interview was conducted with Resident #21 on 8/10/26 at 12:03 PM. Resident #21 revealed when her room sink's hot water was quite warm to touch when she turned it on. Resident #21 stated she had not verbalized this to staff.e. Resident #29 was admitted to the facility on [DATE] with diagnoses that included heart failure and diabetes.An annual MDS assessment dated 6/126 revealed Resident #29 was cognitively intact, was coded as having an impairment to one side of his lower extremity and was coded as requiring moderate to substantial assistance from staff to complete adls.During an observation on 8/10/26 at 12:06 PM the hot water was turned on in Resident #29's sink and was found to be very hot to touch. At 12:07 PM the Maintenance Director checked the hot water in Resident #29's room sink with his calibrated thermometer, and it registered 119.5 F.An interview was conducted with Resident #29 on 8/10/26 at 12:09 PM. Resident #29 stated he used his sink to wash his hair in. Resident #29 revealed at times that the water was too hot to touch, he had to remove his head from the stream of water and adjust the temperature. Resident #29 revealed the sink water had never burned him. The Resident stated he had not notified staff of the hot water temperature.f. Resident #78 was admitted to the facility on [DATE] with diagnoses that included hypertension and kidney failure.A quarterly MDS assessment dated [DATE] revealed Resident #78 was moderately cognitively impaired, was coded as having no impairments to her extremities, and was coded as requiring setup assistance from staff to complete adls.During an observation on 8/10/26 at 12:14 PM the hot water was turned on in Resident #78's sink and was found to be very hot to touch. At 12:15 PM the Maintenance Director checked the hot water in Resident #78's room sink with his calibrated thermometer, and it registered 121.5 F.An interview was conducted with Resident #78 on 8/10/26 at 12:17 PM. Resident #78 revealed she utilized her room's sink to wash her hands and for other personal hygiene tasks. Resident #78 stated she did not feel the hot water from her sink was too hot.An interview was completed on 8/10/26 at 12:30 PM with the Maintenance Director. The Maintenance Director stated he had not received any complaints from staff or residents regarding the temperature of the hot water being too hot. The Maintenance Director revealed he was able to adjust the hot and cold-water mixing valves on each hallway to adjust the water temperatures in resident rooms and hallway bathrooms 1 to 2 degrees but contacted an outside plumber when the temperature needed adjusting more than that. The Maintenance Director stated the hot water temperature range for resident rooms and hallway bathrooms was 105 F to 115 F.An interview was completed on 8/10/26 at 12:58 PM with the facility's Administrator. The Administrator revealed all resident room sinks that were found to have abnormally high hot water, had it turned off and a note placed on the sink to not to use until further notice. The Administrator stated the outside plumbing company had been contacted and will be at the facility shortly to diagnose and fix the issue. The Administrator revealed facility wide staff education had been initiated to ensure staff were aware of potentially higher hot water temperatures and what to do. The Administrator stated the Maintenance Director checked hot water temperatures in random resident rooms on all hallways 5 days a week to ensure the temperatures were within a safe range. The Administrator stated she had not received any complaints or concerns regarding hot water temperatures from staff, residents, or family members. Review of the facility's resident in room sink hot water temperature logs from 1/6/26 through 8/7/26 revealed water temperatures were measured Monday through Friday by the Maintenance Director or his designee on hall 100, 200, 300, 400. The logs revealed the most recent recorded water temperatures were documented on 8/7/26.100 front hallway water temperature was recorded at 112 F.100 back hallway water temperature was recorded at 114 F.200 front hallway water temperature was recorded at 114 F.200 back hallway water temperature was recorded at 112 F.300 upper hallway water temperature was recorded at 114 F.300 lower hallway water temperature was recorded at 112 F.400 front hallway water temperature was recorded at 110 F.400 back hallway water temperature was recorded at 110 F.An interview was completed on 8/11/26 at 11:50 AM with the Plumber. The Plumber stated he was called to the facility on the afternoon of 8/10/26. The Plumber revealed he discovered on the 100 hall the hot and cold-water mixing valves had been adjusted too high, he readjusted the valves, and the temperatures lowered to the safe range of 105 F - 115 F. The Plumber stated he attempted to adjust the hot water temperature on the 300 hall but was unsuccessful. He revealed upon further inspection the recirculating water pump was not working properly and needed to be replaced. The Plumber stated he returned on 8/11/26 replaced the pump, adjusted the hot and cold-water mixing valves on the 300 hall and the hot water temperatures in resident room sinks remained at the safe range of 105 F- 115 F.An interview was completed on 8/10/26 with Nursing Assistant (NA) # 3. NA # 3 stated she had not noticed the water in the resident rooms on the 100 hall being too hot. The NA stated she had not had any residents complain to her regarding the temperature of the water.An interview was completed on 8/10/26 with NA #1. NA #1 stated she had not noticed the water in the resident rooms on the 300 hall being too hot. The NA stated she had not had any residents complain to her regarding the temperature of the water.An interview was completed on 8/14/26 at 3:06 PM with the Administrator. The Administrator stated it was her expectation that hot water in resident rooms and care areas remain with a safe temperature range. 2. An interview was conducted with Unit Manager #1 on 8/14/26 at 11:55 AM. Unit Manager #1 stated the purpose of the fall mat was to prevent serious injury when a resident fell. Unit Manager #1 stated fall mats should be removed when the resident was out of bed because the fall mat could cause the wheelchair to tip backwards if the resident rolled their wheelchair onto the mat. Unit Manager #1 stated the Nurse Aide (NA) was responsible for removing the fall mats when the resident was up out of bed. Unit Manager #1 further stated that all nursing staff should ensure the fall mats are removed. a. Resident # 110 was admitted to the facility on [DATE] with diagnoses that included age related debility and dementia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had moderate cognitive impairment, required substantial/maximal assistance with transfers, and had no falls since the prior MDS assessment. The resident utilized a wheelchair and was able to wheel self-150 feet independently.Resident #110's active care plan, last revised 5/28/25, revealed a focus of resident at risk for falls characterized by history of falls, weakness, impaired mobility, and attempts to get out of bed unassisted. The goal was for the resident to have no falls or accidents resulting in injury. The updated interventions included fall mat on floor when in bed. An observation completed on 8/10/26 at 3:49 PM revealed Resident #110 was up in the wheelchair. The fall mat was on the floor next to the bed and the wheelchair was beside the fall mat. An observation completed on 8/13/26 at 10:38 AM revealed Resident #110 was up in the wheelchair. The fall mat was on the floor next to the bed and the wheelchair was beside the fall mat. An observation completed on 8/14/26 at 9:56 AM revealed Resident #110 was up in the wheelchair by the window on the opposite side of the room and the fall mat was on the floor next to the bed. An observation completed on 8/14/26 at 11:48 AM revealed Resident #110 was up in the wheelchair. The fall mat was on the floor next to the bed and the wheelchair was beside the fall mat. An interview was conducted with Nurse Aide (NA) #4 on 8/14/26 at 11:50 AM. NA #4 verified she was assigned to Resident #110 on 8/10/26, 8/13/26 and 8/14/26 during the first shift. NA #4 stated it had been a while since Resident #110 had fallen. She indicated she was responsible for removing the fall mat for Resident #110 when the resident was out of bed. NA #4 stated the fall mat should be removed because if the resident rolled her wheelchair on the mat, it could cause a fall. NA #4 stated that the fall mat being on the floor was an oversight. NA #4 stated the information for which residents had fall mats was located on the resident's Kardex (a reference tool of resident needs).b. Resident #85 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis and Alzheimer's disease.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #85 had severe cognitive impairment, required substantial/maximal assistance with transfers, and had no falls since the prior MDS assessment. The resident utilized a wheelchair and was dependent upon staff for mobility.Resident #85's active care plan, last reviewed 7/13/26, revealed a focus of resident at risk for falls characterized by multiple risk factors related to impaired mobility and resident will sit self on floor intentionally. The goal was for the resident to have no falls or accidents resulting in injury. This care plan did not list a fall mat as an intervention. The active Kardex, undated, included no intervention for a fall mat. An observation completed on 8/10/26 at 3:49 PM revealed Resident #85 was up in the wheelchair at the foot of her bed. The fall mat was on the floor next to the bed. An observation completed on 8/13/26 at 10:38 AM revealed Resident #85 was up in the wheelchair in the hallway, and the fall mat was on the floor next to the bed.An observation completed on 8/14/26 at 11:48 AM revealed Resident #85 was up in the wheelchair. The fall mat was on the floor next to the bed and the wheelchair was beside the fall mat. An interview was conducted with Nurse Aide (NA) #4 on 8/14/26 at 11:50 AM. NA #4 verified she was assigned to Resident #85 on 8/10/26, 8/13/26 and 8/14/26 during the first shift. NA #4 stated it had been a while since Resident #85 had fallen. NA #4 stated that fall mats were placed on the floor by the evening NA. NA #4 stated she was responsible for removing the fall mat for Resident #85. NA #4 stated the fall mat should be removed because if the resident rolled her wheelchair on the mat, it could cause a fall. NA #4 stated that the fall mat being on the floor was an oversight. NA #4 stated the information for which residents had fall mats was located on the residents' Kardex.c. Resident #11 was admitted to the facility on [DATE] with diagnoses that included dementia and cerebral infarction.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #11 had severe cognitive impairment, required substantial/maximal assistance with transfers, and had no falls since the prior MDS assessment. The resident utilized a wheelchair and was able to wheel self-150 feet independently.Resident #11's active care plan last, revised 7/10/26, revealed a focus of resident at risk for falls characterized by multiple risk factors related to impaired balance and impaired cognition. The goal was for resident to have no falls or accidents resulting in injury. The care plan did not list a fall mat as an intervention. The active Kardex, undated, included no intervention for a fall mat. An observation completed on 8/11/26 at 11:48 AM revealed Resident #11 was up in the wheelchair, and the fall mat was on the floor beside the bed, underneath the resident.An observation completed on 8/12/26 at 9:10 AM revealed Resident #11 was up in the wheelchair in hallway and the fall mat was on the floor beside the bed.An observation completed on 8/14/26 at 11:43 AM revealed Resident #11 was up in the wheelchair The fall mat was on the floor next to the bed and the wheelchair was beside the fall mat. An interview was conducted with Nurse Aide (NA) #4 on 8/14/26 at 11:50 AM. NA #4 verified she was assigned to Resident #11 on 8/11/26 and 8/12/26 during the first shift. NA #4 stated that fall mats were placed on the floor by evening NA. NA #4 stated she was responsible for removing the fall mat for Resident #11. NA #4 stated that the fall mat being on the floor was an oversight. NA #4 stated the fall mat should be removed because if the resident rolled her wheelchair on the mat, it could cause a fall. NA #4 stated the information for which residents had fall mats was located on the resident's Kardex. An interview was conducted with the Director of Nursing (DON) on 8/14/26 at 4:17 PM. The DON stated the fall mats should have been removed when residents were up in the wheelchair to prevent a fall. The DON stated staff had access to the Kardex which included the care planned interventions for resident care needs. An interview was conducted with the Administrator on 8/14/26 at 4:19 PM. The Administrator stated she expected that staff would follow the care plan interventions and fall mats would be removed from the floor when the residents were up in the wheelchair to prevent a fall.

Based on record review, observations and interviews with resident, staff and the Medical Director, the facility failed to ensure a resident with a stage 3 pressure ulcer (full thickness skin loss) was assessed for pain prior to initiating pressure ulcer treatment for 1 of 3 residents reviewed for pain management during pressure ulcer care (Resident #1).Findings included:Resident #1 was most recently readmitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with diabetic neuropathy, atherosclerotic heart disease, peripheral vascular disease, anxiety disorder, and major depressive disorder.A physician's order for Resident #1 dated 7/2/26 included acetaminophen 325 milligrams (mg) 2 tablets (650 mg total) by mouth every 6 hours as needed (PRN) for pain. Resident #1's care plans included one for potential for pain, acute/chronic related to diabetic neuropathy, peripheral vascular disease, and left knee osteoarthritis, initiated on 12/13/24 and revised on 7/2/26. The goal was for the resident to voice a level of minimal pain daily through next review date. Interventions included: administer pain medication as per physician orders and note the effectiveness; notify physician if pain management is not effective; observe for and document characteristics of pain ( location, severity, frequency, precipitating factors, etc.); observe for signs/symptoms of non-verbal pain such as changes in breathing, grunting, moans, yelling out, mood/behavior changes, sad expression, crying, clenched teeth, grimacing, tenseness, rigidity of body/limbs and report to nurse.A physician's order for Resident #1 dated 7/9/26 for Stage 3 pressure ulcer care to the sacrum indicated to clean with wound cleanser (a solution which gently cleans wound beds without harming healthy cells), apply silver alginate (antimicrobial and absorbs drainage) and cover with foam (dressing for protection). Change every 3 days and as needed. Ensure the dressing is dry and intact daily, every day shift for wound care.A physician's order for Resident #1 dated 7/10/26 indicated vital signs to be measured every day shift (7:00 AM to 7:00 PM) and every night shift (7:00 PM to 7:00 AM) for monitoring. Vital signs included blood pressure, temperature, pulse, respiratory rate, oxygen saturation level and pain level.Resident #1's most recent Minimum Data Set, a significant change in status assessment dated [DATE], noted she was cognitively intact with no behaviors. One stage 3 pressure ulcer/injury was noted as present on admission. The Pain Assessment Interview had been completed and revealed Resident #1 received as needed pain medication and reported having occasional pain over the last 5 days. The pain occasionally made it hard for her to sleep at night, occasionally limited her day-to-day activities, and rarely or not at all limited her participation in rehabilitation therapy sessions. Resident #1 rated her worst pain over the last 5 days on a 0 to 10 scale (with 0 being no pain and 10 being the worst pain possible) as a 7.Review of Resident #1's August 2026 Medication Administration Record (MAR) from 8/1/26 through 8/11/26 indicated she reported pain symptoms on 8/4/26 and 8/9/26 and had received PRN acetaminophen both times.An observation of Resident #1's pressure ulcer care was conducted on 8/12/26 at 10:00 AM through 10:20 AM with the Treatment Nurse and Medication Aide (MA) #1. MA #1 was helping Resident #1 to stay turned onto her left side by supporting her left side and hip with her hands. The old dressing was removed, and the pressure ulcer was cleaned with a gauze soaked with wound cleanser. The Federal Surveyor reported Resident #1 had flinched and the Treatment Nurse immediately stopped the wound care. The Federal Surveyor walked around the bed to talk with Resident #1 and asked her if she was experiencing pain. Resident #1 reported she felt like she was being pinched. She was asked by the Federal Surveyor to rate the pain on a 0-10 scale and she said 7. The Treatment Nurse immediately covered Resident #1 and left the room to ask Nurse #1 about pain medication for Resident #1. At 10:11 AM the Treatment Nurse returned to the room with Nurse #1. Nurse #1 asked Resident #1 about her pain and she stated her pain level was an 8 out of 10. The Treatment Nurse covered the pressure ulcer with a protective dressing and repositioned her for comfort. Nurse #1 administered acetaminophen 650 mg.During interviews on 8/12/26 at 10:34 AM and 4:05 PM with Nurse #1 she indicated she had taken care of Resident #1 regularly since she was admitted to the facility. She stated Resident #1 was alert, able to make her needs known, able to say when she had pain and able to ask for pain medication. Nurse #1 reported that she had asked Resident #1 about her pain level that morning while completing vital signs (temperature, heart and breathing rates, oxygen saturation level, and blood pressure) and Resident #1 had not reported any pain. She could not say exactly what time this pain assessment had been completed. Nurse #1 pulled up Resident #1's MAR for review and showed she had assessed the resident's pain level which was marked as 0. She explained the resident's complaint of pain during wound care was possibly related to the wound care and Resident #1 had never voiced any concerns directly to her related to wound care. Nurse #1 confirmed there had been no communication between herself and the Treatment Nurse or MA #1 today before the wound treatment started. An interview with the Treatment Nurse was conducted on 8/12/26 at 10:48 AM. The Treatment Nurse explained she usually asked residents about pain before starting treatments then would check if pain medication was due or had been administered. She stated she had not asked Resident #1 about pain prior to providing pressure ulcer care that morning and explained that Resident #1 was able to report having pain and had never complained to her about pain during wound treatments. The Treatment Nurse also explained Resident #1 had never asked for the treatment to stop, report she was having pain during the treatment, or needed to be premedicated. The Treatment Nurse stated she had not noticed any signs or symptoms of pain during the wound care provided today but heard Resident #1 respond to a question asked by the Federal Surveyor about pain when she said the wound care felt like a pinch, then Resident #1 was asked by the Federal Surveyor to rate the pain on a scale of 1 to 10 and reported the pain as 7 out of 10.On 8/12/26 at 10:13 AM and 10:57 AM interviews conducted with MA #1. MA #1 stated she regularly assisted the Treatment Nurse with wound care. She explained that Resident #1 had not complained about pain related to pressure ulcer care previously. MA #1 further explained the Federal Surveyor had said Resident #1 flinched during the wound care, but she did not see or feel Resident #1 flinch, tighten up, make a noise, or say she was having pain until asked by the Federal Surveyor. On 8/12/26 at 8:58 AM an interview was conducted with Unit Manger #4. She stated Resident #1 was alert and sometimes confused but could make her needs known.On 8/12/26 at 12:22 PM an interview was conducted with Resident #1 after the wound care had been provided by the Treatment Nurse on 8/12/26, Resident #1 stated she was not having any pain.During a follow up interview on 8/14/26 at 2:58 PM Resident #1 stated she did not have wound care this morning (not scheduled daily) and that she was not having any pain and could ask for pain medication and when she asked for pain medication it helped. On 8/14/26 at 12:30 PM an interview with the Medical Director was conducted. When the Medical Director was asked about wound care and pain management, he stated it was optimal to medicate before wound care was provided. He explained he had spoken with Nurse #1 after Resident #1 reported pain during wound care on 8/12/26. They discussed scheduled and as needed pain medication for Resident #1 and decided it would be best to keep her pain medication as needed and for Nurse #2 to communicate with the floor nurse before wound care to ensure Resident #1 was medicated well before the treatment. The Medical Director stated the nurses should make sure the process was unified with the start of wound care and to ask about pain management. He explained that Resident #1 was alert, oriented and could make her needs known.On 8/14/26 at 3:45 PM an interview with the Administrator and the Director of Nursing (DON) was conducted. The DON stated Resident #1 had not previously complained of pain from her pressure wound. The Administrator stated Resident #1 should have been assessed for pain prior to starting wound care.

Based on record review and interviews with residents and staff, the facility failed to provide options for alternative meals to residents who ate in their rooms for 1 of 3 residents (Resident #31) reviewed for food preferences. The findings included: Resident #31was admitted to the facility on [DATE]. Resident #31's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. During an interview with Resident #31 on 8/10/26 at 3:22 PM she stated that the facility did not offer her choices for an alternative meal option when she ate in her room. Resident #31 explained that when she ate in her room and complained about a meal, she would receive a new tray with an alternative meal, but the cook made the meal choice for her. Resident #31 further explained that when she went to the dining room and did not like what was served, the cook would come around and explain to her the alternative choices available. Resident #31 stated that she felt helpless when she could not go to the dining room and did not like what was served. Resident #31 revealed that she ate her snacks when she did not like what was served when she ate in her room. During a Resident Council meeting on 8/12/26 at 2:00 PM, the six Resident Council members present verified that if a resident ate a meal in their room and did not like it, they were not offered the opportunity to make a choice of an alternative meal and instead were chosen by the cook. The Resident Council members clarified that when residents went to the dining room and did not like what was served, the cook verbally provided the choices that were available for an alternative meal. In an interview on 8/11/26 at 3:30 PM with the Dietary Manager (DM) she spoke about the facility's process for alternative meal options being provided when a resident chose not to eat the meal served. She reported that the facility did not have a written choice/menu for alternative meals for the residents. The DM stated that the cook would walk around the dining room and tell the residents what options that could get for an alternative meal if they did not like what was served. The DM stated that the residents who did not come out of their rooms for meals were not able to make a choice of an alternative meal and that the cook would determine what to serve them. The DM stated that the residents who could not come to the dining room did not have the opportunity to know what alternative meal choices were available. In an interview with Nurse #3 on 8/12/26 at 9:09 AM she stated that if a resident did not like a meal that was served the staff could go to the kitchen and get an alternative meal determined by the cook. She stated that only residents who went to the dining room got to choose from alternative meal options. In an interview with Nurse Aide (NA) #1 on 8/12/26 at 2:29 PM she stated that when a resident who was eating a meal in their room requested an alternative meal she went to the kitchen and the cook decided what to get the resident for their alternative meal. NA #1 stated that she was not provided with an alternative meal list to give to a resident to make a choice of what they preferred if they did not like what was served. During an interview with the Unit Manager (UM) #2 on 8/12/26 at 2:35 PM she stated that if a resident did not like a meal that was served, staff were supposed to go back to the kitchen and get an alternative meal. UM #2 stated that the cook would either provide an alternative meal with equal nutritional value or a resident would get snack that was kept on the unit. UM #2 stated that they did not have an alternative meal list that would be brought to a resident to choose from. An interview conducted with the Director of Nursing (DON) on 8/12/26 at 2:57 PM revealed that the NAs were expected to go to the kitchen and request an alternative meal if a resident did not like what was served. She stated that she was not aware that the residents were not offered choices of alternative meals that were available unless they ate in the dining room. During an interview with District Certified Dietary Manager on 8/12/26 at 3:35 PM he stated that he had not been aware that the facility did not offer choices for alternative meals via a menu for residents who did not go to the dining room and who did not like what was served. He revealed that choices on the alternate list were available to residents since 8/11/26. He stated that it was a mistake that the residents who ate in their rooms did not have choices. An interview was conducted with the Administrator on 8/12/26 at 4:00 PM. During the interview the Administrator revealed that the residents who did not like a meal should be able to get a choice for an alternative meal. The Administrator stated that the choices in the alternate menu were now available to all residents. The Administrator stated that it was a mistake that residents who ate in their rooms did not have the opportunity to choose from the alternative menu.

Based on observations and staff interviews the facility failed to ensure the dumpster was maintained free of leakage and pooled spillage for 1 of 1 dumpster. This practice had the potential to attract pests and rodents. The findings included: On 5/07/25 at 1:58 PM the dumpster area was observed. The middle bottom rim of the 22-foot-long compact dumpster was observed with a 6 inch by 4-inch buildup of gray sludge on the exterior side. From the sludge a large pool of milky grey liquid puddled, 6 feet long beside and underneath the dumpster. A second observation of the dumpster on 5/08/25 at 9:25 AM revealed the middle bottom rim of the 22-foot-long compact dumpster was observed with a 6 inch by 4-inch buildup of gray sludge on the exterior side. From the sludge a large pool of milky grey liquid puddled, 6 feet long beside and underneath the dumpster and continued to spread 18 feet away from the dumpster. In an interview on 5/08/25 at 9:30 AM the Dietary Manager stated the dumpster had been emptied that week and trash company replaced that dumpster with the leaking dumpster. He indicated he would call the dumpster company and have the dumpster replaced. In an interview on 5/08/25 at 10:57 AM the Administrator stated all staff use the dumpster and should report on any concerns with the area to management.

Based on record review and interviews with residents and staff, the facility failed to notify residents and resident representatives of the results of the investigation and any corrective measures taken or to be taken by the facility as a result of the grievance. The facility also failed to ensure the residents' right to receive written notification of the decision regarding the grievance investigation and the date the decision was issued for 3 of 3 residents reviewed for the grievance process (Resident #42, Resident #52, Resident #95). The findings included: Review of the facility policy last revised 7/1/2018 titled Resident Grievance Policy read in part: The Administrator is responsible for overseeing, directing, and investigating grievances in a prompt manner. The Administrator will review the results of grievance investigations for conclusion, ensure confidentiality of grievance information and initiate corrective measures or actions in accordance with state law, state survey agency, quality improvement organization, or local law enforcement agency as indicated. The Administrator will assure the residents, or resident representatives, are notified timely of the results of the investigation, of any corrective measures taken, and notification will be documented. a. Resident #42 was admitted to the facility on [DATE]. Review of the significant change Minimum Data Set assessment dated [DATE] revealed the resident was cognitively intact. Review of the grievances filed since the last standard survey on 4/18/24 revealed Resident #42 had filed a grievance with the facility on 2/14/25. The 2/14/25 grievance revealed Resident #42 complained of staff answering the call bell but did not assist her to the bathroom. The form had the Unit Manager #1 as the person receiving the grievance and the person responsible for completing the investigation. The area of outcome expectation of person voicing concern was not filled out. The grievance form investigation revealed staff went in to check on Resident #42 and told her she would be back because she was in the middle of providing care. Staff retraining was conducted was the action taken. The resolution section was checked no for investigation findings were reported to the person voicing concern and no written response was requested. There was no documentation for notification issuance of the decision regarding the grievance investigation. The Administrator signed off the grievance on 8/10/25. An interview was conducted with Resident #42 on 5/5/25 at 12:50 PM and she reported she had not received a written resolution regarding the outcome of the grievance she had reported and had not been informed verbally how the issue with staff answering the call bell and not assisting her was corrected. b. Resident #95 was admitted to the facility on [DATE]. Review of the most recent quarterly Minimum Data Set assessment dated [DATE] revealed the resident was cognitively intact. Review of the grievances filed since the last standard survey on 4/18/24 revealed Resident #95 had filed 3 grievances with the facility on 3/6/25, and 4/23/25. The 3/6/25 grievance filed by Resident #95 was related to staff not waiting 3 to 5 minutes between eye drops during administration. The document showed the grievance was received by the nurse. The area of outcome expectation of person voicing concern was not filled out. The grievance form was assigned to the Director of Nursing. The grievance form investigation revealed Resident #95 had three different eye drops due at the same time for his left eye. Staff training on the administration of eye drops was conducted. The grievance resolution section was blank. The Administrator signed off the grievance on 3/7/25. The grievance filed on 4/23/25 was regarding ants on Resident #95's room windowsill. The document showed the grievance was received by the nurse. The grievance form investigation revealed 6 to 7 ants were observed on the windowsill. The area of outcome expectation of person voicing concern was not filled out. The grievance for was assigned to Maintenance. Resident's skin was assessed by the nurse, and room checked for open food. Maintenance sprayed windowsill inside resident's room and outside of room. Other rooms were checked, and the resident's room was deep cleaned. The grievance resolution section was blank except for the Administrator's signature on 4/24/25. An interview was conducted with Resident #95 on 5/8/25 at 2:40 PM and he reported he had not received a written resolution regarding the outcome of the grievances he had reported and had not been informed verbally. c. Resident #52 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed the resident was cognitively intact. Review of the grievances filed since the last standard survey on 4/18/24 revealed Resident #52 had filed 4 grievances with the facility on 2/7/25, 3/31/25, 4/4/25, 4/10/25. Review of the 2/7/25 grievance revealed Resident #52 complained she did not receive her nighttime insulin dose. The document showed the grievance was received by the nurse. The area of outcome expectation of person voicing concern was not filled out. The grievance was assigned to the Director of Nursing. The grievance form investigation indicated staff were interviewed and had administered Resident #95's nighttime insulin. There was no documentation in the action taken/action to be taken section. The resolution section was blank except for the Administrator's signature on 2/8/25. The 3/31/25 grievance revealed Resident #52 complained her room was too hot. The section for employee receiving the grievance was not filled out. The area of outcome expectation of person voicing concern was not filled out. The grievance was assigned to the Director of Nursing. The grievance investigation revealed the room temperature was at 71 degrees Fahrenheit and within normal range. The vent was closed by maintenance. The resolution section was checked no for investigation findings were reported to the person voicing concern and no written response was requested. There was no documentation for notification issuance of the decision regarding the grievance investigation. The Administrator signed off the grievance on 4/1/25. The grievance filed by Resident #52 on 4/4/25 was related to a staff member not changing gloves between providing care of another resident and Resident #52. The nurse was the person who received the grievance. The area of outcome expectation of person voicing concern was not filled out. The grievance was assigned to the Director of Nursing. The investigation revealed the staff member completed a return demonstration of hand hygiene and glove donning and doffing. The resolution section was blank except for the Administrator's signature on 4/5/25. Review of the grievance initiated by Resident #52 on 4/10/25 revealed staff did not get resident up the previous day as requested and Resident #52 did not receive her nighttime insulin. The Director of Nursing received the grievance. The area of outcome expectation of person voicing concern was not filled out. The grievance was assigned to the Director of Nursing. The grievance investigation revealed Resident #52 refused to allow staff to use the lift pad because she stated it was not in good repair. The investigation further revealed Resident #52 received her nighttime insulin. The resolution section was blank except for the Administrator's signature on 4/11/25. An interview was conducted with Resident #52 on 5/8/25 at 2:50 PM and she reported she had not received a written resolution regarding the outcome of the grievances she had reported and had not been informed verbally of the grievance outcomes. An interview was conducted with the Social Worker on 5/8/25 at 8:55 AM. The Social Worker stated concerns voiced by residents were written up on the Facility Concern/Grievance Form. The Social Worker revealed grievances were reviewed daily in the morning interdisciplinary team (IDT) explain meeting. The Social Worker stated the grievance was entered into the grievance log and sent to the responsible department for follow up. The Social Worker reported grievance follow-ups were communicated verbally. She indicated that the person filing a grievance could receive a written copy of the grievance resolution upon request. An interview was conducted with the Director of Nursing (DON) on 5/8/25 at 9:05 AM revealed the grievances were reviewed daily in the morning interdisciplinary meeting and each evening in the evening interdisciplinary meeting. The DON stated once she received the concern, she or one nursing staff would conduct an investigation. The DON stated she sometimes discussed the outcome of the grievances verbally with the complainants. The DON stated once the investigation was completed and the grievance form filled out, the grievance forms were returned to the Administrator for review. During an interview with the Administrator on 5/8/25 at 9:15 AM she stated she was responsible for coordinating the grievance process. She stated once she received the concern from the Social Worker, the concern was distributed to the department responsible for addressing the issue. The Administrator stated the grievances were returned to her to be reviewed as the grievance officer. The Administrator stated grievance resolutions were communicated verbally or in writing if requested. The Administrator stated she was not aware that there had to be written documentation of the grievance outcomes.

Based on staff interview and record review, the facility failed to refer a resident with a newly identified serious mental illness for a Level II Preadmission Screening and Resident Review (PASRR) for 1 of 2 residents reviewed for PASSR (Resident #9). The findings included: Resident #9 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder and recurrent anxiety disorder. A Level I PASRR determination notification letter dated 2/19/2016 indicated No further PASRR screening is required unless a significant change occurs with the individual's status which suggests a diagnosis of mental illness or mental retardation or, if present, suggests a change in treatment needs for those conditions. Resident #9's medical record revealed on 8/18/2023 she had a new diagnosis of bipolar disorder with depression. Review of Resident #9's medical record revealed no documentation indicating a Level II PASRR referral had been completed after the diagnosis of a serious mental illness had been made. Resident #9's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she had moderate cognitive impairment and did not have a PASRR level II. During an interview with the Social Worker on 5/7/2025 at 2:17 PM she revealed she was only able to locate the PASRR level I that was conducted on 2/19/2016. The Social Worker stated she was unaware that a PASRR level II referral had not been completed for Resident #9 after she was newly identified with the diagnosis of bipolar disorder with depression. The Social Worker stated she was responsible for submitting the PASRR level II referral. The Social Worker stated new mental health diagnoses were reviewed daily in the morning interdisciplinary team meetings and Resident #9 had been overlooked. An interview was conducted with the Administrator on 5/8/2025 at 3:55 PM who revealed the Social Worker was responsible for Resident #9's PASRR review.

Based on record review, staff interviews, and Medical Director interview, the facility failed to maintain ongoing communication with the dialysis treatment center for 1 of 1 residents reviewed for dialysis (Resident #23). The findings included: Resident #23 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (ESRD), and dependence on dialysis. Resident #23 had an active physician order dated 3/12/24 for dialysis on Monday, Wednesday, and Friday. The care plan, last reviewed 3/29/24, revealed Resident #23 had ESRD and was at risk for complications related to dialysis with an intervention to communicate with dialysis treatment center. Review of Resident #23's dialysis communication notebook on 4/16/24 revealed 18 out of the 50 dialysis communication forms in the notebook were not completed by the facility staff prior to dialysis treatment for Resident #23. The 18 dialysis communication forms did not have the following information noted from the facility: name of resident, name of primary care physician, date, vital signs, medications administered prior to dialysis, diet, fluid restrictions, access site assessment, significant alerts, and name of facility nurse. An interview was conducted on 4/16/24 at 11:48 am with Nurse #1 who was assigned to Resident #23. Nurse #1 revealed he was assigned to Resident #23 on multiple dates when the dialysis treatment was scheduled. He stated Resident #23 had a dialysis communication form that the vital signs were written on prior to Resident #23 being transferred to the dialysis treatment center. Nurse #1 reviewed the blank dialysis communication forms and was unable to state if he was assigned to Resident #23 when the forms were not completed because there were no dates on the forms to confirm. Nurse #1 stated he knew about the dialysis communication forms and he normally put the vital signs on the form before Resident #23 went to dialysis, but he was unable to state why the forms were blank on the facility portion of the form. An interview was conducted on 4/16/24 at 11:54 am with the Unit Manager who revealed Resident #23's dialysis communication forms should be completed prior to dialysis and sent with the Resident. The Unit Manager stated he tried to check the dialysis communication notebook but did not do it consistently and he was unable to state why Resident #23's dialysis communication forms were not completed. A telephone interview was conducted on 4/16/24 at 12:10 pm with Nurse #2 who revealed she was assigned to Resident #23 every Friday. Nurse #2 stated the dialysis communication notebook was sent with the resident when they went to dialysis and the communication forms were supposed to be completed by the nurse before going to dialysis. Nurse #2 stated she did her best to complete the dialysis communication forms for Resident #23 before dialysis, but she was unable to state why the forms were not completed. An interview was conducted on 4/16/24 at 12:35 pm with Nurse #3 who revealed she was assigned to Resident #23 on dialysis days but was unable to recall the exact dates. Nurse #3 stated the dialysis communication forms were supposed to be completed by the nurse and sent to the dialysis treatment center with Resident #23. Nurse #3 reviewed Resident #23's blank dialysis communication forms and was unable to state why the forms were not completed by the facility. During an interview on 4/16/24 at 1:03 pm Nurse #4 revealed she was assigned to Resident #23 on dialysis days. Nurse #4 stated she was aware of the dialysis communication forms that were supposed to be completed prior to dialysis and sent with Resident #23 but she stated at times she was busy and did not fill the forms out. An interview was conducted on 4/16/24 at 1:39 pm with the Director of Nursing (DON) who revealed the dialysis communication forms were to be completed prior to Resident #23's dialysis treatment by the nurse that was assigned to their care. The DON reviewed Resident #23's dialysis communication forms and confirmed the forms were not completed by the facility. The DON stated the facility did not have a process in place to ensure the dialysis communication forms were being completed. An interview was conducted on 4/17/24 at 9:48 am with the Medical Director who stated the dialysis communication forms were important to communicate with the dialysis treatment center about the care of the resident and they should be filled out by the facility prior to the resident going to dialysis. During an interview on 4/17/24 at 2:31 pm the Administrator revealed the nurses assigned to Resident #23 on the dialysis treatment days were responsible for the completion of the dialysis communication forms.

Based on a lunch meal tray line observation, staff interviews and record review the facility failed to provide pureed food items with a smooth consistency. This failure had the potential to affect 21 of 21 residents who had diet orders for a pureed diet texture. The findings included: A review of the Order Listing Report dated 4/17/24 revealed 18 residents with diet orders for a pureed diet texture and 3 residents with an order for pureed meats. Review of the menus revealed the facility followed the National Dysphagia Diet (NDD) for residents with diet orders for a pureed diet texture. The NDD recorded a dysphagia pureed diet required all foods pureed and thickened, if necessary, to a pudding-like consistency, lump free, requiring little to no chewing. A continuous observation of the lunch meal tray line with the Nutrition Consultant on 3/12/24 from 11:57 AM - 12:01 PM revealed the pureed chicken pastry was placed on the steam table with a lumpy consistency. The Cook stated she was intending to serve these items at lunch meal today, and that she had prepared them. She stated the consistency should be smooth, like pudding. The Nutrition Consultant agreed that the pureed chicken and pureed carrots had visible lumps. He asked the Cook to further blend both pureed items. An interview was conducted with the Dietary Manager (DM) on 4/16/24 at 1:13 PM. He revealed that pureed foods should be a pudding-like consistency. The DM stated he had not observed lumpy consistency of pureed foods previously and did not receive any complaints on this issue. He indicated that the Cook had been cooking at the facility for the last [AGE] years, so perhaps she was nervous, or it was an oversight. The DM stated the Cook will receive re-education on puree consistency, but it was good that she corrected it in the moment. During an interview with the Registered Dietitian (RD) on 4/17/24 at 12:26 PM, she revealed that the consistency of pureed foods should be like pudding. If residents on a puree diet were served foods with a lumpy consistency, they could possibly choke. She stated she had not noticed lumpy pureed foods at the facility and ordered pre-pureed rice, pasta, corn, and bacon due to high risk of inappropriate consistency with these foods. The Speech Language Pathologist (SLP)/Rehab Manager was interviewed on 4/17/24 at 1:52 PM. She revealed that the puree diet consistency should be like pudding, which is smooth without particles without the need for chewing. If a lumpy consistency was served, it would not be considered pureed but more like mechanical soft. The risks would be pocketing (hold pieces that they cannot swallow in their cheek), and residents may get tired or have decreased strength due to more chewing. The SLP/Rehab Manager stated she had not witnessed pureed foods to have lumpy consistency at the facility. The Administrator stated in an interview on 4/17/24 at 10:48 AM that if the pureed foods had lumps in them, then those dishes would need to be further blended to a proper puree consistency.

Based on observation and staff interviews, the facility failed to allow cook pans and dome lids to completely dry prior to assemblage and stacking for three of three observations. The facility also failed to clean the convection ovens. These practices had the potential to affect food served to residents. The findings included: 1. An observation of the kitchen and interview with the Dietary Manager (DM) was conducted on 4/15/24 at 9:58 AM. Twelve steam table pans were observed to be stacked wet and ready for reuse on a cart next to the 3-part sink. The DM stated the pans should be air dried and stacked at an angle to prevent wet nesting. During a follow-up tour of the kitchen on 4/16/24 at 8:46 AM with the DM, three pans on the cart next to the 3-part sink were observed with wet nesting. The DM stated the wet pans were due to them falling on top of each other and not stacked at an angle to air dry. An observation of the kitchen during lunch meal service on 4/16/24 at 12:27 PM revealed water dripped from a dome lid as a Dietary Aide took it from the rack and placed it on top of a plated meal. Fifty-two dome lids were observed with wet nesting on the inside edge. The DM stated they should be dry, but the water collected on the inside edge due to placement on the dry rack. He instructed the Dietary Aide to shake off the excess water before placed on top of the plate. During a follow-up interview with the DM on 4/16/24 at 1:08 PM, he revealed the pans had slipped and fallen from their stacking position. The DM stated his staff had been trained on how to properly place clean pans to prevent wet nesting. The Administrator was interviewed on 4/17/24 at 12:31 PM. She revealed that she went to the kitchen on 4/17/24 and noticed the water on the inside edge of the dome lids. She stated it was a manufacturer issue. However, when she purposely put water on the inside edge of one of the domes and placed it on top of a plate, she noticed the water did not touch the plate. The Administrator indicated there was a short period of time in between breakfast and lunch for dishes/pans to air dry. The Administrator revealed that there should not be any water on any clean dishes/pans for service. Staff needed to be re-educated on how the pans needed to be placed to ensure they were completely air dried. 2. An observation of the kitchen and interview with the DM were conducted on 4/15/24 at 9:58 AM. The convection oven had a thick, black layer on the bottom and brown grease covered both glass doors on the top oven. The bottom oven did not have the black substance, but grease covered both glass doors on the inside. The DM stated the ovens were due to be cleaned, and they were usually cleaned every few weeks. An observation of the kitchen and interview with the DM were conducted on 4/16/24 at 11:43 AM. The inside of all glass doors was covered by brown grease. The top oven doors were cleaned slightly, and the black substance on the bottom of the top oven remained. The DM stated that staff started to clean the convention ovens. During a follow-up interview with the DM on 4/16/24 at 1:09 PM, he revealed that the convention ovens should be cleaned fully by the end of the day. Kitchen staff began cleaning the ovens the night before. The Administrator was interviewed on 4/17/24 at 12:33 PM. She stated that the black substance on the bottom of the top oven was part of the equipment itself and could not be scraped off. The Administrator indicated that the black substance might be due to overuse and was not present when ovens were new. She revealed that the convention ovens were supposed to be cleaned every two weeks, but that was changed to weekly. On 4/17/24 at 1:59 PM, the Administrator presented a piece of the black substance on the bottom of the top oven. She stated it seemed like plastic material caused by the degreaser that could be removed. The Administrator indicated that the convention ovens were not delivered with the black substance present.

Based on observations, staff interviews, and record review, the facility failed to maintain an effective pest control program as evidenced by observations of fly activity in the kitchen on 3 different occasions. The facility failed to utilize insect light traps and implement pest service recommendations to prevent reoccurring pest activity. This practice had the potential to affect residents in the facility. The findings included: Review of the Pest Control Service Agreement without a date revealed the following pests were covered by the contract: roaches, rodents, ticks, ants (except carpenter), crickets, fleas, spiders, ground beetles, earwigs, silverfish, and stored product pests. Observations of live pest activity occurred on the following: - 4/15/24 at 10:00 AM: 3 flies observed at the entrance to the drain in the middle of the kitchen in between the steamer and convention ovens. The Dietary Manager (DM) was present and stated the cover to the drain cracked, and a new one has been ordered. - 4/16/24 at 11:51 AM: 1 fly observed on overhead light above steam tray line. - 4/16/24 at 12:22 PM: 1 fly observed flying around steam table during lunch meal service On 4/16/24 at 3:45 PM, two wall mounted insect light traps were observed unplugged at the front entrance across from the dining room and on the administrative hall adjacent to the front entrance. The Maintenance Director was seen servicing both light traps at the time. The DM was interviewed on 4/16/24 at 1:10 PM. He revealed that the kitchen was sprayed for pests monthly. The DM stated that he had not observed flies in the kitchen before, but now that the temperature was increasing, there would be more fly activity. He indicated that he would call the pest control company for the observance of the flies within the last 2 days. The DM presented an invoice for drain covers ordered on 4/15/24. During an interview with the Maintenance Director on 4/17/24 at 11:09 AM, he revealed that the pest control company visited monthly to spray areas of the facility and lay down traps. He indicated that a fly spray was used during the monthly visits. He heard about the flies in the kitchen on 4/15/24 and had not received any complaints about flies previously.The Maintenance Director stated that the fuses blew at least once monthly in both insect light traps outside of the dining room and on administrative hall. He stated the traps were working last week, and they were serviced on 4/15/24 and were now operable. The Maintenance Director indicated that an indoor fly spray was purchased on 4/15/24. The back service hall outside door was used frequently and flies entered through that door. He stated that the insect light trap in the back service hall was knocked down by a meal cart about 2 weeks ago, and it was replaced on 4/15/24. He had observed flies in the back service hall next to the kitchen since the trap was knocked down. The Maintenance Director indicated the pest control company was asked to service the facility on 4/15/24 outside of the monthly visits, and he sprayed outside the service door where the trash was located as well as the service loading dock. On 4/17/24 at 12:36 PM, the Administrator was interviewed. She revealed that when she went into the kitchen on 4/16/24, she saw a few flies flying around. The Administrator stated that the meal carts were hard to control in the service hallway, and the fly light trap kept getting knocked down. She had 3 new fly light traps installed on 4/16/24, including the traps outside of the dining room, on the administrative hallways, and the back service hall. The Administrator indicated that the pest control company came out yesterday to spray extra around doors, windows, and traffic areas. She stated that a kitchen/building with multiple doors was difficult to be fly-free. They controlled it the best they could with tactics including pest control, fly lights, manual fly swatters, and education to staff to not leave the doors open.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of restraints for 1 of 1 resident reviewed for restraints (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included dementia. Review of Resident #1's active physician orders revealed an order dated 12/29/23 for soft belt restraint while up in chair. The care plan dated 12/31/23 revealed Resident #1 had a physical restraint device (soft belt) in use for prevention of injury to self. The nursing progress note dated 3/25/24 at 3:56 pm revealed Resident #1 was in the wheelchair with the soft belt restraint applied. The nursing progress note dated 3/26/24 at 12:13 pm revealed Resident #1 was up in the chair with the soft belt restraint in place. The MDS quarterly assessment dated [DATE] revealed Resident #1 was not coded for the use of the soft belt restraint. An interview was conducted on 4/16/24 at 1:09 pm with the MDS Nurse who stated the MDS Nurse Consultant had completed Resident #1's quarterly assessment. The MDS Nurse stated the normal process to code use of the restraint was to observe the resident and review nursing notes to confirm the restraint was used. The MDS Nurse stated Resident #1 should have been coded for use of the soft belt restraint on the quarterly assessment. A telephone interview was conducted on 4/16/24 with the MDS Nurse Consultant who reported normally she reviewed nursing assessments or progress notes for the use of restraints to code the restraint on the assessment. The MDS Nurse Consultant stated she apparently missed the nursing notes for Resident #1's restraint use when she completed the quarterly assessment so the restraint was not coded. An interview was conducted on 4/17/24 at 2:36 pm with the Administrator who stated the MDS Nurse Consultant was responsible to ensure Resident #1's MDS quarterly assessment was coded accurately.

Based on record review and staff interviews, the facility failed to complete a Minimum Data Set (MDS) significant change assessment within 14 days for the use of a soft belt restraint for 1 of 1 resident reviewed for restraints (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included dementia. The Physical Device Use Evaluation-Initial dated 12/29/23 revealed Resident #1 was evaluated for the use of a soft belt restraint for prevention of injury to self-characterized by high risk for injury and falls related to dementia and poor safety awareness. Review of Resident #1's physician orders revealed an order dated 12/29/23 for soft belt restraint while up in chair for safety. Remove for activities, meals, and activities of daily living (ADLs) care. The care plan dated 12/31/23 revealed Resident #1 had a physical restraint device (soft belt) in use for prevention of injury to self with interventions which included to remove during supervised activities and meals and re-apply upon completion. The MDS significant change assessment with a completion date of 1/19/24 revealed Resident #1 was coded for use of a trunk (torso) restraint daily when in chair or out of bed. An interview was conducted on 4/17/24 at 11:38 am with the MDS Nurse who reported the significant change assessment was to be completed within 14 days of Resident #1's order for the soft belt restraint. The MDS Nurse stated the normal process was the significant change assessment was completed within 14 days of the significant change, but she was unable to state why Resident #1's significant change assessment was completed late. During an interview on 4/17/24 at 2:34 pm the Administrator stated the MDS Nurse was responsible to ensure the MDS assessment was completed on time for Resident #1's soft belt restraint.

Based on staff interviews and record review, the facility failed to maintain a complete and accurate medical record for 1 of 26 residents' medical records reviewed (Residents #79). The findings included: Resident #79 was readmitted to the facility on [DATE] with a diagnosis of dysphagia (difficulty swallowing). The medical record included no evidence of a signed waiver related to Resident #1's dietary status. An interview was conducted with Resident #79 on 4/15/24 at 11:13 AM. He revealed that he wanted to eat regular food and drink thin liquids and signed a waiver in the past to do so freely. On 4/16/24 at 1:20 PM, the Dietary Manager (DM) was interviewed. He stated that Resident #79 had mentioned to him recently that he signed a waiver to eat regular foods. The Speech Language Pathologist (SLP)/Rehab Director was interviewed on 4/16/24 at 3:29 PM. She revealed that Resident #79 previously signed a waiver (date unknown) to eat regular foods despite his NPO status. During a follow-up interview with the SLP/Rehab Director on 4/17/24 at 9:11 AM, she revealed that once the waiver was signed, it would be discussed in the interdisciplinary team (IDT) morning meeting and given to either the assigned Unit Manager or Medical Records to upload into the chart. An interview was conducted with the Registered Dietitian on 4/17/24 at 9:42 AM. She revealed that Resident #79 was presented with a waiver to discuss the benefits/risks of by mouth intake or going against medical advice. The Director of Nursing (DON) was interviewed on 4/17/24 at 9:14 AM. She revealed that she was aware Resident #79 had a signed waiver in place provided by the SLP/Rehab Manager and the MD was aware of Resident #79's signed waiver for regular foods/liquids. Once the waiver was signed, Medical Records should have uploaded it to Resident #79's chart. During an interview with the Medical Director (MD) on 4/17/24 at 10:00 AM, he revealed that the waiver form was to make sure the resident understood and was aware of the risks of their decision to go AMA. He was aware that Resident #79 signed a waiver to eat regular foods. The Administrator was interviewed on 4/17/24 at 10:42 AM, and she revealed that the purpose of the signed waiver was for education only to notify Resident #79 of the risks/benefits of his actions when he ate and aspirated. Review of the signed waiver by Resident #79 dated 4/17/24 revealed that he understood the risks and wished to go AMA for his dietary order.

Based on observations, record review, and staff interviews the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the 2/4/22 recertification and complaint investigation survey. This was for one deficiency previously cited in the area of infection prevention and control (F880). This deficiency was recited during the facility's current recertification survey of 4/18/24. The continued failure of the facility during 2 federal surveys shows a pattern of the facility's inability to sustain an effective QAA Program. The findings included: The tag is cross referenced to: F880: Based on observations, record review, and staff interviews, the facility failed to handle visibly soiled and wet linen to avoid contamination of staff clothing for 1 of 1 laundry aides observed (Laundry Aide #1). During the facility's recertification and complaint investigation survey of 2/4/22 the facility failed to follow the Centers for Disease Control and Prevention (CDC) guidelines for personal protective equipment (PPE) when a staff member was observed entering a quarantine room without wearing gloves and a gown An interview was completed on 4/18/24 at 9:30am with the Administrator and Director of Nursing. The Administrator indicated the QAA committee met monthly to discuss the facility's ongoing performance improvement plans. The Administrator indicated there were no current monitoring plans in place for infection prevention and control. The Administrator indicated it was her expectation the facility continued to follow the QAA process and monitor those issues within the facility so they would not receive a recited deficiency.

Based on observations, record review, and staff interviews, the facility failed to handle visibly soiled and wet linen to avoid contamination of staff clothing for 1 of 1 laundry aides observed (Laundry Aide #1). The findings included: Review of the facility policy titled The Infection Prevention and Control Program (IPCP) dated April 2023 revealed the facility was to establish and maintain an effective program that provides a safe, sanitary, and comfortable environment and attempts to prevent the development and the transmission of diseases and infections. Review of the facility policy titled Laundry Infection Control Responsibilities dated April 2023 revealed soiled linen may contain germs that are capable of causing possible infections. The policy further read to always wear personal protective equipment (PPE) when handling soiled linen which included an apron or gown to protect your clothing and gloves. A continuous observation on 4/17/24 from 8:18 am through 8:28 am revealed Laundry Aide #1 pushed a laundry bin from the soiled linen area to the washing machine with gloved hands and removed visibly soiled and wet linen from the laundry bin and placed the items in the washing machine. The Laundry Aide #1 was then observed to lean her upper body to the waist into the laundry bin to remove the remainder of the visibly soiled and wet linen from the laundry bin with the front and sleeves of her uniform touching the top and interior of the laundry bin. The empty laundry bin was then pushed to the soiled linen area, and it was observed to have multiple areas of brown substance on the interior upper portion of the laundry bin. Laundry Aide #1 returned from the soiled linen area with a second laundry bin and placed the visibly soiled and wet linen into the washing machine with gloved hands. Laundry Aide #1 did not wear an apron or gown while handling the soiled and wet linens and no aprons or gowns were observed in the laundry area. An immediate interview was conducted on 4/17/24 at 8:28 am with Laundry Aide #1 who revealed she only used gloves when handling soiled linens and she removed the gloves after sorting the laundry and then used hand sanitizer. She stated she did not use any other PPE when handling or sorting laundry. A follow-up interview was conducted on 4/17/24 at 10:00 am with Laundry Aide #1who stated the facility had given her a gown to wear one day when she was doing the laundry, but gowns had not been provided for use again. Laundry Aide #1 stated she was not educated that a gown or apron was supposed to be worn when handling the soiled linens and she stated she did not know where to locate a gown or an apron to use. During an interview on 4/17/24 at 10:04 am with the Housekeeping Manager, she revealed that only gloves were required to be worn when handling soiled linens. She stated if the linen was very soiled the staff had the option to wear a gown if they wanted to, but she was not aware of a requirement to wear a gown on when handling soiled linens. The Housekeeping Manager stated the Infection Preventionist (staff member responsible for the facility's IPCP) had provided education to the staff in laundry, but she did not recall being told gowns were required when sorting soiled linens. An interview with the Infection Preventionist (IP) was conducted on 4/17/24 at 10:11 am who revealed the laundry staff should wear gloves when handling the dirty linen. She stated that the education she provided to the laundry staff was that gloves were to be worn when working with soiled linen, no other PPE was needed for soiled or regular linen. The IP was unable to recall when the education for the laundry staff was conducted. A follow-up interview was conducted on 4/17/24 at 10:55 am with the IP who clarified the education that was provided to the laundry staff included the use of gowns when handling soiled linen. The IP stated she must have misunderstood when asked about what PPE laundry staff were required to use when handling soiled linen. An interview was conducted on 4/17/24 at 2:19 pm with the Director of Nursing (DON) who revealed she would have to review the policy and speak with the IP regarding the requirements for laundry staff handling soiled linen. During an interview on 4/17/24 at 2:25 am the Administrator stated Laundry Aide #1 should have worn a gown when handling soiled linen if the policy stated it was required. A follow-up interview on 4/18/24 at 8:20 am with the Administrator and DON revealed the policy had been reviewed and the laundry staff had been educated in the proper use of PPE when handling soiled linen.

Based on record review, staff and resident interviews, the facility failed to invite the resident to participate in the care planning process for 1 of 26 residents whose care plans were reviewed (Resident #84). The findings included: Resident #84 was admitted to the facility on [DATE]. The care plan general note dated 11/08/23 by Social Worker #1 revealed a care plan meeting was held with Resident #84's Responsible Party (RP). Review of the care plan general note dated 1/25/24 by Social Worker #2 revealed Resident #84's RP was invited to participate in a care plan meeting but had not responded to the invite. A message was left for Resident #84's RP to return the call to review the care plan via telephone. Review of the progress notes from 1/25/24 through 4/16/24 revealed no documentation regarding Resident #84 being invited to attend a care plan meeting or that a care plan meeting was held. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #84 was cognitively intact. During an interview on 4/15/24 at 11:25 am, Resident #84 stated she had not been invited to attend a care plan meeting and did not recall participating in the development of her care plan. Resident #84 stated she wanted to attend the care plan meeting so she could discuss her goal to return home. An interview was conducted on 4/16/24 at 2:48 pm with Social Worker #1 who reported she did not recall participating in a care plan meeting with Resident #84 or the RP since her admission. She stated when she reviewed the care plan progress note dated 1/25/24 from Social Worker #2, she thought the care plan was reviewed with Resident #84, but she did not confirm that the care plan review occurred. Social Worker #1 stated the normal process was for Social Worker #2 to send the invitations to the RP to confirm they would be attending the scheduled care plan either in person or via telephone and when the care plan meeting was held a sign in sheet was completed with names of those in attendance. Social Worker #1 was unable to find any documentation that the care plan meeting took place from 1/25/24 to present and she was unable to state why a care plan meeting for Resident #84 was not held. Social Worker #1 stated she spoke with Resident #84 and the RP often but could not remember when the last care plan meeting took place. During an interview on 4/16/24 at 3:03 pm with Social Worker #2 she revealed she was responsible to send the invitations for care plan meetings but did not hold the care plan meeting. Social Worker #2 stated she attempted to contact Resident #84's RP on 1/25/24 because she did not receive a response to the mailed care plan meeting invitation to set up a time to review the care plan over the phone with Social Worker #1. Social Worker #2 stated she documented in a progress note that she was unable to speak with Resident #84's RP but did leave a message regarding scheduling a time to review the care plan for Resident #84. Social Worker #2 stated she did not review the care plan with Resident #84 for the 1/25/24 planned care plan meeting. An interview was conducted with the Administrator on 4/17/24 at 2:37 pm, and she revealed Social Worker #1 was responsible to ensure Resident #84 was invited to the care plan meeting and that the care plan meeting was held as required.

Based on observations, record review, resident and staff interview the facility failed to maintain residents ' dignity by failing to provide incontinence care when a nurse aide (NA #2) told a resident he would have to wait (Resident # 36). This made Resident #36 feel embarrassed and uncared for. The facility also failed to maintain a residents' dignity by allowing a resident to sit in a soiled brief during her meal (Resident #235). Resident #325 stated she felt like poop and complained of being uncomfortable and burning to her skin. This occurred for 2 of 2 residents (Resident #36, Resident #235) reviewed for dignity and respect. The findings included: 1.Resident #36 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (inability to move muscles) and hemiparesis (weakness of the muscles) following stroke. A review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #36 was cognitively intact and was totally dependent on staff for toilet use and extensive assistance for personal hygiene. Resident #36 was coded as always incontinent of bowel and bladder. During an observation of Resident #36 on 1/9/23 at 1:21 PM, he was seen propelling himself down the hall in his wheelchair. Resident #36 stopped at the medication cart and told the NA #5 that he needed to see the Nursing Assistant to be cleaned up. The staff acknowledged she would let the nursing assistant know. An interview was conducted with Resident #36 on 1/9/23 at 1:27 PM. Resident #36 stated that he had to wait to be cleaned up every day. Resident #36 stated that he was tired of sitting in the hallway wet. Resident #36 stated sometimes it could take more than an hour for someone to assist him. He stated that it made him feel embarrassed and upset that staff acted like they didn ' t care that he needed to be changed. An observation and interview were conducted of Nursing Assistant (NA) #2 on 1/9/23 at 1:33 PM. NA #2 was observed telling Resident #36 that she was not able to provide him with incontinent care until she had finished taking up the meal trays off the hall. During an interview with NA #2 she stated that she could not change Resident #36 while the meal trays were on the hall. NA #2 stated that incontinence care was provided as needed and she rounded on the residents every 2 hours. An observation revealed that the meal trays were still in the hall at 1:33 PM. Resident #36 was provided incontinent care at 1:50 PM. An interview was conducted with the Director of Nursing on 1/9/23 at 1:35 PM. The DON stated that she expected that staff would stop passing trays, take care of the resident, perform hand hygiene, and continue to pass out trays. 2.Resident #235 was admitted to the facility on [DATE] with multiple diagnoses to include urinary tract infection. An interview was conducted with Nurse #2 on 1/9/23 at 10:10 AM. Nurse #2 stated Resident #235 was alert and oriented X 4. During an interview with Resident #235 on 1/10/23 at 10:13 AM Resident #235 stated she had asked to be changed before breakfast about 8:15 AM and knew the time because of the clock on her wall and staff (unable to recall which staff) stated they were busy and would change her when they got time. Resident #235 stated that this made her feel like poop because she had to lay in urine and bowel while her meal was in the room. Resident #235 stated that it was uncomfortable and burned when she was incontinent due to the open area on her buttocks. Resident # 235 stated that she had to eat her breakfast meal soiled. There were no odors present or evidence of incontinence on the bed linens. An interview was conducted with Nursing Assistant #4 who was assigned to Resident #235 on 1/10/23 at 10:18 AM. NA #4 stated that she had not been made aware that Resident #235 needed assistance. NA #4 stated that she would wait until after she had passed out the breakfast trays before providing incontinent care. NA #4 stated that incontinent rounds were conducted every 2 hours and as needed. NA #4 further stated she was always on the hall checking on the residents. NA#4 stated she had rounded on Resident #235 at the beginning of the shift about 7:30 AM. Incontinence care was provided to the resident at 10:40 AM. An interview was conducted with the Director of Nursing (DON) on 1/10/23 at 10:45 AM. The DON stated that she expected that staff would stop passing trays, take care of the resident, perform hand hygiene, and continue to pass out trays.

Based on observation, staff and resident interviews and record reviews the facility staff allow Resident#7 to remain sitting in a brief soiled with stool and urine for an extended period of time. The facility failed to offer a toilet or commode to Resident#4 while experiencing a bowel movement This was evident in 2of 2 residents in the sampled survey observed during incontinence care. 1. Resident #4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED].#4 to be alert and oriented with moderately impaired condition for decision making. He required extensive assistance of two staff members for all activities of daily living, including mobility, personal care and transfers. During an observation of incontinent care on 02/22/2011 at 3:46 PM, NA #6 announced to the resident it was his day for a shower so she was going to shower him now. NA # 6 attached the sling to the transfer device and proceeded to raise the resident to a standing position on the transfer/lift device; as the resident was positioned suspended on the unlocked transfer/lift device, NA #6 removed the resident incontinent brief which was noted to have a large amount on matted brown soft stool that covered most of the back of the incontinent brief. The resident was observed to turn away from NA#6 as she removed the soiled brief. He looked up towards the ceiling with a look of embarrassment. NA #6 did not wipe or clean the resident after she removed the soiled incontinent brief; she threw the soiled brief in the trash and proceeded to position the resident in front of the shower chair which had an open bottom. The shower chair can convert to a commode or can be placed directly over the toilet bowl. The shower chair was positioned with the back of the shower chair facing the wall, and she lowered the resident to the unlocked shower chair. The resident was positioned in the shower chair with stool noted to his buttocks, the resident shook his head in a back and forth motion in frustration raising his hand to his face with a look of despair on his face. NA #6 removed the transfer/lift sling from the resident ' s back and collected the resident ' s soap and shower supplies and covered the resident ' s shoulders with a sheet. The resident had another incontinent episode of loose brown liquid stool the size of a baseball which landed on the floor under the shower chair; NA #6 bent down next to the resident, and reached under the resident in the shower chair; wiped his buttocks once with a with a cloth, as NA #6 was wiping his bottom, the resident looked toward the surveyor with an embarrassed, humiliated look noted on his face. NA #6 cleaned the floor with a wipe and she threw the cloth away, and changed her gloves. The resident was observed to look at the NA#6 as she walked away to throw away the soiled wipe with a saddened expression on his face. NA #6 did not ask the resident if he needed privacy or needed to continue having a bowel movement. The resident let out a deep sighed of frustration, as NA #6 bent down next to the resident wiped the stool from the floor and placed a sheet under the resident in the shower chair. NA #6 did not respond to the resident ' s expressions of frustration, despair or humiliation. NA #6 proceeded to throw the soiled cloth away and turned back towards the resident and noted a formed stool on the sheet under the resident in the shower chair. The resident shook his head, hung his head down towards his chest and sighed in frustration and despair. She took the commode bucket from the resident private bathroom in his room and put the formed stool in the bucket and flushed into in the toilet and discarded the soiled sheet. NA #6 proceeded to cover the resident with a sheet and wheeled him into the shower room. During an interview with the NA #6 on 02/24/11 at 9:42 AM she stated " I did not realize I did not wash my hands when I came into the room. " She also stated " She indicated that she did not think to ask him if he had to continue having a bowel movement after each stool episode. She further indicted she could have wheeled him into his private bathroom, so he could have sat over the toilet to have a bowel movement. She stated " I did not think about it. " She also revealed he was stooling when he was in the shower and she could have placed him over the commode in the bathroom so he could have a bowel movement privately, then finish his shower. She again stated " I did not think about doing that. " She revealed she did not think how the resident felt when she had to clean up the stool off the floor. During an interview with the DON on 2/22/11 at 5:00 PM revealed her expectation was the resident should have been wheeled into the private bathroom in his room to have a bowel movement. She indicated it was unacceptable to allow a resident to stool on the floor or a sheet placed under the resident. 2, Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. He was alert and oriented, and able to make his needs known. He requires extensive assistance with all transfers and mobility. He was independent for mobility once he was in his wheelchair; he could propel himself throughout the facility. During an observation on 2/2/11 at 10:20 AM revealed resident #7 was pacing in his wheelchair outside his room; wring his hands together looking at his wrist watch. A strong odor of stool was noted around the resident. He stated in a frustrated tone " the nurse brought me back from [MEDICAL TREATMENT] to have my brief changed and I am waiting to have it changed. I have put the call light on twice and the nurse who brought me back from [MEDICAL TREATMENT] told me the NA (nursing assistant) was coming to change me. " The resident shook his head in disgust, he stated " LPN #3 came in and turned off my light and told me the NA was coming as soon as she could. " He wheeled himself back into his room and pushed the call bell again at 10:26 AM. An overhead page for help to the resident ' s room was heard. As he waited for the call bell to be answered he stated " this happens a lot, I do not know why the nurse who brought me back from [MEDICAL TREATMENT] could not have changed me. I do not understand why I have to wait; I need to get back to [MEDICAL TREATMENT]. " The resident was noted to hang his head down towards his chest and shook his head in frustration and a tone of despair was noted to his voice. The nurse consultant came to answer the call bell at 10:30 AM; LPN #3 also came to answer the call light at that time. The resident said to the nurse consultant in an angered tone, " I need to be changed and get back to [MEDICAL TREATMENT]. " LPN #3 stated to the nurse consultant " the NA is busy doing care with another resident and she (the NA) told me she would be here soon. " The nurse consultant instructed LPN #3 to get another NA and change the resident now. LPN #3 returned to the room at 10:38 AM with the lift device and supplies, the nurse consultant left the room and NA #7 returned at 10:46 AM and began to assist to secure the resident in the lift and provide incontinent care. After care was completed the resident was placed back in his wheelchair and taken back to [MEDICAL TREATMENT] at 10:56 AM. During an interview with Resident #7 on 2/22/11 at 4:00 PM revealed he was very upset that he had to wait to have his soiled brief changed. He stated as he shook his head in frustration, " I do not know why I had to wait; the nurse who brought me back from [MEDICAL TREATMENT] knew I needed my brief changed and get back to [MEDICAL TREATMENT]. " He also stated " even if I was not at [MEDICAL TREATMENT], I still have to wait when I put my call light on for the NA to help me. " During an interview with LPN #3 on 2/22/11 at 10:58 AM revealed she brought the resident back from [MEDICAL TREATMENT] because he needed to have his brief changed, so she put his call bell on and went to get the NA that works with him to change his soiled brief. She stated " I did not realize she did not come when I told her too, she was caring for another resident. " She indicated that any nurse or NA could change a resident ' s incontinent brief. During an interview with the nurse consultant at 11:10 AM on 2/22/11 revealed her expectations was that any staff member can provide care to a resident. She further indicated a resident should not have to wait to have care provided. During an interview with the staff member that sits at the main desk and the 300 hall desk on 2/22/11 at 3:30 PM, she stated " we are responsible to answer the call light and overhead announce the room number who pressed the call light. " She revealed there is someone at each desk until 5:00 PM and then nurse supervisor takes care of the call lights after that. She indicated she does not know what the resident needs because they do not speak to the resident they just announce the room number for the staff to answer. She further indicated if a resident calls several times we still just announce the room number overhead for the staff. During an interview with the DON (Director of nurses) on 2/22/11 at 5:00 PM revealed her expectations was the nurse who brought the resident back from [MEDICAL TREATMENT] should have changed his brief and returned him to [MEDICAL TREATMENT] as soon as possible. She also revealed a resident should not have to use the call bell several times to have care provided, any staff member who is trained to provide care can help the resident. She continued and stated " all staff member are instructed to answer a call bell to see what the resident needs and get the appropriate staff member to help them. "

Based on record review, observations and staff interviews the facility failed to protect 1 of 2 residents from receiving a skin injury (burn) measuring 1 inch (long) x 1/4 inch (wide) to her forehead ( Resident # 1). 2. The facility staff failed to have 2 staff members for safe transferring and failed to lock Resident #4 ' s wheelchair during a transfer when using a mechanical lifting device for 1 of 5 residents. Findings included: Resident # 1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].# 1 had short and long term memory impairment and was severely impaired for activities of daily living. The MDS revealed Resident # 1 had bilateral total impairment of all extremities. Resident # 1 was totally dependent on nursing staff for her nursing care. The care plan for Resident # 1 dated 2/5/09 listed a " Problem " as " at risk for injury related to unstable health condition. " The " Goal: " was Resident # 1 " will remain free of injury as evidenced by no falls or accidents thru next review. " One of the " Approaches " listed was " provide frequent staff observation of resident (Resident # 1). " Record review of the Physicians progress notes dated 12/21/10 revealed, "Burn on forehead - _______(family member) wants evaluation. " On 12/17/10 and 12/23/10 the 24 hour and 5 day " Injury of Unknown Source " reports were sent to the NC Nurse Aide/Healthcare Personnel Registry for an injury of unknown origin. The " Allegation Details " were " skin discoloration observed by staff at hairline approximately 1 inch (long) x 1/4 inch (wide). " After investigation and staff interviews the facility could only determine that Resident # 1 had been known to wear a head wrap (doo rag) on the day prior to the injury but they were unsure this was the cause of the injury to her forehead. Record review of the Report of Dermatology Consultation dated 1/6/11 revealed , " Impression: Post inflammatory hypopigmentation (the loss of skin color). Plan: Patient has a linerer healed scar on forehead with post inflmatory solar change that will resolve over time. " On 2/24/11 at 12:40 pm an interview was conducted with Nurse # 1 she was responsible for the care of Resident # 1 on the 7:00 am - 3:00 pm shift on 12/16/10 and 12/17/10). She stated she made rounds on 12/16/10 and did not notice an injury to Resident # 1 ' s forehead. On 12/17/10 she made rounds at 7:30 am and observed Resident # 1 (did not enter room) lying in her bed with nothing unusual observed. She stated she came back to Resident # 1 ' s room between 9:00 am - 10:00 am to check Resident # 1 ' s tube feeding and give her medications. The nurse said she remarked to another NA (unable to contact) in the room "Oh, my God what is this!" Nurse # 1 reported the finding to the DON (director of nurses) and ADON (assistant director of nurses) immediately. Nurse # 1 stated the wound on Resident # 1 ' s forehead " looked like a burn. " She stated it was " dark in color and it had a big blister on it. " The nurse revealed the " blister was not broken and wound was as long as a large nail clipper and as wide as a regular band aide. " Nurse # 1 stated she had not seen a curling iron in Resident # 1 ' s room. Nurse#1 stated Resident # 1 had not been to the beauty parlor recently and would not need a curling iron because of prior chemical damage to her hair braided hair. She did say she had not seen family or staff using a curling iron on her hair but she had seen Resident # 1 wearing a head wrap on her head on 12/16/10. On 12/17/20 a statement from Nurse # 2 (no longer employed) indicated she was responsible for the care of Resident # 1 on 12/16/10 on the 3:00 pm - 11:00 pm shift and 12/17/10 on the 11:00 pm - 7:00 am. The nurse stated at 11:30 pm " the head rag (head wrap) had been removed by at least 11:30 that night. " She revealed she did not see anything on Resident # 1 ' s forehead at 11:30 pm on 12/16/10 or at 6:30 am on 12/17/10. On 12/21/10 a written statement from NA # 1 (nursing assistant who was no longer employed) revealed she was responsible for Resident # 1 on 12/16/10 on the 7:00 am to 3:00 pm shift. The NA stated she (Resident # 1) " did not have any marks on her head. " There was no information in the report to indicate if she put on Resident # 1 ' s head wrap during her shift. An interview was conducted with NA # 2 on 2/23/11 at 1:56 pm. The NA stated she was responsible for the care of Resident # 1 on 12/16/10 on the 3:00 pm to 11:00 pm shift. NA # 2 stated she went in Resident # 1 ' s room to put her to bed at 9 pm. She stated the lights were on in the resident ' s room and she took her head wrap off. NA # 2 stated she did not see any dark skin, skin indention from pressure or redness on Resident # 1 ' s forehead. She stated she had not seen a curling iron in her room. A written statement from NA # 3 revealed she was responsible for the care of Resident # 1 on the 11:00 pm - 7:00 am shift on 12/16/10. She stated the last time she and NA # 4 saw Resident # 1 was at 6:30 am on 12/17/10. She stated she did not see any marks on Resident # 1 ' s forehead. A written statement from NA # 4 revealed she worked the 11:00 pm - 7:00 am shift on 12/16/10. The NA stated she helped NA # 3 with Resident # 1 ' s care. She revealed she did not see any marks on Resident # 1 ' s forehead. On 2/24/11 at 1:45 pm the Evening Supervisor on the 3:00 pm - 11:00 pm shift) stated she worked on the evening of 12/16/10. She stated she last observed Resident # 1 in her bed at 6:30 PM on 12/16/10 and she noticed nothing unusual on Resident # 1 ' s forehead. The nurse revealed she saw Resident # 1 ' s head wound on the evening of 12/16/10 and she stated it looked like " rug burn. " The wound had a darker skin tone (naturally brown skin) with unbroken skin and indentation measuring vertically 1 inch and horizontally 2. " The Nurse stated she had seen Resident # 1 wearing a head wrap on 12/16/10). On 2/24/11 at 3:35 pm Nurse#5 (supervisor) (7:00 am - 3:00 pm shift on 12/16/10) stated she made rounds on her shift several times and did not see anything unusual on Resident # 1's forehead. The Supervisor stated that the wound on Resident # 1's forehead on 12/17/10 was "near the hair line and looked like a burn." She stated the original injury measured 3 cm x 1 cm. The nurse stated the wound was slightly raised and the skin was not broken. The supervisor stated she had seen a head wrap on Resident # 1's head on 12/16/10 but has not seen it on her head since that time. An interview with the Nurse#6 Supervisor on the 11:00 pm - 7:00 am shift on 12/16/10 could not be accomplished because she could not be reached for an interview. An interview with NA # 5 2/23/11 at 11:47 am revealed she worked with Resident # 1 two times a week on the 7:00 am - 3:00 pm shift. The NA stated she saw Resident # 1 shortly after the wound was discovered on her forehead. She stated it looked like " a burn. " NA # 5 stated the skin was dark, dried scaby, and lightly indented. " The NA stated she had not seen a curling iron in her room, but she had seen a mens head wrap in Resident # 1 ' s dresser drawer. On 2/23/11 at 12:29 pm the Wound Nurse stated the facility investigation revealed " something happened on the 11:00 pm - 7:00 am shift. " The Nurse sated Resident # 1 had previously had a head wrap prior to the injury. The wound looked " browner than her skin color and slightly concaved (slightly inward dip). " The Wound Nurse stated the injury was " not an abrasion but could have been curling iron burn except no blister formed and the skin was not broken. " The nurse said Resident # 1 ' s injury could have been " a reaction from silk head wrap and/or chemicals on her hair. " The Wound Nurse stated she called the wound a " Stage 2 because it was skin disruption from pressure (head wrap tied too tight) or hair chemicals . " The Medication Administration Record (MAR) dated 12/17/10 - 12/31/10 revealed " Betadine swab to stage 3 on forhead daily " for Resident # 1 signed by the Wound Nurse. On 2/24/11 at 3:14 pm the Wound Nurse measured the pink scar on Resident # 1's forehead. Nurse # revealed the wound measured 1 cm (centimeter) x 5 cm. The nurse stated the wound looked like a "narrow sear mark, intermingled with dark pigmentation and red spots." An interview was conducted with the ADON on 2/24/11 at 3:42 pm revealed she had viewed the dark pigmented area on her (Resident # 1's) forehead on 12/17/10." She stated the facility staff did an Injury of Unknown Origin Report because the source of the injury was unknown. The ADON stated that Resident # 1 had been known to wear a head wrap and she had "observed a slight vertical indention from her hair line to slightly above her eyebrows" on 12/17/10. She thought the injury was from "the seam" on the front of the head wrap, but she was not sure what caused the injury. She stated the dark area was "smooth but slightly indented." On 2/24/11 at 3:56 pm the DON stated the injury was reported on the morning of 12/17/10. The DON stated she, the ADON, and the DON went to Resident # 1's room. The DON stated she observed a dark area on Resident # 1's forehead that looked like a "rug burn." The area was "1/2 inches below her hair line and the skin was not broken." The DON stated an investigation was completed and they were unable to determine how the injury occurred. On 2/24/11 at 4:11 pm an interview with the Administrator revealed she observed a " red, moon shaped area about 1/2 inch wide " on Resident # 1 ' s forehead on 12/17/10. She stated the area was "more like a horizontal indention in the middle of the wound. " The administrator stated she thought the injury came from a head wrap seam that runs horizontally just below hairline across her forehead. The Administrator stated was not sure if the injury came for the head wrap and could not determine if a family member or nursing staff had put the head wrap on. 2. Resident #4 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE] coded Resident #4 to be alert and oriented with moderately impaired condition for decision making. He required extensive assistance of two staff members for all activities of daily living, including mobility, personal care and transfers. He required the use of a lifting device for all transfers. During an observation of Resident #4 being transferred from the wheelchair to the shower chair using a lifting/ transfer device on 02/22/2011 at 3:46 PM. NA #6 brought the transfer/lifting device (sit to stand) into the room, pushed the transfer/lifting device in front of Resident #4 ' s who was sitting in a wheelchair on the transfer sling positioned in front of the wall sink in the resident ' s room. NA #6 attached the sling to the transfer/lifting device and proceeded to raise the resident to a standing position on the transfer device. The wheels of the wheelchair were not locked before the transfer began. As the resident was being raised with the transfer device, the wheel chair rolled backwards slightly approximately 2-3 inches, coming to a stop against the sink edge. The resident was positioned on the transfer device and NA #6 moved the resident and positioned him over a shower chair. As the resident was positioned on the unlocked transfer/lifting device, NA #6 removed the resident ' s incontinent brief, and she proceeded to position the resident in front of the shower chair and lowered the resident to the unlocked shower chair. As Resident #4 was being lowered into the shower chair, it slid slightly back approximately 3-4 inches and stopped as it touched the wall. NA #6 transferred the resident out of the room to the shower room across the hall. NA #6 pushed the resident into the shower stall and closed the door to the shower room. NA #6 did not lock the shower chair when she positioned it in the shower stall. After NA #6 completed the resident ' s shower, NA #6 positioned the transfer/lift device in front of the unlocked shower chair and raised the resident onto the transfer device. The NA #6 positioned the resident on the bed. During an interview with the NA #6 on 02/24/11 at 9:42 AM she stated " when I use the transfer/lifting device I am supposed to lock the wheels of the wheel chair the resident is being transfer from before the lift is used. " She continued, we are also supposed to lock the chair the resident is to be transferred into. " She explained the resident should not be left in the transfer/lifting device to provide care and we need two people when we use the transfer/lifting device. " She continued and explained that she was not aware she forgot to lock the brakes of the wheelchair when she transferred the resident, nor was she aware the wheelchair slide backwards against the sink while she was lifting the resident. She further explained she had to remove the resident ' s incontinent brief and it is easier to remove it when she has him in the lift before she sits him in the chair. She also stated " I did not realize I had not locked the shower chair or that it moved backwards as I was lowering him into the chair. " She further explained she did not realize when she was giving the resident his shower that she did not lock the shower chair. NA #6 revealed she was not sure when she was in-serviced about using the transfer/lifting device. During an interview with the Staff Development Coordinator (SDC) on 2/23/11 at 3:15 PM revealed the facility policy for using a transfer/lifting device requires two staff members at all times. She also indicated according to the policy the wheels of the chair the resident is being transferred from and too was to be locked. She also indicated the resident should never be suspended in a transfer lift device to provide care. She also provided three in service dates that NA #6 attended specifically dealing with instruction for using the transfer/lifting device. Review of the in services NA #6 attended was noted. The dates were her initial/ orientation training on 5/1/09 and subsequent training on 2/14/11 and 2/23/11. During an interview with the consultant nurse coordinator on 02/24/11 at 12:30 PM revealed a facility audit was conducted on 2/14/11 and NA #6 was identified as having problems with transferring and was in-serviced for the use of the transfer/lifting devices. During an interview with the Director of Nursing on 02/23/11 at 4:14 PM revealed her expectation and the facility policy was that two staff members were to be involved with any resident who the transfer/lifting devices were being used. She further revealed the chair the resident is being transfer from and to should be locked during the transfer.