Every finding on record at Good Samaritan Rehab and Care Center

Based on observation, interview, and record review, the facility failed to ensure an environment free of accident hazards for 9 of 28 sampled residents (Residents 2, 27, 30, 34, 52, 65, 71, 81, and 90) when:Resident 2 did not have an updated smoking reassessment.Residents 27 and 81 smoked without supervision and had smoking paraphernalia (items used for smoking, such as cigarettes, lighters, and matches) with them instead of having it secured by staff.Residents 30 and 65 did not have updated smoking reassessments, smoked without supervision, and had smoking paraphernalia with them instead of having it secured by staff.Resident 34 smoked without supervision and did not have a smoking care plan.Resident 52 smoked without supervision, had smoking paraphernalia with them instead of having it secured by staff, and did not have a smoking care plan.Resident 71 smoked without supervision.Resident 90 did not have an initial smoking assessment completed, did not have a smoking care plan, smoked without supervision, and had smoking paraphernalia with them instead of having it secured by staff.These failures had the potential to place Residents 2, 27, 30, 34, 52, 65, 71, 81, and 90, as well as other residents in the facility, at risk for accidental burns, fire-related injuries, and other smoking-related accidents. Findings:1. Review of Resident 2's admission RECORD, indicated Resident 2 was admitted to the facility with diagnoses including other specified respiratory disorders, fracture of the mandible (jaw), quadriplegia at the C1-C4 level (paralysis of all four limbs), unspecified psychosis (disconnection from reality), cognitive communication deficit, primary osteoarthritis of the hand, and schizophrenia (a mental illness that affects how a person thinks, feels, and behaves).Review of Resident 2's Brief Interview for Mental Status (BIMS, an assessment used to evaluate a resident's thinking and memory) dated 3/31/26, indicated Resident 2 had a BIMS score of 7, which indicated severely impaired cognition (13-15 = intact, 8-12 = moderate impairment, 0-7 = severe impairment).During a concurrent interview and record review on 6/18/26, at 12:42 PM, with the Director of Nursing (DON), Resident 2's Smoking Data Collection and Assessment, dated 1/5/25, and ASSESSMENT OF SAFE POSSESION OF SMOKING PARAPHERNALIA, dated 1/5/25, were reviewed. The DON confirmed that Resident 2 did not have the quarterly assessments completed after 1/5/25 and stated that smoking reassessments were necessary to ensure Resident 2 could continue to smoke safely. 2a. Review of Resident 27's admission RECORD, indicated Resident 27 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD, a lung disease that makes it hard to breathe), transient cerebral infarction (a temporary interruption of blood flow to the brain), lack of coordination (difficulty controlling body movements), hemiplegia and hemiparesis following cerebral infarction (weakness or paralysis on one side of the body after a stroke), bipolar disorder (a mental health condition that causes extreme changes in mood), paranoid schizophrenia (a mental illness that can affect a person's thoughts, judgment, and behavior), schizoaffective disorder (a mental illness with symptoms of schizophrenia and a mood disorder), and auditory and visual hallucinations (hearing or seeing things that are not actually present).Review of Resident 27's BIMS dated 6/9/26, indicated Resident 27 had a BIMS score of 15, which indicated intact cognition.During an interview on 6/16/26, at 1:34 PM, with Resident 27, Resident 27 stated that he kept his own lighter and smoked outside independently without staff supervision.During a concurrent interview and record review on 6/18/26, at 12:11 PM, with the DON, Resident 27's Smoking Data Collection and Assessment, dated 3/20/26, and ASSESSMENT OF SAFE POSSESION OF SMOKING PARAPHERNALIA, dated 11/15/25, were reviewed. The Smoking Data Collection and Assessment, indicated Resident 27 could smoke independently but required staff to keep his lighter and matches secured at the nurses' station. The ASSESSMENT OF SAFE POSSESION OF SMOKING PARAPHERNALIA, indicated Resident 27 had no clinical and physical limitations affecting his ability to smoke safely. The DON acknowledged that Resident 27 had physical limitations, including hemiplegia, hemiparesis, and lack of coordination, as well as mental health conditions and antipsychotic medication that could cause sleepiness, dizziness, and decreased alertness, limiting his ability to smoke safely without staff supervision and increasing the risk of burns or fire if he kept a lighter in his possession.2b. Review of Resident 81's admission RECORD, indicated Resident 81 was admitted to the facility with diagnoses including COPD, pneumonia, and acquired absence of the right leg below the knee (amputation of the lower right leg).Review of Resident 81's BIMS dated 6/15/26, indicated Resident 27 had a BIMS score of 14, which indicated intact cognition.During a concurrent observation and interview on 6/17/26, at 9:20 AM, with Resident 81 in the smoking area, Resident 81 was seated on a table alone smoking with no other staff present. Resident 81 stated that he kept his own cigarettes and lighter with him and smoked without supervision as he did not need supervision from staff. During a concurrent interview and record review on 6/18/26, at 12:11 PM, with the DON, Resident 81's Smoking Data Collection and Assessment, and ASSESSMENT OF SAFE POSSESSION OF SMOKING PARAPHERNALIA, both dated 3/6/26, were reviewed. The Smoking Data Collection and Assessment indicated Resident 81 could smoke independently but required staff to keep his lighter and matches secured at the nurses' station. The Assessment of Safe Possession of Smoking Paraphernalia indicated Resident 81 had no clinical conditions and physical limitations that would affect his ability to smoke safely. The DON acknowledged that Resident 81 had medical and clinical conditions that limited his ability to smoke safely without staff supervision, including COPD, heart failure and major depressive disorder. The DON stated Resident 27 was not safe to smoke without staff supervision or to keep his smoking paraphernalia in his possession. 3a. Review of Resident 30's admission RECORD, indicated Resident 30 was admitted to the facility with diagnoses including peripheral vascular disease, acquired absence of the right leg above the knee, transient ischemic attack, cerebral infarction (stroke), and a personal history of other mental and behavioral disorders.Review of Resident 30's BIMS dated 4/13/26, indicated Resident 30 had a BIMS score of 13, which indicated intact cognition.During a concurrent observation and interview on 6/18/26, at 10:20 AM, with the Minimum Data Set Coordinator (MDSC) in the hallway near the exit to the smoking area, Resident 30 entered the building from the smoking area while self-propelling her wheelchair. Resident 30 stated that she carried her lighter and cigarettes in her pouch and had just finished smoking without staff supervision. The MDSC confirmed Resident 30 smoked without staff supervision and kept her smoking paraphernalia in her possession.During a concurrent interview and record review on 6/18/26, at 10:33 AM, with the DON, Resident 30's Smoking Data Collection and Assessment, dated 4/14/25 and the undated ASSESSMENT OF SAFE POSSESSION OF SMOKING PARAPHERNALIA, were reviewed. The DON stated quarterly smoking assessments had not been completed after 4/14/25 and should have been completed as scheduled to determine whether Resident 30 could safely continue smoking. The Smoking Data Collection and Assessment, indicated that Resident 30 could smoke independently but required staff to keep her lighter and matches secured at the nurses' station. The ASSESSMENT OF SAFE POSSESSION OF SMOKING PARAPHERNALIA, indicated Resident 30 had no clinical conditions and physical limitations that would affect her ability to smoke safely. The DON acknowledged that Resident 30 had physical limitations, including cerebral infarction and acquired absence of the right leg above the knee, and clinical conditions, including severe major depressive disorder and a history of mental and behavioral disorders. The DON stated Resident 30 was not safe to smoke without staff supervision or to keep smoking paraphernalia in her possession because her physical limitations and clinical conditions and the use of antipsychotic medication could impair her ability to smoke safely without staff supervision.3b. Review of Resident 65's admission RECORD, indicated Resident 65 was admitted to the facility with diagnoses difficulty in walking, other symptoms and signs involving the musculoskeletal system, muscle weakness, displaced fracture left clavicle (broken collarbone with the bone out of its normal position), and multiple fractures of ribs.Review of Resident 65's BIMS dated 6/15/26, indicated Resident 27 had a BIMS score of 13, which indicated intact cognition.Review of Resident 65's MAR dated 6/1/26 through 6/17/26, indicated Resident 65 received oxycodone (narcotic pain medication that can cause sleepiness, dizziness, slowed thinking, and impaired judgment) 5 mg every 6 hours for pain, administered 1 to 3 times dailyDuring a concurrent observation and interview on 6/16/26, at 2:44 PM, with Resident 65 in Resident 65's room. Resident 65 was lying in bed with the head of bed elevated, the overbed table next to the bed on the right side with 2 lighters on top. Resident 65 stated he owned the lighters to smoke.During a concurrent interview and record review on 6/18/26, at 11:09 AM, with the DON, Resident 65's Smoking Data Collection and Assessment, dated 1/22/26 and the undated ASSESSMENT OF SAFE POSSESSION OF SMOKING PARAPHERNALIA, were reviewed. The DON stated quarterly smoking assessments had not been completed after 1/22/26 and should have been completed as scheduled to determine whether Resident 65 could safely continue smoking. The Smoking Data Collection and Assessment concluded that Resident 65 could smoke independently but required staff to keep her lighter and matches secured at the nurses' station. The Assessment of Safe Possession of Smoking Paraphernalia indicated Resident 65 had no clinical conditions and physical limitations that would affect his ability to smoke safely. The DON acknowledged that Resident 65 had physical limitations, including difficulty walking, musculoskeletal problems, muscle weakness, a displaced left clavicle fracture, and multiple rib fractures. The DON stated Resident 65 was not safe to smoke without staff supervision or to keep smoking paraphernalia in his possession because of his physical limitations and the use of medications that can cause sleepiness, dizziness, and decreased alertness.4. Review of Resident 34's admission RECORD, indicated Resident 34 was admitted to the facility with diagnoses including arthropathy (joint disease), muscle weakness, other symptoms and signs involving the musculoskeletal system, unsteadiness on feet, major depressive disorderReview of Resident 34's BIMS dated 6/5/26, indicated Resident 34 had a BIMS score of 15, which indicated intact cognition.During an interview on 6/17/26 at 9:38 AM with Resident 34, Resident 34 stated that she smoked without staff supervisionDuring a concurrent interview and record review on 6/18/26, at 9:50 AM, with the DON, Resident 34's Smoking Data Collection and Assessment, dated 5/20/26 and the undated ASSESSMENT OF SAFE POSSESSION OF SMOKING PARAPHERNALIA, were reviewed. The Smoking Data Collection and Assessment, indicated that Resident 34 could smoke independently. The ASSESSMENT OF SAFE POSSESSION OF SMOKING PARAPHERNALIA, indicated Resident 34 had no clinical conditions and physical limitations that would affect her ability to smoke safely. The DON acknowledged that Resident 34 had physical limitations, including arthropathy, muscle weakness as well as clinical conditions, including major depressive disorder and the use of medication that can cause sleepiness, dizziness, and decreased alertness, which limited her ability to smoke safely without staff supervision. Resident 34's care plan was also reviewed with the DON, the DON confirmed Resident 34 did not have a smoking care plan and stated nursing staff were expected to develop a care with resident-specific interventions to ensure she smoked safely.5. Review of Resident 52's admission RECORD, indicated Resident 52 was admitted to the facility with diagnoses including COPD, unspecified psychosis, schizophrenia, bipolar disorder, transient ischemic attack and cerebral infarction, pulmonary embolism (blood clot in the lungs that can make it hard to breathe), lack of coordination, and other symptoms and signs involving the musculoskeletal system.Review of Resident 52's BIMS dated 4/13/26, indicated Resident 52 had a BIMS score of 15, which indicated intact cognition.Review of Resident 52's MAR dated 6/1/26 through 6/17/26, indicated Resident 34 received olanzapine (antipsychotic) 2.5 mg daily at 9 PM.During an interview on 6/16/26, at 11:03 AM, with Resident 52, Resident 52 stated that she smoked without staff supervision and kept her own smoking paraphernalia in her possession.During a concurrent interview and record review on 6/18/26, at 10:18 AM, with the DON, Resident 52's Smoking Data Collection and Assessment, dated 4/10/26 and the undated ASSESSMENT OF SAFE POSSESSION OF SMOKING PARAPHERNALIA, were reviewed. The Smoking Data Collection and Assessment, was not completely answered. The ASSESSMENT OF SAFE POSSESSION OF SMOKING PARAPHERNALIA, indicated Resident 52 had no clinical conditions and physical limitations that would affect her ability to smoke safely and Resident 52 may possess smoking paraphernalia. The DON acknowledged that Resident 52 had physical limitations, including obesity, cerebral infarction and lack of coordination as well as clinical conditions including schizophrenia and bipolar disorder and the use of antipsychotic medication that can cause sleepiness, dizziness, and decreased alertness, which limited her ability to smoke safely without staff supervision. The DON stated Resident 52 was not safe to keep her own lighter because her physical limitations and medications increased the risk of burns or fire. Resident 52's care plan was also reviewed with the DON, the DON confirmed Resident 52 did not have a smoking care plan and stated nursing staff were expected to develop a care with resident-specific interventions to ensure she smoked safely.6. Review of Resident 71's admission RECORD, indicated Resident 71 was admitted to the facility with diagnoses including abnormalities of gait and mobility, other symptoms and signs involving the musculoskeletal system and schizoaffective disorder.Review of Resident 71's BIMS dated 6/5/26, indicated Resident 71 had a BIMS score of 12, which indicated moderately impaired cognition.During a concurrent interview and record review on 6/18/26, at 12:45 PM, with the DON, Resident 71's Smoking Data Collection and Assessment, and ASSESSMENT OF SAFE POSSESSION OF SMOKING PARAPHERNALIA, both dated 4/8/26 were reviewed. The Smoking Data Collection and Assessment, indicated Resident 71 could smoke independently but required staff to keep his lighter and matches secured at the nurses' station. The Assessment of Safe Possession of Smoking Paraphernalia indicated Resident 71 had no clinical conditions and physical limitations that would affect his ability to smoke safely. The DON stated that Resident 71 smoked without staff supervision, but his smoking paraphernalia was kept at the nurses' station. The DON acknowledged that Resident 71 had physical limitations, including abnormalities of gait and mobility as well as clinical conditions including schizoaffective disorder and the use of antipsychotic medication that can cause sleepiness, dizziness, and decreased alertness, which limited her ability to smoke safely without staff supervision. 7. Review of Resident 90's admission RECORD, indicated Resident 90 was admitted to the facility with diagnoses including other symptoms and signs involving the musculoskeletal system, muscle weakness, abnormalities of gait and mobility, acquired absence of right leg below knee, major depressive disorder, insomnia due to other mental disorder, and ischemic cardiomyopathy (a weakened heart caused by reduced blood flow). Review of Resident 90's BIMS dated 4/7/26, indicated Resident 90 had a BIMS score of 15, which indicated intact cognition.During a concurrent observation and interview on 6/17/26, at 9:17 AM, with the DON in Resident 90's room, the room was wide open, and Resident 90 was not present. Resident 90's lighter and a pack of cigarettes were on top of table, visible from the doorway and readily accessible to anyone entering the room. The DON stated it was not safe to leave the lighter in the room because anyone could take it and it could create a fire hazard.During an interview on 6/17/26, at 9:53 AM, with Resident 90, Resident 90 stated that he smoked without staff supervision and kept his lighter in his possession.During a concurrent interview and record review on 6/18/26, at 10:50 AM, with the DON, Resident 90's electronic health record (EHR - the resident's computerized medical record) and physical chart were reviewed. The DON stated Resident 90's initial smoking assessment had not been completed by the due date, which was a safety concern because Resident 90 had not been assessed to determine whether he could smoke safely while smoking independently and keeping his lighter in his possession. The DON further stated Resident 90 did not have a smoking care plan, which was a safety concern because nursing staff did not have resident-specific interventions to ensure he smoked safely. The DON stated Resident 90 was not safe to smoke without staff supervision or to keep smoking paraphernalia in his possession because he had not been assessed to determine whether he could do so safely.During a concurrent interview and review on 6/18/26, at 12:50 PM, with the DON, the facility's .RESIDENT SMOKING TIME SCHEDULE, was reviewed. The facility's smoking time indicated from 8 AM, 9 AM, 11 AM, 1 PM, 2 PM, 4 PM, 6:30 PM, and 8:30 PM, there was a list of staff designated to supervise residents who were smoking in the smoking area. The DON stated staff who were assigned were expected to be at the smoking area at that time to ensure residents who needed to smoke had supervision. The DON further stated if the assigned staff were not there, then no supervision to smokers would be provided and it was a safety risk, including a potential fire hazard.Review of the facility's undated policy and procedure titled, POLICY AND PROCEDURE ON SMOKING, indicated .In the case of any resident who is physically or mentally incapacitated, resident shall be permitted to smoke provided that smoking is done under close supervision of staff.Residents who are not capable of smoking safely including handling smoking paraphernalia safely may be placed on scheduled and/or supervised smoking.Review of the facility's undated policy and procedure titled, POLICY AND PROCEDURE ON SMOKING: SMOKING PARAPHERNALIA, indicated .The inter-disciplinary team shall assess residents who smoke, for safety awareness and self-handling of smoking paraphernalia.Assessment of residents shall include the following.Medical conditions or diagnoses that would limit or affect a resident's ability to smoke i.e. Parkinson's disease.Dementia.Huntington Chorea.Psychosis, others.Resident's physical ability to smoke, i.e. motor skills such as muscle coordination, grasp, and mobility.Resident's cognitive ability, i.e. alertness.Any periods of confusion.Behavioral problems.For residents who are incapable of keeping or possessing smoking paraphernalia.will be kept the licensed staff.

Based on observation, interview, and record review, the facility failed to provide food storage and preparation in accordance with professional standards for food safety for the 74 residents who received facility prepared meals when:An opened and unlabeled food item was found in one of the freezers, and;Multiple temperature logs were found with missing documentation.These failures had the potential to place residents who ate the facility prepared meals at risk for foodborne illnesses.Findings:1. During a concurrent observation and interview during the initial kitchen tour on 6/16/26, at 9:10 a.m., with the Dietary Supervisor (DS), the DS confirmed the stand-up freezer was found with one bag of opened whipped cream that was unlabeled. The DS stated the kitchen staff were supposed to have labeled food items upon opening and before putting them back in the freezer.During an interview on 6/18/26, at 3:37 p.m., with the Registered Dietician (RD), the RD stated it was her expectation for the kitchen staff to have labeled opened food items with both the open date and use by date. The RD further stated it was important for staff to properly label opened food items because it could be easily forgotten. The RD stated the risk of improper labeling of opened food items could be providing food to the residents that were not nutritionally complete or food could have developed decay or bacteria.A review of the facility's policy titled, Labeling and Dating of Foods, dated 1/21/26, indicated, .Policy: All food items in the storeroom, refrigerator and freezer will be labelled and dated.Procedures.Newly opened foods will be closed and labeled with an open date and use-by date.A review of the facility's undated policy titled, PROCEDURE FOR FREEZER STORAGE, indicated, .PROCEDURE.6. All frozen food should be labeled and dated. 2a. During a concurrent interview and record review on 6/16/26, at 9:05 a.m., with the DS, the Quaternary Ammonium (chemical sanitizer used to kill bacteria, viruses, and fungi on food- contact surfaces) Log was reviewed. The DS confirmed the log had missing documentation readings for AM (morning) shift for dates 6/13/26, 6/14/26, 6/15/26 and 6/16/26, and PM (afternoon) shift for 6/15/26. The DS stated the dietary aides or the cook scheduled to work could have checked and document the readings. The DS further stated it was her expectation for these checks to have been done in the morning and afternoon timeframes.During a concurrent interview and record review on 6/18/26, at 3:37 p.m., with the RD, the Quaternary Ammonium Log was reviewed. The RD stated the staff should have checked the temperatures when they made the sanitizing solution. The RD further stated the risk of not checking the sanitizing solution would have been the solution not being as effective in killing surface bacteria with the possibility of cross contamination.A review of the facility's undated policy titled, QUATERNARY AMMONIUM LOG POLICY, indicated, .POLICY: The concentration of the ammonium in the quaternary sanitizer will be tested to ensure the effectiveness of the solution.PROCEDURE.Food and Nutrition Services staff will record the readings twice a day, once in the AM and once in the PM, to document the process was completed. 2b. During a concurrent interview and record review on 6/16/26, at 8:48 a.m., with the DS, the Cold Storage Temperature logs for both the freezer and refrigerator were reviewed. The DS confirmed missing logged information or readings were found on both temperature logs for 6/15/26 for both AM and PM readings and AM reading for 6/16/26. The DS stated the cook was supposed to check the temperature before the breakfast and lunch meals were prepared.A review of the facility's undated policy titled, COLD STORAGE TEMPERATURE MONITORING AND RECORD KEEPING, indicated, .POLICY: Food & Nutrition staff shall review and record temperatures of all refrigerators and freezers to ensure they are at the correct temperature for food storage and handling.PROCEDURE.2. Food & Nutrition Services staff will record and initial the temperatures.at the beginning of the AM and PM shifts. 2c. During a concurrent interview and record review on 6/16/26, at 9:20 a.m., with the Assistant Dietary Supervisor (ASD), the Dish Machine Temperature Log was reviewed. The ASD confirmed missing documentation or readings for dates 6/15/26 for breakfast, lunch and dinner timeframes and 6/16/26 for breakfast readings. The ASD stated the staff should have checked the temperatures readings were correct and to have ensured the sanitizer was working.During a concurrent interview and record review on 6/18/26, at 3:37 p.m., with the RD, the Cold Storage Temperature logs and Dish Machine Temperature logs were reviewed. The RD stated it was her expectation for the kitchen staff to have checked for the temperatures for the shifts indicated on the forms. The RD further stated the risk of not checking the temperatures would be for the temperature to have increased and any food contained could potentially have bacterial growth creating a food hazard for the residents.A review of the facility's undated policy titled, DISHWASHING, indicated, .PROCEDURE:.8. A temperature log (and chorine log for low-temperature machines) will be kept and maintained by the dishwasher to assure that the dish machine is working correctly. This log will be completed each meal prior to any dishwashing.

Based on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control practices for 5 of 28 sampled residents (Resident 52, Resident 1, Resident 14, Resident 37, and Resident 81) when:Staff failed to perform hand hygiene (cleaning hands with soap and water or alcohol-based hand sanitizer to remove germs and prevent the spread of infection) between delivering meal trays to Resident 52 and Resident 1, and;Multiple urinals (portable, handheld containers designed for men with limited mobility to urinate while in bed or seated) used by Resident 14, Resident 37, and Resident 81 were not labeled.These failures had the potential to spread infection and cause adverse health outcomes for residents in the facility. Findings: 1. During a concurrent observation and interview on 6/16/26, at 12:30 PM, with Certified Nursing Assistant (CNA) 4 in the hallway outside Resident 1's and Resident 52's shared room, CNA 4 delivered a meal tray to Resident 52, placed the meal tray on Resident 52's over-bed table, and assisted Resident 52 with meal set-up (helped prepare the meal so the resident could eat). CNA 4 then exited the shared room without performing hand hygiene, opened the meal cart in the hallway, picked up the meal tray for Resident 1, returned to the shared room, placed the meal tray on Resident 1's over-bed table, and assisted Resident 1 with meal set-up. CNA 4 then exited the shared room without performing hand hygiene. CNA 4 stated she did not perform hand hygiene between delivering meal trays to Resident 52 and Resident 1 or after exiting the shared room. CNA 4 further stated that failure to perform hand hygiene between meal tray deliveries and after exiting residents' rooms was an infection control concern because germs on staff's hands could contaminate food and spread infection. During an interview on 6/18/26, at 11:51 AM, with the Director of Nursing (DON), the DON stated that staff were expected to perform hand hygiene between delivering meal trays to different residents and before entering and after exiting residents' rooms to prevent the spread of infection. Review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 2001, indicated .This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Hand hygiene is indicated.after touching the resident's environment . 2a. During a concurrent observation and interview on 6/16/26, at 9:51 AM, with Licensed Nurse (LN) 4, Resident 14's urinal was observed. LN 4 confirmed that Resident 14's urinal was dirty and not labeled with identifying information and should have been labeled. LN 4 stated that her expectation was for urinals to be labeled. LN 4 further stated that urinals should have been emptied right away and not have urine still in them. LN 4 stated that it was an infection control risk having urinals in active use without them being labeled. LN 4 further stated that urinals could get switched or mixed up and posed cross-contamination (the transfer of harmful bacteria, viruses, or allergens from one surface, object, or person to another) risks for the residents. 2b. During a concurrent observation and interview on 6/16/26, at 9:52 AM, with LN 4, Resident 37's two urinals were observed. LN 4 confirmed that Resident 37's urinals were dirty and not labeled with identifying information and should have been labeled. 2c. During a concurrent observation and interview on 6/16/26, at 10:09 AM, with CNA 5, Resident 81's urinal was observed. CNA 5 confirmed that Resident 81's urinal was not labeled with identifying information and should have been labeled. CNA 5 stated that the urinals could get mixed up with other residents who have urinals and cause contamination. During an interview on 6/16/26, at 10:14 AM, with the Director of Staff Development (DSD), the DSD stated that urinals should have been cleaned or replaced if they were too dirty to be cleaned. The DSD further stated that the urinals should have been labeled with the residents' initials or room number. The DSD stated that infection control and cross-contamination could be a huge problem for the residents. During an interview on 6/18/26, at 9:25 AM, with the Infection Preventionist Assistant (IPA), the IPA stated that residents could get sick if the urinals were to be mixed up and potentially cause the residents to develop urinary tract infections (UTIs- are bacterial infections that affect any part of the urinary system, most commonly the bladder and urethra). The IPA further stated the urinals should have been labeled so that the staff would know which resident they belonged to. During an interview on 6/18/26, at 3:22 PM, with the DON, the DON stated that her expectation was for urinals to have been labeled for each individual resident. The DON further stated that if the urinals were not labeled, they could get commingled or mixed up. The DON stated that if urinals were labeled, it would be easy to identify who they belonged to. During a review of the facility's undated P&P titled, Policies and Procedures - Infection Prevention and Control, the P&P indicated, .maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public . During a review of the facility's undated P&P titled, POLICY AND PROCEDURE ON LABELING OF PERSONAL ITEMS/PERSONAL EFFECTS, the P&P indicated, .Residents shall have adequate supply of personal items/personal effects necessary to perform some aspect of daily living (i.e. personal hygiene).Residents identified to be in need of such items or materials shall be given appropriate assistance to ensure that adequate supply is secured.

Based on interview, and record review, the facility failed to provide education, offer, and document the influenza (commonly known as the the flu, a contagious viral infection that attacks the respiratory system, including the nose, throat, and lungs) vaccinations and pneumococcal (a serious bacterial infection caused by Streptococcus pneumoniae. It spreads via respiratory droplets and can lead to severe illnesses like pneumonia, meningitis, and bloodstream infections) vaccinations for 4 of 5 sampled residents (Resident 27, Resident 81, Resident 37, and Resident 14) when:The influenza vaccine was not given, and education was not provided for Resident 27, Resident 81, and Resident 37, and;The pneumococcal vaccine was not given, and education was not provided for Resident 81, Resident 37, and Resident 14.This deficient practice placed Resident 27, Resident 81, Resident 37, and Resident 14 at higher risk of acquiring and transmitting complications from the influenza and pneumococcal diseases and violated the residents and/or responsible parties' rights to make an informed decision.Findings:1a. During a concurrent interview and record review on 6/17/26, at 3:30 PM, with the Infection Preventionist Assistant (IPA), Resident 27's Electronic Health Record (EHR) and medical chart were reviewed. The IPA confirmed that there was no evidence of the influenza vaccine being offered during the flu season in late 2025/early 2026 or education being provided to Resident 27.1b. During a concurrent interview and record review on 6/17/26, at 3:43 PM, with the IPA, Resident 81's EHR and medical chart were reviewed. The IPA confirmed that there was no evidence of the influenza vaccine being offered during the flu season in late 2025/early 2026 or education being provided to Resident 81.1c. During a concurrent interview and record review on 6/17/26, at 3:46 PM, with the IPA, Resident 37's EHR and medical chart were reviewed. The IPA confirmed that there was no evidence of the influenza vaccine being offered during the flu season in late 2025/early 2026 or education being provided to Resident 37.During a review of the facility's undated policy and procedure (P&P) titled, Influenza Vaccine, the P&P indicated, .All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents (or residents' legal representatives).Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents.Prior to the vaccination, the resident (or resident's legal representative) or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine.Provision of such education shall be documented in the resident's/employee's medical record.A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record.2a. During a concurrent interview and record review on 6/17/26, at 3:43 PM, with the IPA, Resident 81's EHR and medical chart were reviewed. The IPA confirmed that there was no evidence of the pneumococcal vaccine being offered or education being provided to Resident 81.2b. During a concurrent interview and record review on 6/17/26, at 3:46 PM, with the IPA, Resident 37's EHR and medical chart were reviewed. The IPA confirmed that there was no evidence of the pneumococcal vaccine being offered or education being provided to Resident 37.2c. During a concurrent interview and record review on 6/17/26, at 3:48 PM, with the IPA, Resident 14's EHR and medical chart were reviewed. The IPA confirmed that there was no evidence of the pneumococcal vaccine being offered or education being provided to Resident 14.During an interview on 6/18/26, at 9:41 AM, with the IPA, the IPA stated that it was her expectation for the influenza and pneumococcal vaccines to be offered and education given upon the residents' admission to the facility. The IPA further stated that the residents should have been provided with education on the vaccines so they could make the best decisions for their health. The IPA stated that influenza vaccines were important to prevent the development of the flu.During an interview on 6/18/26, at 9:50 AM, with the Admissions Coordinator (AC), the AC stated that immunizations were not offered as part of the initial admission packet when residents were admitted to the facility. During an interview on 6/18/26, at 3:22 PM, with the Director of Nursing (DON), the DON stated that it was important for the residents at the facility to receive the influenza and pneumococcal vaccinations to help prevent the diseases. The DON further stated that it was important to educate the residents on the risks and benefits so they could make informed decisions to receive the vaccines or not. The DON stated that the staff should have documented the education being provided for the residents on their EHR or medical chart.During a review of the facility's undated P&P titled, Pneumococcal Vaccine, the P&P indicated, .All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections.Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series.Assessments of pneumococcal vaccination status are conducted within five (5) working days of the resident's admission if not conducted prior to admission.Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine.Provision of such education is documented in the resident's medical record.Residents/representatives have the right to refuse vaccination. If refused, appropriate information is documented in the resident's medical record indicating the date of the refusal of the pneumococcal vaccination.

Based on interview, and record review, the facility failed to provide education, offer, and document Covid-19 (Coronavirus Disease 2019, a respiratory viral infection that affects primarily the lungs and results in coughing and difficulty breathing) vaccinations for four (4) of five (5) sampled residents (Resident 27, Resident 81, Resident 37, and Resident 14).This deficient practice placed the residents and staff at risk for possible Covid-19 infection due to missed vaccination dosage and violated the residents and/or responsible parties' rights to make an informed decision.Findings:a. During a concurrent interview and record review on 6/17/26, at 3:30 PM, with the Infection Preventionist Assistant (IPA), Resident 27's Electronic Health Record (EHR) and medical chart were reviewed. The IPA confirmed that there was no evidence of the Covid-19 vaccine being offered or education being provided to Resident 27.b. During a concurrent interview and record review on 6/17/26, at 3:43 PM, with the IPA, Resident 81's EHR and medical chart were reviewed. The IPA confirmed that there was no evidence of the Covid-19 vaccine being offered or education being provided to Resident 81.c. During a concurrent interview and record review on 6/17/26, at 3:46 PM, with the IPA, Resident 37's EHR and medical chart were reviewed. The IPA confirmed that there was no evidence of the Covid-19 vaccine being offered or education being provided to Resident 37.d. During a concurrent interview and record review on 6/17/26, at 3:48 PM, with the IPA, Resident 14's EHR and medical chart were reviewed. The IPA confirmed that there was no evidence of the Covid-19 vaccine being offered or education being provided to Resident 14.During an interview on 6/18/26, at 9:45 AM, with the IPA, the IPA stated that it was her expectation for the Covid-19 vaccine to be offered and education given upon the residents' admission to the facility. The IPA further stated that residents should have been provided with education on Covid-19 so they could make the best decisions for their health.During an interview on 6/18/26, at 9:50 AM, with the Admissions Coordinator (AC), the AC stated that immunizations were not offered as part of the initial admission packet when residents were admitted into the facility. During an interview on 6/18/26, at 3:22 PM, with the Director of Nursing (DON), the DON stated that it was important for the residents at the facility to receive the Covid-19 vaccine to help prevent against the disease. The DON further stated that it was important to educate the residents on the risks and benefits so they could make informed decisions to receive the vaccine or not. The DON stated that staff should have documented the education being provided for the residents on their EHR or medical chart.During a review of the facility's policy and procedure (P&P) titled, Coronavirus Disease (COVID-19) - Vaccination of Residents, revised 5/23, the P&P indicated, .Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident is fully vaccinated .COVID-19 vaccine education, documentation and reporting are overseen by the infection preventionist and coordinated by his or her designee.Before the COVID-19 vaccine is offered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine.The resident's medical record includes documentation that indicates, at a minimum, the following: .That the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine.If the resident did not receive the COVID-19 vaccine due to medical contraindications, prior vaccination or refusal, appropriate documentation is made in the resident's record.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for 3 of 28 sampled residents (Residents 24, 70, and 84) when:Resident 24 was observed lying in bed without lower body clothing or a covering and was visible from the hallway and through the room window while wearing only a fully soaked incontinent brief (a disposable undergarment designed to absorb urine and stool).Certified Nursing Assistant (CNA) 4 stood over Resident 70 and CNA 3 stood over Resident 84 while assisting with meals and did not position themselves at the residents' eye level.These failures had the potential to negatively affect the residents' dignity, privacy, psychosocial well-being (emotional and social functioning), and quality of life. Findings: 1. Review of Resident 24's 'admission RECORD' indicated Resident 24 was admitted to the facility with diagnoses of dementia (a condition that affects memory, thinking, and decision-making), pseudobulbar affect (a condition that causes sudden, uncontrollable episodes of laughing or crying), conduct disorder (a condition characterized by behavioral problems), and other symptoms and signs involving appearance and behavior. Review of Resident 24's Brief Interview for Mental Status (BIMS-to assess a resident's thinking and memory) dated 6/17/26 indicated Resident 24 had a BIMS score of 10, which showed Resident 24 had moderately impaired cognition (the ability to think, understand, remember, and make decisions; 13-15 = Intact, 8-12 = Moderate, 0-7 = Severe). Review of Resident 24's Task: B&B - Bladder Elimination (urination and bladder control). dated 6/1/26 through 6/18/26 indicated Resident 24 was incontinent of bladder most of the time, with three episodes of continence (able to control bladder function). Review of Resident 24's Task: ADL (Activities of Daily Living - routine self-care activities) - Toilet Use dated 6/1/26 through 6/18/26 indicated Resident 24 was totally dependent (required full staff assistance) for cleaning after elimination, changing pads, and adjusting clothing most of the time, with five episodes requiring limited assistance (resident performed most of the activity with some staff assistance). During a concurrent observation and interview on 6/17/26 at 9:14 AM with Licensed Nurse (LN) 1 in the hallway outside Resident 24's room, Resident 24 was visible from the hallway while lying in bed without lower body clothing or a covering, exposing the incontinent brief that Resident 24 was wearing. Resident 24's bed was positioned next to a large glass window, allowing Resident 24 to be visible from the parking lot outside the facility while wearing only an incontinent brief. LN 1 stated that Resident 24 should not be left uncovered because it was a dignity issue, as individuals in the hallway and outside the facility could see Resident 24 wearing an incontinent brief. Resident 24 stated that he needed his brief changed and had last been assisted with incontinent care at 4 AM, approximately five hours before the observation. LN 1 confirmed that Resident 24's incontinent brief was fully soaked and stated that it needed to be changed to prevent skin breakdown (damage to the skin caused by prolonged exposure to moisture). During a concurrent observation and interview on 6/17/26 at 4:09 PM with Certified Nursing Assistant (CNA) 2 in the hallway outside Resident 24's room, Resident 24 was sleeping in bed without lower body clothing or a covering and was visible from both the hallway through the entrance door and outside through the large window. CNA 2 stated that Resident 24 should be covered and not exposed while wearing an incontinent brief to maintain privacy and dignity. During an interview on 6/18/26 at 8:23 AM with Certified Nursing Assistant (CNA) 3, CNA 3 stated that she was assigned to Resident 24 during the AM shift on 6/17/26. CNA 3 stated that she did not change Resident 24's incontinent brief before 9 AM on 6/17/26 because Resident 24 did not ask to be changed. CNA 3 further stated that she was not aware of the last time Resident 24 had been changed before the AM shift on 6/17/26. During an interview on 6/18/26 at 9:03 AM with the Director of Nursing (DON), the DON stated that staff were expected to check on residents every two hours, or more frequently as needed, including determining whether residents required incontinent care. The DON stated that leaving residents wet or soiled in an incontinent briefs and exposing them to view by others while wearing those briefs was a dignity issue and increased the risk for skin breakdown and urinary tract infections (UTIs - infections involving the bladder, kidneys, or urinary system). The DON further stated that staff were expected to maintain residents' privacy and dignity by ensuring residents were appropriately covered. Review of the facility's undated policy and procedure titled, POLICY AND PROCEDURE ON PROVIDING ASSISTANCE WITH ADL CARE, indicated, .Always check with the resident if he or she is doing all right in his or her ADL care.Provide privacy at all times. Review of the facility's undated policy and procedure titled, DIGNITY AND RESPECT, indicated .Privacy of a resident body shall be maintained. 2. Review of Resident 70's 'admission RECORD' indicated Resident 70 was admitted to the facility with diagnoses of seizures, stimulant dependence (physical or psychological reliance on stimulant drugs), schizoaffective disorder (a mental health disorder characterized by symptoms of schizophrenia, such as hallucinations or delusions, along with mood disorder symptoms), cerebral infarction (stroke), and major depressive disorder. Review of Resident 70's Brief Interview for Mental Status (BIMS-to assess a resident's thinking and memory) dated 5/22/26 indicated Resident 70 had a BIMS score of 7, which showed Resident 70 had severe cognitive impairment. Review of Resident 70's Task: ADL (Activities of Daily Living - routine self-care activities) - Eating dated 6/1/26 through 6/18/26 indicated Resident 70 was totally dependent (required full staff assistance) for eating. During a concurrent observation and interview on 6/16/26 at 12:40 PM with LN 2 in the hallway outside Resident 70's room, Resident 70 was lying in bed with the head of the bed elevated while CNA 4 assisted Resident 70 with meals while standing over Resident 70 at the side of the bed. LN 2 stated CNA 4 was not at eye level while assisting Resident 70 with meals. LN 2 further stated staff should position themselves at eye level when assisting residents with meals to promote dignity because standing over residents may cause them to feel intimidated, disrespected, or belittled. Review of Resident 84's 'admission RECORD' indicated Resident 84 was admitted to the facility with hemiplegia and hemiparesis following cerebral infarction (paralysis and weakness on one side of the body following a stroke), moderate protein-calorie malnutrition (inadequate intake of protein and calories resulting in poor nutritional status), dysphagia (difficulty swallowing), other symptoms and signs involving the musculoskeletal system (problems affecting the muscles, bones, or movement), type 2 diabetes mellitus, and cerebral insufficiency (reduced blood flow to the brain). Review of Resident 84's Brief Interview for Mental Status (BIMS-to assess a resident's thinking and memory) dated 3/30/26 indicated Resident 84 had a BIMS score of 7, which showed Resident 84 had severe cognitive impairment. Review of Resident 84's Task: ADL (Activities of Daily Living - routine self-care activities) - Eating dated 6/1/26 through 6/17/26 indicated Resident 84 was totally dependent (required full staff assistance) for eating. During a concurrent observation and interview on 6/18/26 at 8:19 AM with the Director of Staff Development (DSD) in the hallway outside Resident 84's room, Resident 84 was lying in bed with the head of the bed elevated while CNA 3 assisted Resident 84 with the meal. CNA 3 was standing over Resident 84 and was not at eye level while assisting at the bedside. The DSD stated CNA 3 should have been seated on a stool at eye level with Resident 84 to promote engagement, prevent Resident 84 from feeling rushed, and promote dignity. During an interview on 6/18/26 at 8:23 AM with CNA 3, CNA 3 acknowledged that she stood over Resident 84 while assisting Resident 84 with the meal which was a dignity issue. During an interview on 6/18/26 at 12:03 PM with the DON, the DON stated staff were expected to be at eye level with residents when assisting with feeding to promote safety, encourage engagement, and maintain resident dignity, and avoid appearing authoritative. Review of the facility's undated policy and procedure titled, DIGNITY AND RESPECT, indicated .It is the policy of this facility that all residents be treated with kindness, dignity and respect .The staff shall display respect for residents when.caring for.as constant affirmation of their individuality and dignity as human beings.

Based on interview, and record review, the facility failed to ensure a resident was properly informed of and consented to the use of psychotherapeutic medications (medications used to control behavior or treat thought disorders) for 1 of 28 sampled residents (Resident 52), when Resident 52's informed consent for olanzapine (an antipsychotic medication used to treat mental health conditions that affect a person's thinking, mood, behavior, or perception of reality), signed on 1/22/25, was not renewed within the required timeframe while Resident 52 continued to receive the medication.This failure had the potential to violate Resident 52's right to make informed decisions regarding psychotherapeutic medication use, including understanding the benefits of medication, risks, side effects, and alternative treatment options.Findings:Review of Resident 52's admission RECORD, indicated Resident 52 was admitted to the facility with diagnoses including unspecified psychosis, schizophrenia (a mental health disorder characterized by disturbances in thinking, perception, and behavior), bipolar disorder (a mental health disorder characterized by episodes of mood changes ranging from depression to elevated mood), cerebral infarction (brain damage caused by interrupted blood flow to the brain, also known as a stroke), lack of coordination, and other symptoms and signs involving the musculoskeletal system.Review of Resident 52's Brief Interview for Mental Status (BIMS-to assess a resident's thinking and memory) dated 4/13/26, indicated Resident 52 had a BIMS score of 15, which showed Resident 52 had intact cognition (13-15 = Intact, 8-12 = Moderate, 0-7 = Severe).Review of Resident 52's Medication Administration Record (MAR, a document that indicates what medications have been ordered, given, or held), dated 6/1/26 through 6/17/26, indicated Resident 52 received olanzapine 2.5 milligram (mg - unit measure) at 9 PM daily from 6/1/26 through 6/17/26.During a concurrent interview and record review on 6/18/26, at 10:12 AM, with the Director of Nursing (DON), Resident 52's FACILITY VERIFICATION OF RESIDENT INFORMED CONSENT TO PSYCHOTROPIC MEDICATIONS [Informed Consent], for olanzapine dated 1/22/25 was reviewed. The DON stated that 1/22/25 was the last date informed consent for olanzapine was obtained from Resident 52. The DON acknowledged that the informed consent for the psychotherapeutic medication olanzapine was not renewed as required despite Resident 52's continued use of the medication. The DON further acknowledged that antipsychotic medications such as olanzapine could cause adverse reactions, especially in elderly residents. The DON acknowledged that renewing informed consents ensured residents were informed of the medication's risks and benefits and could make informed decisions about continued treatment. The DON stated she was not aware of the requirement to renew the informed consent for the psychotherapeutic medication olanzapine every six months.Review of the facility's undated policy and procedure titled, POLICY AND PROCEDURE ON CONSENT, indicated, .In accordance with state and federal regulations, and in adherence with patient's bill of rights, facility shall obtain consent, whereby applicable and indicated, from resident.for administration of treatment.

Based on observation, interview, and record review, the facility failed to accommodate the needs of 1 of 28 sampled residents (Resident 1) when Resident 1 had a call light (device used to contact staff for assistance) that was not within Resident 1's reach.This deficient practice placed Resident 1 at increased risk for unmet care needs, delayed staff response, falls, and potential injury.Findings:Review of Resident 1's 'admission RECORD' indicated Resident 1 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (a long term lung disease that causes ongoing breathing problems), asthma (a lung condition that causes episodes of breathing difficulty when the airways narrow), muscle weakness, cerebral infarction (stroke caused by interrupted blood flow to the brain), schizophrenia (a mental health disorder that affects thinking and perception), bipolar disorder (a mental health condition causing extreme mood changes), major depressive disorder (persistent feelings of sadness and loss of interest), anxiety disorder (excessive worry or fear), insomnia (difficulty sleeping), hemiplegia and hemiparesis (paralysis or weakness on one side of the body), and low back pain.Review of Resident 1's Brief Interview for Mental Status (BIMS-to check a resident's thinking and memory) dated 6/12/26, Resident 1 BIMS score was 15 which showed that Resident 1 had intact cognition (13-15 = Intact, 8-12 = Moderate impairment, 0-7 = Severe impairment).During a concurrent observation and interview on 6/16/26 at 11:11 AM with Resident 1 in Resident 1's room, Resident 1 was lying in bed. Resident 1's call light was wrapped around the right half bedside rail, hanging toward the floor, and was not within Resident 1's reach. Resident 1 stated that she could not find her call light and that there were other times when she was unable to reach it.During a concurrent observation and interview on 6/16/26 at 11:19 AM with Certified Nursing Assistant (CNA) 1 in Resident 1's room, Resident 1's call light remained wrapped around the right half bed side rail and hanging toward the floor. CNA 1 stated that Resident 1's call light was not within Resident 1's reach and that could result in delayed staff assistance, unmet needs, and an increased risk for falls if Resident 1 attempted to get out of bed without assistance. During an interview on 6/16/26 at 4:17 PM with the Director of Nursing (DON), the DON stated that residents' call lights should always be within residents' reach. The DON further stated that residents being unable to reach their call lights posed a safety risk and increased the risk of falls.Review of undated facility's policy and procedure (P&P), titled POLICY AND PROCEDURE ON CALL LIGHT, indicated .Keep call light within easy reach of the resident.

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS - a standardized assessment used to evaluate a resident's physical, mental, and functional status and identify care needs) discharge assessment was completed, encoded (entered into the facility's MDS software), and transmitted (electronically submitted and accepted into the federal MDS system) within the required timeframe for 1 of 28 sampled residents (Resident 41), when Resident 41 was discharged from the facility on 3/6/26.This failure had the potential to result in incomplete resident assessment information and inaccurate information regarding the resident's discharge status being reported to the Centers for Medicare and Medicaid Services (CMS). Findings:Review of Resident 41's admission RECORD indicated Resident 41 was admitted to the facility with diagnoses of orthopedic after care following surgical amputation (care provided after surgical removal of a body part), acute osteomyelitis right ankle and foot (a bone infection of the right ankle and foot), and type 2 diabetes mellitus (a condition in which the body does not properly regulate blood sugar levels) and was discharged on 3/6/26.During a concurrent interview and record review on 6/18/26 at 4:21 PM with the Minimum Data Set Coordinator Nurse (MDSC - a nurse responsible for completing resident assessments for care planning and reporting), Resident 41's MDS tracking (a record used to monitor the completion and submission status of MDS assessments) was reviewed. Resident 41's MDS tracking indicated that the last MDS assessment completed was an admission assessment dated [DATE], which was transmitted and accepted by CMS, and there were no further MDS assessments documented after the admission assessment. The MDSC confirmed that no additional MDS assessments were completed after 1/13/26 and that Resident 41 was discharged from the facility on 3/6/26. The MDSC stated that an MDS discharge assessment was not completed upon Resident 41's discharge, resulting in the facility being unable to encode and transmit the required discharge assessment to CMS. The MDSC further stated that failure to complete an MDS assessment could result in inaccurate information regarding the resident's status being reported to CMS.During an interview on 6/19/26 at 9:39 AM with the Director of Nursing (DON), the DON stated that the facility was expected to complete MDS assessments, including MDS discharge assessments, and transmit them to CMS by the required due date. The DON further stated that failure to complete MDS discharge assessments and transmit them to CMS could result in inaccurate resident assessments, inaccurate data being reported to CMS, and could affect billing.Review of the facility's undated policy and procedure titled, Minimum Data Set (MDS) Completion, Tracking, and Transmission Policy indicated .It is the policy of this Skilled Nursing Facility (SBF) to ensure the timely, accurate, complete, and compliant completion, tracking, submission, correction, and transmission of all Minimum Data Set (MDS) assessments in accordance with Centers for Medicare & Medicaid Services (CMS), state regulations.

Based on observation, interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR - a required screening process used to identify residents with serious mental illness or intellectual disabilities and determine whether they need specialized services) was completed for 1 of 28 sampled residents (Resident 17) when Resident 17's PASRR completed on 9/25/23 determined Resident 17 did not require a PASRR Level II evaluation (an in-depth evaluation to determine the need for specialized mental health services), but Resident 17 was later prescribed risperidone (an antipsychotic medication used to treat certain mental health conditions) on 9/30/25 due to increased behavioral symptoms and was not referred for PASRR review.This failure had the potential for Resident 17 not to be properly evaluated for specialized mental health services and not to receive the care and services appropriate to the resident's needs. Findings:Review of Resident 17's admission RECORD, indicated Resident 17 was admitted to the facility with diagnosis including schizophrenia (a mental health disorder characterized by disturbances in thinking, perception, and behavior) and cerebral infarction (brain damage by interrupted blood flow to the brain, also known as a stroke).Review of Resident 17's Brief Interview for Mental Status (BIMS-to assess a resident's thinking and memory) dated 5/29/26 indicated Resident 17 had a BIMS score of 9, which showed Resident 17 had moderately impaired cognition (13-15 = Intact, 8-12 = Moderate, 0-7 = Severe).Review of Resident 17's UNABLE TO COMPLETE LEVEL II EVALUATION Letter dated 9/15/23 indicated that Resident 17 did not require a PASRR Level II evaluation because Resident 17 did not have a serious mental illness.Review of Resident 17's Medication Administration Record (MAR) for 6/1/26 through 6/17/26, Resident 17 received risperidone1 milligram (MG - unit measure) daily at 9 PM from 6/1/26 through 6/17/26 for schizophrenia manifested by paranoia and thoughts that food and medications were poisoned, with a start date of 9/30/25.Review of Resident 17's Care Plan, initiated on 11/10/25, in the section titled Focus, indicated .[Resident 17] The resident has potential to be verbally aggressive and has angry outburst as manifested by yelling at her husband. Mood swings, purposeless screaming, exaggerated range no reasons.During a concurrent interview and record review on 6/17/26 at 4:48 PM with the Director of Nursing (DON), Resident 17's PASRR Level I Screening dated 9/14/23 was reviewed. Resident 17's PASRR Level I Screening (an initial screening to determine if further evaluation is needed), in the section titled Section III - Serious Mental Illness - Definition, indicated that risperidone was not documented as a prescribed psychotropic medication. The DON stated risperidone was not documented because the PASRR evaluation was completed before Resident 17 exhibited new behaviors, including paranoia and angry outbursts, and before risperidone was prescribed on 9/30/25, approximately two years after the PASRR evaluation dated 9/15/23. The DON acknowledged the facility failed to complete a PASRR review following Resident 17's increase in behaviors and stated this was a safety risk because Resident 17 was not evaluated to determine whether the facility could safely manage Resident 17's behavioral and mental health needs, and no recommendations were obtained regarding specialized mental health services and interventions to address Resident 17's increased behaviors.Review of the facility's policy and procedure dated titled, Pre-admission SCREENING RESIDENT REVIEW (PASRR) dated 8/2000, indicated .Change in Health Status.resident experiences a significant change in health status.or physical status.must complete a new PASRR form.refer immediately for a Level II determination. This applies as well to the NF [Nursing Facility] resident whose initial Level I did not require a referral for Level II determination, but who has experienced a significant change in health status that raises a question of possible change in the resident's MI/MR [Mental Illness/Mental Retardation] status.

Based on observation, interview, and record review, the facility failed to update the care plan with appropriate, resident-specific fall interventions for 1 of 28 sampled residents (Resident 75) following a fall on 5/12/26 when the Interdisciplinary Team (IDT - a group of healthcare professionals from different disciplines who collaborate to provide resident care) did not complete a root cause analysis or identify recommendations related to the cause of the fall, and nursing staff did not complete post-fall monitoring to identify risks and develop resident-specific interventions to prevent future falls.These failures had the potential to place Resident 75 at risk for recurrent falls and injury. Findings:Review of Resident 75's admission RECORD indicated Resident 75 was admitted to the facility with diagnoses including muscle weakness, other symptoms and signs involving the musculoskeletal system, type 2 diabetes mellitus, major depressive disorder, hemiplegia and hemiparesis following cerebral infarction (partial or complete weakness or paralysis on one side of the body following a stroke), transient alteration of awareness (temporary episodes of confusion or changes in alertness), dementia (a condition that affects memory, thinking, and decision-making), parkinsonism (a condition that causes movement problems such as tremors, stiffness, and slow movements), and gout (a painful type of arthritis caused by a buildup of uric acid crystals in the joints).Review of Resident 75's Brief Interview for Mental Status (BIMS, an assessment used to evaluate a resident's thinking and memory) dated 6/17/26 indicated Resident 75 had a BIMS score of 10, which indicated moderately impaired cognition (13-15 = intact, 8-12 = moderate impairment, 0-7 = severe impairment).Review of Resident 75's FALL RISK ASSESSMENT (an assessment used to identify a resident's risk for falling) dated 6/1/26 indicated Resident 75 had a total score of 13. The assessment indicated that a score greater than 10 represented a high risk for falls. Resident 75 was considered at high risk for falls.Review of Resident 75's progress notes dated 5/12/26 at 3:54 PM indicated that on 5/12/26, at approximately 2:20 PM, staff heard yelling for help in the therapy room and found Resident 75 on the floor. Resident 75 stated that he wanted to climb the stairs but lost his balance when he attempted to get up from his wheelchair.During an observation on 6/17/26 at 10:00 AM in the therapy room, the therapy room was accessible through an unlocked door with a standard doorknob. Upon entering the therapy room, offices were located near the entrance. Therapy equipment used for exercises was located further inside the room.During a concurrent observation and interview on 6/16/26 at 12:16 PM with Certified Nursing Assistant (CNA) 7 in Resident 75's room, Resident 75 was lying in bed without water readily accessible for drinking. CNA 7 confirmed the water was not within Resident 75's reach and stated that if Resident 75 attempted to get out of bed to obtain water, he could fall because Resident 75 required assistance to get out of bed.During a concurrent interview and record review on 6/19/26 at 9:39 AM with the Director of Nursing (DON), Resident 75's IDT Post Fall note dated 5/13/26 was reviewed. The IDT Post Fall note was signed by IDT members but did not include a root cause analysis or recommendations specific to the cause of Resident 75's fall on 5/12/26. The DON confirmed the IDT Post Fall note did not identify interventions to prevent Resident 75 from independently accessing the therapy room without supervision. Resident 75's post-fall monitoring progress notes dated 5/12/26 through 5/14/26 were also reviewed with the DON. The DON confirmed post-fall monitoring documentation was missing for the 5/12/26 PM and night shifts, 5/13/26 PM shift, and 5/14/26 PM shift. The DON stated nursing staff were expected to monitor residents who experience a fall every shift for three days, with the monitoring documented in the progress notes, and acknowledged that incomplete monitoring could result in missed injuries or changes in condition. Resident 75's care plan was also reviewed with the DON. The DON confirmed Resident 75 did not have a care plan specific to the 5/12/26 fall and that the care plan was not updated to include resident-specific interventions to prevent future falls. The DON acknowledged that completing a root cause analysis and post-fall monitoring was essential to identify risks and develop a care plan with resident-specific interventions to prevent future falls.Review of the facility's undated policy and procedure titled, Fall Policy and Procedure indicated .The Interdisciplinary Team (IDT) shall investigate all falls.A root cause analysis shall be completed for.Significant incidents.Following each fall.The interdisciplinary team shall.Review the resident's risk factors.Update the care plan.Implement additional interventions as indicated.Care plan revisions shall be documented.Monitoring After a Fall.Residents shall be monitored for.Pain.Changes in mobility.Changes in cognition.Delayed signs of injury.Neurological changes.Nursing staff.Assess and monitor residents.Document findings.Implement interventions.Review of the facility's undated policy and procedure titled, POLICY AND PROCEDURE ON FALL PREVENTION AND REDUCTION indicated .Residents identified to be at risk for falls or further falls shall have plans of care developed to minimize or reduce risk factors for falls or further falls.Plans of care shall include interventions on the following.Provision of monitoring and supervision to resident to prevent fall incident.Plans of care shall be revised and updated for.Whenever resident experiences actual fall.Whenever there are changes in interventions to prevent and/or reduce fall.

Based on observation, interview, and record review, the facility failed to ensure 1 of 28 sampled residents (Resident 75) had their hydration needs addressed when Resident 75, who preferred to have water readily available at the bedside and within his reach, did not have water available to drink at the bedside.This failure had the potential to place Resident 75 at risk for dehydration (when the body does not get enough fluids to function properly), and overall decline in health.Findings:Review of Resident 75's admission RECORD, indicated Resident 75 was admitted to the facility with diagnoses including muscle weakness, other symptoms and signs involving the musculoskeletal system, type 2 diabetes mellitus (a disease that causes uncontrolled blood sugar), chronic kidney disease (long-term damage to the kidneys that affects their ability to function properly), secondary polycythemia (a condition in which the body produces too many red blood cells), major depressive disorder, hemiplegia and hemiparesis following cerebral infarction (partial or complete weakness or paralysis on one side of the body following a stroke), transient alteration of awareness (temporary episodes of confusion or changes in alertness), dementia (a condition that affects memory, thinking, and decision-making), parkinsonism (a condition that causes movement problems such as tremors, stiffness, and slow movements), and gout (a painful type of arthritis caused by a buildup of uric acid crystals in the joints).Review of Resident 75's Brief Interview for Mental Status (BIMS-to assess a resident's thinking and memory) dated 6/17/26, indicated Resident 75 had a BIMS score of 10, which showed Resident 75 had moderately impaired cognition (13-15 = Intact, 8-12 = Moderate, 0-7 = Severe).During a concurrent observation and interview on 6/16/26, at 12:03 PM, with Resident 75 in Resident 75's room, Resident 75 was lying in bed without water or other fluids within reach. Resident 75 stated he wanted water readily available at bedside and that it had not always been available when needed.During a concurrent observation and interview on 6/16/26, at 12:16 PM, with Certified Nursing Assistant (CNA) 7, in Resident 75's room, Resident 75 remained lying in bed without water readily accessible for drinking. Resident 75's water pitcher was placed on a table across from the bed and was not within Resident 75's reach. CNA 7 confirmed the water was not within Resident 75's reach and stated that if Resident 75 attempted to get out of bed to obtain water, he could fall because he required assistance to get out of bed. Resident 75 stated he wanted his water kept at bedside so he could drink whenever needed. CNA 7 stated that not having water readily available placed Resident 75 at risk for dehydration.During an interview on 6/18/26, at 11:28 PM, with the Director of Nursing (DON), the DON stated that staff were expected to ensure fluids were within residents' reach. The DON further stated if fluids were not readily accessible to residents, residents were at risk for dehydration and falls. Review of the facility's undated policy and procedure titled, POLICY AND PROCEDURES ON HYDRATION, indicated .It is the policy of this facility to maintain a resident's hydration by encouraging adequate fluid intake.As part of facility's hydration program, Certified Nursing Assistants.shall ensure provision of water pitcher by the resident's bedside.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% (% or percentage is a fraction of a number out of 100) during medication administration for a census of 78. The facility had a total of four errors out of 55 opportunities which resulted in a facility wide medication error rate of 7.27%. Medication observations were conducted over multiple days, at varied times, in random locations throughout the facility. The four medication errors were identified in three residents (Resident 72, Resident 12, Resident 15) out of 8 residents observed for medication administration observation as follows: Resident 15 was given 1000 mg (mg -is a milligram a unit of measurement) of Fish Oil (a dietary fat removed from fish) with 300 mg of omega 3 (three essential polyunsaturated [healthy Fats]) instead of the ordered 1000 mg of omega 3.Resident 12 was given [NAME]-Vite (an all-purpose multivitamin) instead of [NAME]-Vite Oral Tablet (B-complex [a group of 8 essential B vitamins] w/ C & Folic Acid [ W-with, C-Vitamin C, &-and]).The directions of administration were not followed for Resident 72's esomeprazole (a medication to reduce stomach acid), and the medication was administered with 5 ml (a unit of liquid measurement) instead of the ordered 50 ml of water ordered. LN 5 did not flush Resident 72's Gastronomy Tube (G-Tube- a tube that enters directly into the stomach) in between medication administration.These failures could contribute to unsafe medication use and inadequate treatment in the facility and have the potential to impact the health and well- being of the residents including Resident 15, Resident 12, and Resident 72.Findings:1. During a medication administration observation on 6/17/26, at 8:49 AM, with Licensed Nurse (LN) 3, LN 3 obtained a small cup to place the medication that will be used to administer medication to Resident 15. While preparing the medications LN 2 used the Medication Administration Record (MAR- A place where medication and treatment orders are placed for staff to view and administer as indicated). LN 3 removed one capsule from a bottle titled, Fish Oil 1000mg Omega -3 300mg and placed the capsule in the small cup with the rest of Resident 15's medication that was added according to the MAR. LN 3 then poured a cup of water and administered the medication to Resident 15.A review of Resident 15's electronic medical record titled, Medication Administration Record, dated 6/2026, indicated an order as follows: .Omega-3 Oral Capsule 1000 MG; Give 1 capsule by mouth one time a day for SUPPLEMENT.During a concurrent interview and record review on 6/19/26, at 1:08 PM, with LN 3, LN 3 confirmed the doctors order for Omega- 3 Oral Capsule 1000 MG for Resident 15 was not the medication administered. LN 3 further confirmed Resident 15 was administered fish oil which was not ordered and 300mg of the ordered 1,000 mg of omega-3. LN 3 explained that the medication was important for heart health. LN 3 stated the dose she administered placed the Resident 15 at risk of not receiving the full benefit of the medication.2 During a medication observation on 6/17/26, at 9:30 AM, with LN 4, LN 4 obtained a small cup to place the medication that will be used to administer the medications to Resident 12. While preparing the medications LN 4 used the MAR. LN 4 removed one tablet from a bottle titled, [NAME]-Vite Tablets Dietary Supplement., and placed that tablet in the small cup with the rest of Resident 12's medication that was added according to the MAR. LN 4 then poured a cup of water and administered the medication to Resident 12.During a record review of Resident 12's electronic medical record titled, .Medication Administration Record., dated 6/2026, indicated an order as follows: .[NAME]-Vite Oral Tablet (B-complex w/ C & Folic Acid) Give 1 tablet by mouth one time a day for supplement.During a concurrent interview and record review on 6/19/26, at 9:29 AM, with LN 4, Resident 12's MAR, dated 6/2026 was reviewed. LN 4 confirmed the doctors order for Resident 12 indicated, .[NAME]-Vite Oral Tablet (B-Complex w/ C & Folic Acid) Give 1 tablet by mouth one time a day for supplement. LN 4 then opened his medication cart and obtained the bottle of Rena Vite and confirmed the bottle used to administer Resident 12's medication did not match the doctors order. LN 4 stated this error placed Resident 12 at risk for of not receiving all of the vitamins as ordered. LN 4 further stated the medication given may have unknown components given to Resident 12.3. During a medication observation on 6/18/26, at 8:16 AM, with LN 5, LN 5 obtained multiple small cups to place each of the medications that were to be used to administer the medications to Resident 72. While preparing the medications LN 5 used the MAR. LN 5 removed one capsule from the bubble pack titled, ESOMEPRAZOLE MAG [magnesium] DR [delayed release] 40 MG., with the directions of, GIVE 1 CAPSULE VIA PEG TUBE [percutaneous endoscopic gastrostomy- a flexible feeding tube] ONCE EVERY DAY: OPEN CAPSULES AND PLACE GRANULES INTO 60ML SYRUNGE; MIX WITH 50ML OF WATER; SHAKE. LN 5 opened the capsule and added 5 ML of water to the small cup and mixed it. LN 5 then placed the small cups with the medication on it, on a tray to administer it to Resident 72. LN 5 flushed the G-Tube with 15 ML of water then administered each medication one after the other. LN 5 administered the esomeprazole mag dr 40mg mixed in 5ML of water. After administering all the medications LN 5 then flushed the tube with 15 ML of water.During a record review of Resident 72's electronic medical record titled, .Medication Administration Record., dated 6/2026, indicated an order as follows: .Esomerprazole Magnesium Oral Capsule Delayed Release 40 MG.Give 1 capsule via PEG-Tube one time a day for GERD with 50 ml of water.4. During a medication observation on 6/18/26, at 8:16 AM, LN 5 was observed giving six different medications to Resident 72 via the G-Tube (Gastric Tube). LN 5 was observed flushing the G-tube with 15ml of water prior to medication administration. LN 5 did not flush the G-tube in between the 6 medications she administered. LN 5 flushed the G-tube line with 15 ML at the end of last medication she administered.During an interview on 6/19/26, at 9:39 AM, with LN 5, LN 5 acknowledged that she administered Resident 72's morning medications via G-Tube without a flush in between. LN 5 stated she believed that the flush should only be before and after the medications were administered. LN 5 further stated Resident 72's G-tube line could have gotten clogged without adequate flushing in-between medications and Resident 72 could become dehydrated.During an interview on 6/19/26, at 8:29 AM, with the Director of Nursing (DON), the DON stated she expect her nurses to follow the proper guidelines to administer medication. The DON stated she expect the licensed nurses to administer the medication as ordered by the doctor. The DON further stated it was the facility's policy that when multiple g-tube medications were being administered, 30 ml of water should be given before and after administration of the medications. The DON stated the nurses needed to flush the g-tube with 15 ml in between each medication administered. The DON further stated this helped with proper absorption of the medications. The DON stated giving the wrong or missing a medication placed the resident at risk for not receiving the intended treatment.A review of the facility's policy and procedure titled, .MEDICATION ADMINISTRATION-GENERRAL GUIDELINES., dated 8/1/19, indicated, .Policy Medications re-administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.FIVE RIGHTS- Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication of administration.Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 rights.A review of the facility's policy and procedure titled, .GENERAL GUIDELINES FOR ADMINISTERING MEDICATIAONS VIA ENTERAL TUBE., dated 8/1/19, indicated, .The facility assures the safe effective administration of enteral formulas and medication via enteral tubes.Enteral tubes are flushed with at least 15 ML of purified or sterile water before administering, between each medication, and after all medications have been administered.Tablets, powders and beads (never crushed) from opened capsules, are mixed with 15-30ml of water piror to administration via the tube.

Based on observation, interview, and record review, the facility failed to ensure safe use and storage of medication and labeling practices for a census of 78 when:1. A carton of an opened and unlabeled nutritional supplement was found on a medication cart.2. Personal items and cleaning chemicals were found stored in one of the cabinets.3. The facility did not monitor the temperatures of both medication rooms, and,4. Unauthorized personnel had access to the medication room.These failures could contribute to the risk of using contaminated products on residents, contribute to unsafe medication use, lack of accountability and risk of drug diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber).Findings:1. During a concurrent observation and interview on 6/17/26, at 10:20 a.m., with Licensed Nurse (LN) 2, the medication room at Nursing Station 3 was observed. LN 2 stated every morning the Central Supply staff would have checked and delivered nutritional supplies to the nursing station medication rooms. LN 2 further stated the nutritional supplements were opened daily and then kept at the medication carts. LN 2 stated the morning shift nurse would have opened a new nutritional supplement carton at the beginning of the shift and would usually be emptied by the end of the shift. LN 2 confirmed the medication room had various cartons of nutritional supplements. During a concurrent observation and interview on 6/17/26, at 10:41 a.m., with LN 2, the medication room at the Nursing Station 1&2 was observed. LN 2 confirmed the medication room contained cartons of nutritional supplements. During a concurrent observation and interview on 6/17/26, at 10:46 a.m., with LN 2, a medication cart was observed with two cartons of nutritional supplement at the nursing station. LN 2 confirmed one carton of Readycare 2.0 (a high calorie protein nutritional drink) was opened and in use and was not labeled by staff. LN 2 stated the nurse who opened the nutritional supplement carton should have labeled with an open date to ensure it was not reused and was safe to be given to the residents.During an interview on 6/17/26, at 11:01 a.m., with LN 3, LN 3 stated the nurse would have opened a new nutritional supplement carton at the start of the shift and labeled with an open date. LN 3 further stated it was important to have labeled the nutritional supplement upon opening so the nurses would know when to throw it away and to ensure it was not spoiled for the residents.During an interview on 6/18/26, at 3:37 p.m., with the Registered Dietician (RD), the RD stated the nursing staff were in charge of labeling opened supplemental feeding cartons. The RD further stated it was important to have ensured open dates and schedules were being followed by the staff. The RD stated that any food item over time could have begun the process of decay and development of bacteria.During an interview on 6/19/26, at 11:01 a.m., with the Director of Nursing (DON), the DON stated it was her expectation for the staff to have labeled nutritional supplements with open dates and daily changes. The DON further stated the staff should have monitored when the nutritional supplements were opened for the staff to know when they need to be thrown out so they were not reused.A review of the facility's undated policy titled, Policy and Procedure: Nutritional Supplements, indicated, .Purpose.To ensure that nutritional supplements are ordered, stored, administered, monitored, and documented appropriately to meet resident's nutritional needs, promote optimal health, prevent malnutrition, and comply with federal, state, and facility regulations.Procedures.B. Storage and Handling.6. Opened supplements shall be labelled with: Resident name, Date opened, time opened.A review of the facility's undated policy titled, Policy: Ready Care Supplement Storage and Temperature Control, indicated, .Purpose.To ensure the safety, quality, nutritional integrity, and proper handling of Ready care nutritional supplements and enteral feeding formulas adherence to temperature control, storage, monitoring, and administration guidelines.Procedures.4. Handling Ordered Supplements.Opened supplements shall be labelled with: Date opened, Time opened, staff initials. 2. During a concurrent observation and interview on 6/16/26, at 9 AM, with the DON, in medication room [ROOM NUMBER], one of the cabinets was found to have a staff member's purse, clothing cleaning chemicals, and personal air fresheners. The DON acknowledged the items and stated that the cabinet was for the staff to place their personal items.During an interview with on 6/19/26, at 9:10 AM, with the DON, the DON stated staff should not have placed personal items in the medication room. The DON further stated the personal items placed a risk for drug diversion. The DON stated the medication room should never had chemicals stored inside of it and the risk was for the medications coming in contact with the chemicals. The DON further stated the personal items in the medication room and the chemicals being stored in the medication room did not meet her expectations and was not the facility's process.3. During a concurrent observation and interview on 6/16/26, at 10:27 AM, with LN 2, the station 3 medication room was observed. LN 2 confirmed that there was no temperature log. LN 2 stated the temperature log should have been available in the medication room because medications and supplements were stored inside. LN 2 stated the risk of not checking the temperature and having a log to record the temperatures was that the facility would be unable to monitor the temperature which could affect the nutritional supplements and the possibility of spoilage if the temperature increased too much.During a follow-up concurrent observation and interview on 6/16/26, at 10:41 AM, with LN 2, the station 1 and station 2 medication room was observed. LN 2 confirmed the absence of a temperature log.During an interview on 6/19/26, at 8:39 AM, with the DON, the DON confirmed that she was aware that the medication room temperatures were not being monitored or logged. The DON stated the Maintenance Director (MD) was responsible for checking the temperatures and log them. The DON stated the facility's policy was to log the temperature of the medication rooms daily. 4. During a concurrent observation and interview on 6/16/26, at 10:27 AM, with LN 2, the station 3 medication room was observed. LN 2 confirmed that there was not a temperature log and stated the MD was the one who checked the temperatures and not the nursing staff.During an interview on 6/19/26, at 8:39 AM, with the DON, the DON confirmed the MD has had access to the medication room and obtained his own key. The DON stated the MD should not have access to the medication rooms because he was not an authorized person. The DON further stated the risk of the MD having access to the medication room was drug diversion.During a review of the facility's policy and procedures titled, MEDICATION STORAGE IN THE FACILITY, dated 8/1/19, indicated, .Medications and biologicals are stored safely, securely, and properly, following manufactures recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel .Potentially harmful substances [Such as urine test reagent tablets, household poisons, cleaning supplies, disinfectants] are clearly identified and stored in a locked area separately from medications .All medications are maintained within the temperature ranges noted in the United States Pharmacopeia . Controlled Room Temperature .with a thermometer to allow temperature monitoring .The facility should maintain a temperature log in the storage area to record temperatures at least once a day .

Based on observation, interview, and record review, the facility failed to accommodate resident meal preferences and food allergies for 1 of 28 sampled residents (Resident 54) when Resident 54 was served a bread roll on the 6/16/26 lunch meal service.This failure placed Resident 54 at risk for an allergic reaction due to her food allergies to wheat products.Findings:Review of Resident 54's admission RECORD, indicated that Resident 54 had diagnoses that included, but were not limited to, systemic lupus erythematosus (a chronic, systemic autoimmune disease where the body's immune system mistakenly attacks healthy tissues and organs), and psoriasis (a chronic, noncontagious immune-mediated disease causing skin cells to multiply up to 10 times faster than normal). Further review of the record indicated that Resident 54 had allergies to cornstarch (a fine, white, flavorless powder made from the starchy part [endosperm] of the corn kernel), cranberry, high fructose corn syrup (a liquid sweetener made from cornstarch, commonly used in processed foods and beverages like sodas, baked goods, cereals, condiments [ketchup, BBQ sauce], and canned fruits), kiwi fruit, mango, peanut, and wheat.During an interview on 6/16/26, at 9:26 AM, with Resident 54, Resident 54 stated that she had multiple food allergies including bread and high fructose corn syrup. Resident 54 further stated that she had talked to the Registered Dietician (RD) about her food allergies and food dislikes in the past. During a concurrent observation and interview on 6/16/26, at 12:51 PM, with Resident 54, Resident 54's lunch meal plate and meal ticket were observed. Resident 54 confirmed that she received a bread roll and had placed it onto the side of her meal plate. Resident 54 further confirmed that her meal ticket also stated that she food allergies and food dislikes to wheat products and was still served a bread roll. Resident 54 stated that she did not want to be loaded up on bread products.During a concurrent interview and record review on 6/16/26, at 2:49 PM, with Licensed Nurse (LN) 7, a picture of Resident 54's lunch meal plate and meal ticket were reviewed. LN 7 confirmed that Resident 54 was served a bread roll on the 6/16/26 lunch meal. LN 7 stated that the LN's were responsible for ensuring the tray carts were providing accurate food items to the residents to ensure resident safety. LN 7 further stated that it was his expectation for residents not to receive food items that they were allergic to or disliked. LN 7 stated that residents could have unwanted reactions if they were to eat food items that they were allergic to.During a concurrent interview and record review on 6/16/26, at 2:41 PM, with the RD, a picture of Resident 54's lunch meal plate and meal ticket were reviewed. The RD confirmed that Resident 54 was served a bread roll on the 6/16/26 lunch meal. The RD stated that her expectation was for residents not to receive food items that they were allergic to. The RD further stated that resident food wishes should be honored as much as possible and that adjustments should be made. The RD stated that unwanted food reactions and problems with food intake could occur if Resident 54 were to eat food products that she was allergic to.During an interview on 6/18/26, at 3:22 PM, with the Director of Nursing (DON), the DON stated that her expectation was for the LN's to check the meal carts before the residents were served their meals. The DON further stated that the LN's were the last line of defense to check the meal carts. The DON stated that it could be dangerous for the residents to receive food products that they were allergic to.During a review of the facility's undated policy and procedure (P&P) titled, FOOD PREFERENCES, the P&P indicated, .Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group.During a review of the facility's undated P&P titled, FOOD ALLERGIES, the P&P indicated, .Allergies will be noted in the medical record.Appropriate food substitutions will be offered for foods the resident cannot eat.Allergies will be noted on the tray card, the resident diet profile, and posted in the kitchen and nursing station.

Based on interview, and record review, the facility failed to provide pain management consistent with professional standards of practice for one of one sampled resident (Resident 1) who experienced severe pain when:1) Pain medication was not administered consistent with the physician's orders and reported pain levels,2) Resident 1's physician ordered narcotic (a strong medicine that relieves severe pain and has a high addiction potential) pain medication was not available; and,3) The physician was not notified when Resident 1 reported uncontrolled severe pain (high-level pain). This failure caused Resident 1 to endure unnecessary pain and suffering and placed the resident at risk for prolonged discomfort, emotional distress, and decreased quality of life. Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with a diagnosis of, but not limited to chronic pain syndrome (long-lasting pain that continues even after the original injury or illness has healed), acquired absence of limb (something that develops later in life, not something you were born with), peripheral vascular disease (PVD - poor blood flow to the arms or legs due to narrowed or blocked vessels), pressure ulcer of unspecified site (bed sores caused by pressure, but the exact body location is not clearly identified), chronic cholecystitis (long term inflammation of the gallbladder) and end stage renal disease (ESRD - the final stage of chronic kidney disease).Review of Resident 1's Order Summary Report, dated 1/23/26, in the section titled, Order Summary, indicated, .Acetaminophen [Tylenol, a pain medicine] Oral Tablet 325 MG [mg -milligrams, a unit of measure] Give 2 tablet by mouth every 6 hours as needed for MILD PAIN [low-level pain, a score of 1-3 on a 0-10 numerical rating scale].Oxycodone [a strong prescription pain medicine]-Acetaminophen Oral Tablet 10-325 MG Give 1 tablet by mouth two times a day for SEVERE PAIN [as a level 7 to 10 on a 0-10 pain scale, representing pain that is disabling, dominates your senses, and prevents you from performing normal daily activities].Review of Resident 1's Care Plan Report, dated 1/23/26, in the section titled, Focus, indicated, .[Resident 1] is on pain medication therapy, Hydrocodone [a strong prescription pain medicine] r/t [related to] disease process, ESRD, PVD, multiple wounds . In the section titled, Goal, indicated, .[Resident 1] will be free of any discomfort.through the review date. In the section titled, Interventions, indicated, .Administer ANALGESIC [a medicine that relieves pain] medications as ordered by physician.Ask physician to review medication.assess whether pain intensity acceptable to resident [Resident 1].Controlled adequately by therapeutic regimen.or changed regimen required.but pain control not adequate, changes required .Review of Resident 1's clinical record titled, NURSING PROGRESS NOTE, dated 1/23/26, indicated, .Open sores to Coccyx [the tailbone], R [right] buttocks, L [left] knee, and L [left] fibula [the smaller bone on the outer side of your lower leg].Gangrene [when part of the body's tissue dies because it does not get enough blood] to R [right] second digit, AKA [above knee amputation - surgical removal of a body part] to R [right] leg and BKA [below knee amputation] to L [left] leg.[Resident 1] expresses 10/10 pain [severe pain]. Offered PRN [as needed] acetaminophen, but pt [patient - Resident 1] refused and states, that shit will do nothing. [Resident 1] made aware that his oxycodone will come tonight with pharmacy delivery.Review of Resident 1's clinical record titled, NURSING PROGRESS NOTE, dated 1/27/26, indicated, .Open sores to sacrum [the large, triangular bone at the base of the spine, just above the tailbone], L knee, and L fibula.Gangrene to R second digit, AKA to R leg, and BKA to L leg. Resident [Resident 1] expresses 10/10 pain. Charge Nurse administered PRN [as needed] Tylenol.Review of Resident 1's clinical record titled, NURSING PROGRESS NOTE, dated 1/27/26, indicated, .Pt [Patient - Resident 1] observed yelling/screaming and stating he is in extreme pain, rated 10/10.PRN Tylenol administered at 2100 [9 PM] with no relief reported.Scheduled oxycodone.were due at 2100; however, medications, were not delivered by [Name of Pharmacy]. [Name of Pharmacy] on-call was contacted to request authorization to obtain medications from the narcotic E-kit [emergency kit] due to pt's [patient's - Resident 1] severe pain.on-call stated they were unable to provide clearance .Pt [Patient - Resident 1] continues to report severe pain.Review of Resident 1's clinical record titled, NURSING PROGRESS NOTE, dated 1/28/26, indicated, .Pharmacy staff [Name of staff] reported that the C-II form [a special prescription form used for strong, highly controlled medications] was mistakenly faxed to the wrong physician and stated it would be re-faxed.Discussion held regarding the possibility of obtaining medication from the E-kit due to the patient's [Resident 1] severe pain. Patient [Resident 1] has been screaming in pain since admission. Pharmacist [Name of Pharmacist] stated she could authorize E-kit use if physician provided a verbal order.During a concurrent interview and record review on 2/25/26, at 1:26 PM, with licensed nurse (LN) 3, Resident 1's electronic health record (EHR) was reviewed. LN 3 stated staff managed pain by first assessing the resident's pain level, reviewing the physician's pain medication orders, and administering the medication as ordered. LN 3 further stated that after giving the medication, staff reassessed the resident to determine if the medication was effective and notified the physician when necessary. LN 3 reviewed Resident 1's Medication Administration Record (MAR - a written or electronic chart that tracks what medicines a person receives) for 2/1/26 through 2/28/26. LN 3 confirmed that she administered Acetaminophen 325 mg, two tablets by mouth every six hours as needed for mild pain, on 2/13/26, 2/18/26, and 2/19/26. On those dates, Resident 1 reported severe pain scores of 10 on 2/13/26, 10 on 2/18/26, and 8 on 2/19/26. LN 3 acknowledged that these pain scores indicated severe pain and did not match the physician's order, which specified the medication for mild pain only. LN 3 stated that she should have contacted the physician to provide an update on Resident 1's severe pain and request a new order to address the severe pain. LN 3 further stated that Resident 1 had multiple wounds and chronic pain syndrome, and even minor movement caused significant pain. LN 3 acknowledged that nurses needed to address Resident 1's pain promptly instead of waiting for the physician to come to the facility, to ensure appropriate pain management.During a concurrent interview and record review on 2/24/26, at 2:20 PM, with the Director of Nursing (DON), Resident 1's EHR was reviewed. The DON confirmed that Resident 1 had been prescribed Oxycodone-Acetaminophen Oral Tablet 10-325 MG, to be taken by mouth twice daily for severe pain, and Acetaminophen Oral Tablet 325 MG, to be taken by mouth two tablets every six hours as needed for mild pain. The DON stated that mild pain meant a resident reported a pain score between 1 and 3 out of 10, moderate pain meant a score between 4 and 6 out of 10, and severe pain meant a score between 7 and 10 out of 10. The DON further stated that Resident 1 did not have a doctor's order for pain medication to treat moderate pain. The DON explained that she expected licensed nurses to assess Resident 1's pain, contact the doctor, review current pain medication orders, and request medication specifically for moderate pain.During a concurrent interview and record review on 2/25/26, at 3:47 PM, with LN 1, Resident 1's nursing progress notes dated 1/23/26 and 1/27/26, which documented Resident 1's admission and re-admission were reviewed. LN 1 stated that on 1/23/26, Resident 1 reported severe pain rated 10 out of 10 and Resident 1 did not receive his prescribed oxycodone because the pharmacy did not deliver the medication. LN 1 further stated that on 1/27/26, she observed Resident 1 yelling and screaming in extreme pain, which he rated as 10 out of 10. LN 1 stated Resident 1 again did not receive his prescribed oxycodone because the pharmacy did not deliver the medication, and the facility did not obtain authorization to access the emergency medication kit. LN 1 further stated that staff did not manage Resident 1's pain effectively because ongoing issues with obtaining oxycodone occurred during both his initial admission and his re-admission.During an interview and record review on 2/25/26, at 4:32 PM, with LN 2, Resident 1's MAR for 1/1/26 through 1/31/26 was reviewed. LN 2 confirmed that she administered Acetaminophen Oral Tablet 325 mg, two tablets by mouth every six hours as needed for mild pain, on 1/28/26 and 1/29/26. On those dates, Resident 1 reported pain scores of 6 on 1/28/26 and 5 on 1/29/26, which indicated moderate pain. LN 2 acknowledged that the physician ordered Acetaminophen 325 mg was for mild pain only. LN 2 stated that she should have reviewed the pain medication orders, reassessed Resident 1's pain level, and contacted the physician to clarify and obtain clear as-needed orders for mild, moderate, and severe pain.During an interview on 2/25/26, at 5:28 PM, with the DON, the DON stated that pain management for Resident 1 was a concern.During an interview on 2/26/26, at 2:12 PM, with the Pharmacist (PH) 1, PH 1 stated the pharmacy received Resident 1's oxycodone order dated 1/23/26. PH 1 further stated that the pharmacy could not dispense the oxycodone until it received a completed Schedule II (C-II) prescription from the physician. PH 1 stated the delay in receiving the completed prescription contributed to the delay in providing pain medication to Resident 1.During an interview on 2/26/26 at 4:30 PM, with the Pharmacist (PH) 2, PH 2 stated that she was not aware of, and was not contacted about, Resident 1's oxycodone concerns. PH 2 further stated that if the facility had contacted her, she could have reviewed the situation, made recommendations, or contacted the dispensing pharmacy to determine the reason for the delay in the oxycodone. PH 2 acknowledged that the facility failed to ensure the availability of the ordered narcotic medication and that Resident 1's severe pain remained untreated as a result.Review of an undated facility policy and procedure (P&P) titled, POLICY AND PROCEDURE ON PAIN ASSESSMENT, indicated, Policy: It is the policy of this facility to assess for pain and provide for patient care services to ensure resident's comfort.For those residents with complaints of pain, further assessment of pain is necessary to determine appropriate interventions to manage pain.Review of an undated facility P&P titled, POLICY AND PROCEDURE ON PAIN MONITORING DURING CARE AND TREATMENT, indicated, .Charge Nurse should review physician order for any order of pain medication administration.Call physician if there is no order for pain medication.Monitor for effectiveness of pain medications and call physician if pain medication is ineffective.Document pain assessment and effectiveness of intervention.

Based on interview and record review, the facility failed to ensure one of five sampled residents, (Resident 3) who was dependent on staff to carry out activities of daily living, (ADLs, tasks of everyday life including eating, dressing, bathing, showering, and using the bathroom) received services to maintain personal hygiene when Resident 3 was not provided with once weekly showers for two months.This failure had the potential to cause discomfort, skin impairment, infection, and a decline in emotional and psychological well-being.Findings:A review of Resident 3's clinical record titled, admission Record, indicated Resident 3 was admitted to the facility in 2018 with diagnoses which included Cerebral Infarction (a result of disrupted blood flow of the brain - also known as a stroke), Hemiplegia (unable to move a part of the body), and Hemiparesis (muscle weakness on one side of the body).A review of Resident 3's clinical record titled, Minimum Data Set, (MDS, a comprehensive care assessment tool) indicated that Resident 3 was dependent of the staff for completion of ADLs.During a phone interview with Resident 3's Responsible Party (RP, the person designated to direct the care of a loved one admitted into a nursing facility) on 7/3/25 at 10:43 a.m., the RP stated that she was concerned that the facility had not provided Resident 3 with showers but had only provided bed baths.During a concurrent interview and record of review on 7/7/25 at 11:33 a.m., with the Director of Staff Development (DSD), Resident 3's clinical record titled, Skin Check Forms, were reviewed. The DSD stated the Certified Nursing Assistants (CNAs) completed the skin check forms and placed them in the binder each day. The DSD stated the residents' skin checks, baths, and/or showers were completed at the same time unless the residents were bedridden. The DSD stated that residents like Resident 3 (who were bedridden) would have received bed baths daily and showers once a week. During a concurrent interview and record review on 7/8/25 at 4:10 p.m., with the Licensed Nurse (LN) 1, the document titled, July 2025 ADL-Bathing, (a task list documentation in the electronic medical record [EMR]) was reviewed. LN 1 stated that the residents' baths and showers were documented with body skin checks by the CNAs. LN 1 stated that residents in A beds were checked Monday, Wednesday, Friday, residents in B beds were checked Tuesday, Thursday, Saturday, and residents in C beds were checked on the days that the residents in the A beds were checked. LN 1 stated that the CNAs also documented baths and/or showers on the task lists electronically in the residents' medical records. LN 1 stated that Resident 3 went to the acute (area that treated new health concerns) care facility on 6/27/25 and returned to the facility from acute care on 7/3/25. LN 1 confirmed that Resident 3 received a shower on 7/8/25.During a concurrent interview and record review on 7/8/25 at 4:35 p.m., with the Medical Records (MR), Resident 3's clinical document titled, May 2025 and June 2025 ADL-Bathing (task list documentation) was reviewed. The MR stated that she was not able to print a report that indicated specifically whether Resident 3 received a bath or shower, as she did not have access to do so. MR stated that the Director of Nursing (DON) would be able to print a report that indicated whether Resident 3 received a shower in May or June 2025. During a concurrent interview and record review on 7/8/25 at 4:40 p.m. with the Minimum Data Set (MDS) Coordinator, Resident 3's clinical document titled, ADL-Bathing (located in the EMR that tracked shower dates) was reviewed. MDS stated the document did not indicate if Resident 3 had a bath or shower. The MDS confirmed that Resident 3's ADL-Bathing task list indicated that Resident 3 did not have a shower in May 2025 or in June 2025. During a concurrent phone interview and record review on 7/9/25 at 9:30 a.m., with the DON, Resident 3's EMR was reviewed. The DON stated that her expectation was that residents in A beds had skin checks Monday, Wednesday, Friday, residents in B beds had skin checks Tuesday, Thursday, Saturday, and residents in C beds had skin checks on the days that the residents in the A beds had skin checks and that the residents received bed baths or showers with the skin checks. The DON stated that her expectation was that residents who were bedridden received bed baths daily and received showers once a week. The DON stated that when the residents received bed baths, they were wet fully while in bed. The DON confirmed that Resident 3 did not receive a shower in May 2025 or June 2025. The DON stated that the risk of Resident 3 not receiving a shower was that a shower was more comfortable and refreshing than a bed bath. The DON acknowledged that the facility policy was not followed.A review of an undated facility policy and procedure (P&P) titled, Policy and Procedure on Bathing, indicated, .Policy .It shall be this facility's policy to provide bathing services to residents to promote cleanliness, good hygiene, and comfort .8. Formulate plans of care to meet the resident's bathing needs .

Based on observation, interview, and record review the facility failed to maintain the confidentiality of two of three sampled residents (Resident 6 and Resident 7) when portions of Resident 6's and Resident 7's medical records were discovered in Resident 3's medical record.This failure had the potential for exposure of Resident 6's and Resident 7's private and confidential information to unauthorized individuals.Findings:A review of Resident 3's clinical record titled, admission Record, indicated Resident 3 was admitted to the facility in 2018 with diagnoses which included Cerebral Infarction (a result of disrupted blood flow of the brain, also known as a stroke), Hemiplegia (unable to moved parts of the body), and Hemiparesis (muscle weakness on one side of the body).A review of Resident 6's clinical record titled, admission Record, indicated that Resident 6 was admitted to the facility in 2014 with diagnoses which included Respiratory Failure (disease that can cause shortness of breath, anxiety, and confusion).A review of Resident 7's clinical record titled, admission Record, indicated that Resident 7 was admitted to the facility in 2019 with diagnoses which included Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar), and Hemiparesis. During a concurrent interview and record review on 7/7/25 at 4:10 p.m. with Medical Records (MR), Resident 3's medical records were reviewed. MR confirmed that intake and output forms for Resident 7 and a physician's order for a Licensed Nurse to pronounce the time of death and release of body to mortuary for Resident 6 were in Resident 3's medical record. The MR stated that the documents were mixed up and someone could have followed the order for the wrong resident. The MR confirmed that the facility policy was not followed.During a review of the faciliy's undated policy and procedure (P&P) titled, Health Policy and Procedure Manual Long Term Care Storage and Protection of Records, indicated, .The facility must maintain clinical records on each resident in accordance with acceptable professional standards and practices that are: 1. Complete 2. Accurately documented .It is the policy of this facility to store all medical records in such a manner so as to protect against .unauthorized use .Each patient is assigned a medical record number upon admission, and this number is retained for all subsequent readmissions .all admissions are filed under the .number .Do not allow records out in an area where they could be lost, misplaced .

Based on observation, interview, and record review, the facility failed to ensure the protection to residents' personal information for a census of 81 when meal tray tickets (contained resident names and other identifying information) were thrown into the trash and outside dumpsters. This failure had the potential for identity theft and misuse of personal information. Findings: During an observation of dishwashing on 2/18/25, at 9:24 AM, with Dietary Aid 1 (DA 1) in the kitchen, DA 1 was observed removing items from residents breakfast trays. DA 1 was threw the meal tray tickets from the breakfast trays into the regular trash along with food scraps. During a concurrent observation and interview on 2/18/25, at 12:56 PM, with DA 2 in the kitchen, DA 2 was observed removing items from the residents breakfast trays. DA 1 was throwing the meal tickets from the breakfast trays into the regular trash along with food scraps. DA 2 confirmed this was the facility's practice of disposal of meal tray tickets. During an interview with the Registered Dietician (RD) on 2/21/25, at 1:26 PM, the RD acknowledged the meal tray tickets being throwing in the trash was a confidentiality issue and stated, she was unaware of any other way to dispose of them. A review of a facility's meal tray ticket indicated the meal tray ticket contained residents' information such as the residents' complete name, where the resident usually eats his/her meal, residents' unit, room, and bed number, residents' diet order, resident's allergies, resident's food notes and alerts, residents' standing food order, resident's likes and dislikes, the date, and type of meal. During an interview on 2/21/25, at 1:36 PM, with the Director of Nursing (DON), the DON stated there were privacy and confidentially concerns, all meal tray tickets should be shredded after recording the intake information. The DON stated this was a violation of the residents privacy and this practice did not meet her expectations. During a review of an undated facility's policy and procedure (P&P) titled, How To Dispose/Destruct Of Patient Health information, the P&P indicated, .The facility shall destruct or destroy medical records by shredding or otherwise destroying Patient Health Information so the PHI is rendered essentially unreadable, indecipherable, and other cannot be reconstructed prior to being placed in a dumpster or other trash receptacle .

Based on observation, interview, and record review, the facility failed to provide safe food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 81 residents who ate facility prepared meals when: 1. Raw chicken was left thawing in the sink without running water; 2. Over-ripe and spoiled produce was available for use in the walk-in refrigerator; 3. Leftover food was kept beyond a safe time frame, incorrectly dated, and the cool down process was omitted; 4. Staff food was stored in the walk-in refrigerator which contained resident food and placed on top of cooked food; 5. Boxes of food, drinks, supplies, and food products were found on the floor in the dry storage room; 6. Non-food items and staff personal items were stored in the dry storage room; 7. Dented cans were found in the dry storage room ready to serve; 8. Clean food service items were found put away wet such as trays and steam table pans; and 9. The oven was found dirty with layers of grease and food debris. These failures placed residents at risk for foodborne illnesses. Findings: 1. During a concurrent observation and interview, during the initial kitchen tour on 2/18/25, at 8:14 AM, the [NAME] (CK) confirmed there were three clear bags of raw chicken placed in an empty bucket over the sink without running water. During an interview with the Registered Dietician (RD) on 2/21/25 at 12:04 PM, when asked about the raw chicken, the RD stated the kitchen staff have been in serviced on the thawing process for raw meat. The RD stated the raw meat if thawing under water should be running at 70 degrees. The RD stated thawing meat without running water is not safe for the residents and the meat will be in the danger zone for bacteria growth. The RD stated chicken needed to be handled safely due to the risk of Salmonella (define) and can effect the quality of the meat. A record review of a facility provided documents titled, Thawing of Meats, dated 2023, indicated, .Submerge under running, potable water at a temperature of 70 degrees or lower, with a pressure sufficient to flush away loose particles .The food product cannot remain in the temperature danger zone (41 F- 140F [Fahrenheit, a unit of temperature measurement]) for more than four hours . Review of the Food and Drug Administration (FDA) Food Code 2022, under section 3-501.1, titled, Thawing, indicated, .(B) Completely submerged under running water: (1) At a water temperature of 21oC [celcius; a unit of temperature measurement] (70F) . With sufficient water velocity to agitate and float off loose particles in an overflow . (https://www.fda.gov/media/164194/download) 2. During a concurrent observation and interview, during the initial kitchen tour on 2/18/25, at 8:14 AM, the CK confirmed the following items were found in the walk in refrigerator in the kitchen where food was stored for residents: a. Three eggplants with black, white, yellow spots, and large indentations on them was available for use. b. One large grey tub of cucumbers was found on the floor of the refrigerator directly below One log of raw ground beef and a package of raw roast beef. c. One large clear container of minced garlic dated 1/20/24 with no use by date written on it. d. One large clear container or prepared ham sandwiches ready to serve dated 2/10/25 with a UBD of 2/14/25 e. Eight out of fifteen red bell peppers were found in pieces with exposed seeds, mushy in texture, and with green and white fuzzy substances on them ready to serve. f. One out of four tomatoes were found with a black fuzzy substance on it and mushy in texture. During an interview with the RD on 2/21/25 at 12:44 PM, the RD stated the facility policy was as soon as any brown is seen on a produce they were to be removed. The RD stated her expectation was for staff to remove produce from use as soon as there was any discoloration. The RD stated use of food in a decomposed state posed a risk to the residents due to potential exposure to bacteria. The RD stated the quality of the produce could affect the quality of the food. A review of a facility provided document titled, STORING PRODUCE, dated 2023, indicated, .Check boxes of fruit and vegetables for rotten, spoiled items. One rotten tomato, apple, or potato in a box can cause the rest of the produce to spoil faster. Throw away the spoiled items .When storing vegetables that should remain crisp such as lettuce and other leafy greens .green bell peppers .they will stay fresh longer if you place them in a sealed bag or container A record review of a facility provided document titled, Produce Storage Guidelines, dated 2023, indicated, .Garlic, Jarred, Chopped or Minced unopened on the shelf 8 months . opened in the refrigerator use by date . A review of The Food and Drug Administration (FDA) Food Code 2022, under section 3-501.17 (A) (B) (C) (D), indicated, .the day the original container was opened in the food establishment shall be counted as Day 1 .The date marked shall not exceed a manufacturer's use-by date .mark the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises . (https://www.fda.gov/media/164194/download) 3. During a concurrent observation and interview, during the initial kitchen tour on 2/18/25, at 8:14 AM, the CK confirmed there was the following left overs in the walk in refrigerator located in the facility kitchen where food was stored for residents: a. One medium size tray line container with left over ground beef and approximently eight hamburger patties inside of it with aluminum foil placed over and dated 2/17/25. b. One small tray line container halfway full with left over brown gravy inside of it with aluminum foil placed over and dated 2/17/25. c. One large tray line container with left over tuna salad and aluminum foil placed over it and dated 2/17/25. d. One small tray line container with left over sausage patties and bacon covered with aluminum foil and dated 2/17/25. e. One medium size tray line container with left over porkchops with aluminum foil placed over it and dated 2/14/25. f. One small tray line container with left over white rice with aluminum foil over it and dated 2/14/25. g. One medium size container of left over ground sausage with aluminum foil placed over it and dated 2/17/25. During an interview with the Certified Dietary Manager (CDM) on 2/21/25 at 11:51 AM, the CDM stated the leftovers were kept for 24 hours in the refrigerator and then discarded. The CDM stated the facility's practice is the day the leftovers were cooked they were placed into a container, dated, and then placed in the refrigerator. The CDM stated the leftovers may be used the following day for an alternative if a resident requested. The CDM stated if the leftovers will be reused, then the cook would reheat the food to 155 degrees for twenty seconds and then serve it. The CDM stated prior to storing the leftovers they do not use the cool down process (steps to monitor the temperature of cooked food to prevent bacteria growth) or any other monitoring tool. The CDM stated, when cooking food, they followed the menu strictly. During a concurrent interview and record review on 2/21/25 at 12:16 PM, the facility weekly menus for the month of Feburary 2025 were reviewed with the RD. The RD stated the expectation was for the cooks to use the cool down process and log when saving leftovers. The RD reviewed the photos taken during the initial walk through of the various leftovers. The RD stated the leftovers were unacceptable and should have been thrown out. A review of the weekly menus for 2/17/25- 2/23/25 revealed, the items that were left over were not cooked on 2/17/25 when comparing the times to the menu for 2/17/25. A review of the menu for 2/10/25-2/16/25 showed no items that were leftover in the fridge were cooked on 2/16/25 and 2/15/25. Further review of the menu indicated the left-over items were first listed on the menu on 2/14/25 and earlier in February. A concurrent review of a document titled Meal Service Alternatives for winter 2024-2025 was reviewed as well with no correlation to the leftovers. The RD stated her expectations were that the leftovers should be disposed of 24 hours after being cooked. The RD stated leftovers that were kept longer than the 24 hours have a decrease in the quality of the food and placed the residents at risk for food born illness. A review of an undated facility provided document titled, Cool Down Log, indicated the last documented entry was on 12/19/25 for roast beef. A review of a facility provided document titled, Leftover foods, dated 2023, indicated, .Policy: Left over foods will be stored and served in a safe manner .Should food be cooled off before placing in the refrigerator? .The answer is that food is not safe when it is between 41 F to 140F. Therefore, as soon as hot food has dropped to 140 F the proper methods of cooling food must be used . Review of The Food and Drug Administration (FDA) Food Code 2022, under section 3-501.17 (A) (B) (C) (D), indicated, .the day the original container was opened in the food establishment shall be counted as Day 1 .The date marked shall not exceed a manufacturer's use-by date .mark the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises . (https://www.fda.gov/media/164194/download) 4. During a concurrent observation and interview, during the initial kitchen tour on 2/18/25, at 8:14 AM, the CK confirmed there was raw tilapia with only the heads cut off found in a small tray line container with aluminum foil placed over the container and written with marker Tilapia Head without a date . The CK confirmed the tilapia was stacked on top of cooked food and vegetables in the refrigerator. During an interview on 2/18/25 at 8:43 AM, with the Dietary Aide (DA) 3, when asked about the tilapia, DA 3 stated the tilipia was going to be cooked by the CDM for their personal consumption. During an interview with the CDM on 2/18/25 at 3:45 PM, the CDM stated the tilapia was something she was going to cook for the staff. The CDM confirmed the facility was not supposed to store and cook food where the resident's food was cooked and stored. During an interview with the RD on 2/21/25 at 12:57 PM, the RD stated the food should be stored in the refrigerator and handled properly for food safety practices which was not the case with the tilapia. The RD stated the tilapia that was in the resident's refrigerator and the improper placement in the refrigerator placed the residents at risk for cross contamination and food borne illnesses. The RD stated the facility was not aware of the origin of the tilapia and if safe handling practices were implemented. The RD stated the tilapia belonging to the staff being stored in the resident's refrigerator did not meet her expectations. The RD stated her expectations were for the staff to store their items in the designated areas for staff. A review of the facility's provided document titled, Good For Your Health Menus, for the following dates 2/17/25-2/23/25 indicated, no future item listed as Head of Tilapia. A review of a facility provided documents titled, Thawing of Meats, dated 2023, indicated, .Store raw meat, poultry, and fish separately from cooked and ready to eat food to prevent cross contamination .Store cooked or ready to eat food above raw meat, poultry, and fish if these items re stored in the same unit. This will prevent raw- product juices from dripping onto the raw prepared food causing food borne illness . A review of a facility provided document titled, Employee Personal Items, dated 2023, indicated, .POLICY: Personal items brought in by staff from outside will not be kept in the kitchen. PROCEDURE: Employees bringing in personal items from outside . will not be kept in the kitchen area. These items will be kept in the corner outside the storeroom . A Review of The Food and Drug Administration (FDA) Food Code 2022, under section 6-305.11 Designation, indicated, .personal belongings can contaminate food, food equipment, and food-contact surfaces. Proper storage facilities are . (https://www.fda.gov/media/164194/download) A Review of The Food and Drug Administration (FDA) Food Code 2022, under section 6-403.11 Designated Areas, indicated, .Because employees could introduce pathogens to food by hand-to-mouth-to-food contact and because street clothing and personal belongings carry contaminants, areas designated to accommodate employees' personal needs must be carefully located. Food, food equipment and utensils, clean linens, and single-service and single-use articles must not be in jeopardy of contamination from these areas . (https://www.fda.gov/media/164194/download) A Review of The Food and Drug Administration (FDA) Food Code 2022, under section 6-501.110 Using Dressing Rooms and Lockers indicated, .personal belongings can contaminate food, food equipment, and food preparation surfaces and consequently must be stored in properly designated areas or rooms . (https://www.fda.gov/media/164194/download) 5. During a concurrent observation and interview, during the initial kitchen tour on 2/18/25, at 8:49 AM, the CK confirmed the following items located on the floor in the dry storage area: one box of coffee covers, one box of roasted coffee placed, one box of 24 pack of pepper soda, one box of 24 pack of lemon-lime soda, three cases of water stacked on top of one another, and two cases of 24 pack of cola soda placed on top of the 24 pack of pepper soda. During an interview with the RD on 2/21/25 at 1:18 PM, the RD stated the facility did not allow food or food items to be placed on the floor and food items must be at least 6 inches off of the ground for safety and risk of insects and pests. The RD stated her expectations was for all items in the dry storage room to be placed at least 6 inches from the floor. A review of a facility provided document titled, Storage of Food Supplies, dated 2023, indicated, .All food and food containers are to be stored 6 [inches] off the floor and on a clean surface in a manner that protects it from contamination . A review of The Food and Drug Administration (FDA) Food Code 2022, under section 4-903, indicated, .Storing (D) Items that are kept in closed PACKAGES may be stored less than 15 cm (6 inches) above the floor on dollies, pallets, racks, and skids that are designed as specified under S 4-204.122 . (https://www.fda.gov/media/164194/download) 6. During a concurrent observation and interview, during the initial kitchen tour in the dry storage room on 2/18/25, at 8:49 AM, the CK confirmed the findings of one kids blue chair, one black chair with four wheels, one plastic foot stool, one black space heater, one black round house fan, and one blue personal lunch pail. During an concurrent observation and interview with Dietary Aide (DA) 3 on 2/18/25 at 8:49 AM, DA 3 stated the items were being used by staff who took their breaks in the dry storage room. During a concurrent interview and observation in the dry storage with the CDM on 2/18/25 at 12:30 PM, the CDM confirmed the personal items present belonged to staff. The CDM also stated the items found were utilized by staff while taking their breaks in the dry storage room. During an interview with the RD on 2/21/25 at 1:21 PM, the RD stated the employees have access to breakrooms. The RD stated the items found in the dry storage room did not appear to be clean or safe to use for staff. The RD stated the facility was unaware of where the items came from and how often they were cleaned. The RD stated the facility aims to minimize the amount of human contact wherever food is stored and these items that was found in the dry storage room goes against the facility food storage policy. The RD stated only food was to be stored in the dry storage room. The RD stated her expectations were for the staff to take breaks in their designated break rooms and for only food to be stored in the dry storage room. A review of a facility provided document titled, Employee Personal Items, dated 2023, indicated, .POLICY: Personal items brought in by staff from outside will not be kept in the kitchen. PROCEDURE: Employees bringing in personal items from outside . will not be kept in the kitchen area. These items will be kept in the corner outside the storeroom . A Review of The Food and Drug Administration (FDA) Food Code 2022, under section 6-305.11 Designation, indicated, . personal belongings can contaminate food, food equipment, and food-contact surfaces .(https://www.fda.gov/media/164194/download) A Review of The Food and Drug Administration (FDA) Food Code 2022, under section 6-403.11 Designated Areas, indicated, .Because employees could introduce pathogens to food by hand-to-mouth-to-food contact and because street clothing and personal belongings carry contaminants, areas designated to accommodate employees' personal needs must be carefully located. Food, food equipment and utensils, clean linens, and single-service and single-use articles must not be in jeopardy of contamination from these areas . (https://www.fda.gov/media/164194/download) A review of The Food and Drug Administration (FDA) Food Code 2022, under section 7-209.11, titled, Storage indicated, .Employee personal care items may serve as a source of contamination and may contaminate food, food equipment, and food-contact surfaces if they are not properly labeled and stored .(https://www.fda.gov/media/164194/download) A review of the facility provided document titled, storage of food and supplies, dated 2023, indicated, Storage areas should be used for food only . 7. During a concurrent observation and interview during the the initial kitchen tour on 2/18/25, at 8:49 AM, the CK confirmed the findings of two dented cans of pineapple, one dented can of ripe olives, two dented cans of fruit salad, one dented can of shredded sauerkraut, and one dented can of pork and beans. These cans were stocked and stored in a ready to serve area. During an interview with the RD on 2/21/25 at 1:11PM, the RD stated having dented cans on the shelves ready to serve did not meet the facility's expectations. The RD stated the facility's process and her expectations were when dented cans were discovered the staff should place the cans in a separate area and have them returned to the vendor for a credit. The RD stated the dented cans posed a serious risk because the integrity of the can was compromised and presented the ability of bacteria growth that could become deadly. A review of a undated facility provided document titled, FOOD STORAGE-DENTED CANS OR ALTERATION IN PACKAGING OF ANY FOOD ITEM POLICY AND PROCEDURES, indicated, .Policy: Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents or swells shall not be retained or used by the facility .Update: Do not use any food item, canned or in any form that has altered packaging .dented cans .If a food item has a dent or crumpled carton, separate the item DO NOT USE. Return to the vendor for credit . 8. During a concurrent observation and interview during the initial kitchen tour on 2/18/25 at 9:08 AM, the CK confirmed twelve tray line pans were found stocked and stored wet with visible drops of liquid. During an interview with the RD on 2/21/25 at 11:11 PM, the RD stated the tray line pans should be allowed to air dry prior to storing them. The RD stated the pans being stocked and stored wet placed a risk for bacteria growth and contamination of the residnets food and posed a food borne illness risk. The RD stated her expectations were for the pans to be fully air dry prior to being stored. A review of a facility provided document titled, 3-Compartment Procedure for Manual Dishwashing, dated 2023, indicated, .Step 1. Clean and sanitize all work surfaces. Set up area for air drying .Step 6. All items are air dried, which means no water or droplets are present . Review of The Food and Drug Administration (FDA) Food Code 2022, under section 4-901.11 Equipment and Utensils, Air-Drying Required, indicated, .Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils . (https://www.fda.gov/media/164194/download) 9. During a concurrent observation and interview during the initial kitchen tour on 2/18/25 at 9:09 AM, the CK confirmed that the stove was found with layers of a black greasy substance, layers of black hard flaky debris in the range area, and the oven was found to have layers of splattered liquid of various colors on the inside of the door of the oven and on the base of the oven. During a concurrent record review and interview with the CDM on 2/18/25 at 3:45 PM, the CDM stated the stove was to be cleaned after each shift to be prepared for the next shift on duty. The CDM stated the cleaning of the oven and stove was the cook on duty responsibility. The CDM stated maintenance cleans only the hood to the oven and the other duties belong to the cook. When shown the picture of the stove. the CDM confirmed the cooks need to scrub it with a scrubber and the chemicals provided by the vendor to get the stove and oven to meet her expectations. During an interview with the RD on 2/21/25 at 12:51 PM, the RD stated the stove and oven have a cleaning schedule and the expectations were for the cleaning schedule to be followed. The RD stated the purpose for the stove to be cleaned appropriately is to maintain the temperature along with fire safety and if it was not cleaned properly there could be gaps in the temperature when cooking food. The RD stated that her expectations was for the stove to be cleaned after every use by the cook. A review of a facility provided document titled, Ranges and Ovens, dated 2023, indicated, .CLEANING PROCEDURE: 1 .Immerse grills in a solution of water and grease solvent to soak. Remove encrusted material with a blunt scraper . 2 .Clean clogged burner posts with a stiff wire brush .5.Grills must be cleaned after each use .OVENS CLEANING PROCEDURE: .2. Weekly, and as often as necessary, racks and shelves should be removed and cleaned in a warm detergent solution following manufactures instructions .5. Clean the exterior of the oven according to the manufacture's instructions . Review of The Food and Drug Administration (FDA) Food Code 2022, under section 4-501.14 Warewashing Equipment, Cleaning Frequency, indicated, .During operation, warewashing equipment is subject to the accumulation of food wastes and other soils or sources of contamination. In order to ensure the proper cleaning and sanitization of equipment and utensils, it is necessary to clean the surface of warewashing equipment before use and periodically throughout the day . (https://www.fda.gov/media/164194/download) Review of the FDA 2022 Food Code, under section 4-601.11, indicated, .Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, version 1/23, indicated, .(A) Equipment Food-Contact Surfaces and utensils shall be clean to sight and touch. (B) The Food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-Contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris . (https://www.fda.gov/media/164194/download)

Based on staff interview and clinical record review, and hospital documentation, the facility failed to ensure adequate assessment and treatment was provided when Resident A developed open sores on the 3rd and 4th fingers of her right hand and, Findings: Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS - an assessment tool), dated 7/16/13, indicated Resident A was rarely or never understood and she had long and short term memory impairments. Resident A was dependent on staff for mobility and transfers and had limited range of motion on one side of her upper and lower extremities. Documentation on the MDS indicated Resident A did not have venous or arterial ulcers (ulcers not caused by pressure). A Care Plan entry, dated May 2013, indicated Resident A had the potential for the development of altered skin integrity related to the presence of a contracture (permanent shortening of a muscle or joint) of her right hand (resulting in a closed fist). The Care Plan goal was to prevent the development of skin breakdown. The Care Plan approach plan included providing hand rolls (rolled gauze placed in the hand) after cleansing and drying the hand, check hand every shift for symptoms of skin breakdown, change hand roll as needed when soaked or there is a foul odor, clip nails as needed, and notify the physician of changes. A Nurses Note, dated 8/13/13 at 4 p.m., included the following information, "Noted redness on 3rd and 4th finger tip informed (doctor) (with) order to monitor and just continue hand roll use." A Non-Decubitus (non-pressure ulcer) Skin Problem Report, dated 8/13/13, indicated Resident A's right 3rd and 4th fingers had "redness." The Weekly Progress portion of the form indicated the following: 8/21/13 redness still noted. 8/28/13 redness still noted. 9/2/13 see other page. A Non-Decubitus Skin Problem Report, dated 9/2/13, indicated there was an "open area" on Resident A's 3rd and 4th fingertips. There was no other description or measurements of the "open area" on the report form. The preventative measures listed on the report were to apply triple antibiotic ointment and hand rolls for the contracture. The Weekly Progress Report portion of the form was not completed the following week on 9/9/13. A Nurses Note, dated 9/2/13 at 10 a.m., included the following, "Noted open wound to 3rd & 4th finger tip to right hand (with) order obtained to keep area clean and dry and apply triple antibiotic ointment noted and carried out." There was no documented evidence Resident A's responsible party was notified of the open wounds on the resident's finger tips. Review of physician progress notes [REDACTED]. There was no documentation regarding Resident A's right hand or fingers. Certified Nurse's Aide (CNA) Daily Flow Sheets for August 2013 "Day Shift", dated 8/1/13-8/31/13, were reviewed. Under the section "hand rolls", the letter "N" was documented daily for the entire month. Daily Flow Sheets for the PM shift 8/1/13-8/31/13 under section "hand rolls" was reviewed. The letter "N" was documented daily for the entire month. Daily Flow Sheet for the Night Shift 8/1/13-8/31/13 under section "hand rolls" was reviewed. The letter "L" was documented daily for the entire month. An interview was conducted with the Director of Nurses (DON) on 10/10/13 at 11:30 a.m. The DON stated the letter codes for hand roll documentation on the CNA Flow Sheets were as follows: R=right L=left B=bilateral N=none The DON acknowledged documentation on the CNA flow sheet regarding the placement of a hand roll in Resident A's right hand were inconsistent with the hand roll not placed at all or placed in the wrong hand. Nurses Notes, dated 9/10/13 at 10:30 a.m., documented Resident A was lethargic (lack of energy) with cold clammy skin. At 11 a.m. paramedics transferred Resident A to the general acute care hospital (GACH). Resident A's interfacility transfer record, completed at the facility upon Resident A's transfer to the GACH on 9/10/13, was reviewed. The transfer record had a section to document skin condition and decubitus ulcers. The open areas to Resident A's right 3rd and 4th finger tips were not documented on the transfer record. Wound/Skin Documentation Records, completed upon Resident A's admission to the GACH on 9/10/13, were reviewed. Resident A's right hand finger tip wounds were documented as pressure ulcers, Stage 3, full thickness to the right 3rd and 4th finger and palm of the hand. The wounds were measured as 1.2 centimeters (cm) x 1.2 cm. The Wound/Skin Documentation Record "Glossary" section of the record indicated a Stage 3 pressure ulcer was full thickness tissue loss. Subcutaneous (beneath the skin) fat may be visible, but bone, tendon, or muscle are not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (tissue destruction around the edges of the wound under intact skin, the opening is smaller than the actual wound). A Social Service Assessment, dated 9/11/13, indicated the nurse that admitted Resident A to the GACH contacted the Social Service Department with concerns. Documentation indicated photographs were taken of Resident A's right hand upon admission to the GACH. The documentation indicated Resident A's right hand was "contracted with gauze that looked like it hadn't been cleaned or changed for a while." The Admitting Nurse reported the gauze was "moldy" and the "finger looks like she has no more nail and the gauze infused into her hand." Continued documentation indicated the staff put Resident A's hand in saline (salt water solution) to soak for a while and the fingers bled after they were released from the gauze. A Wound Care consultation, dated 9/11/13 at 10:30 a.m. and completed at the GACH, indicated Resident A had right hand 3rd and 4th finger tip ulcers. The wounds were described as "full thickness" with loss of the nail bed. An interview was conducted with the DON on 10/10/13 at 12 p.m. The DON reviewed the GACH photographs and stated a photograph of the wound which was labeled as Stage 3 full thickness was the pad of Resident A's 3rd finger. The DON acknowledged Resident A's visible finger nails were long and untrimmed. The DON stated, regarding the length of the finger nails, "that could have happened in a week." The DON stated she was aware of the open area on the pad of Resident A's 3rd finger. The DON acknowledged the areas were not described or measured on the facility's skin wound documentation sheets. The DON stated she did not know what else the facility could do besides Resident A having her fingers amputated. The DON acknowledged there was no documentation which indicated Resident A's physician had assessed the open wounds on the fingers and the Resident's responsible party had not been notified of the open wounds on Resident's right hand 3rd and 4th finger tips.