Every finding on record at Grant Rehabilitation and Care Center

Based on observation and staff interview, facility failed to ensure all exit doors are free from potential accident hazards. This failed practice was a random opportunity for discovery during the Long Term Care Survey process. Facility Census 90. Findings include: A) Policy Review The facility's policy reads in part: -Section 5. All personnel shall keep exits clear at all times. Exit doors are never blocked, even briefly. B) Observation on 400 Unit On 02/09/2026 at 09:30 AM, an observation at end of 400 unit found the following items were blocking easy access to exit the facility in case of an emergency:-Bath/Shower bed -Wheelchair-Bedside commode-Fan During an observation with the Administrator present, completed on 02/09/2026 at 11:00AM, the following items were still blocking easy access to exit the facility in case of an emergency:-Bath/Shower bed -Wheelchair-Bedside commode-Fan c) Interview with Administrator During an interview on 02/09/2026 at 11:01AM, the Administrator verified the exit door was not to have anything blocking exit. The Administrator added, I will get it corrected.

Based on record review and staff interviews, the facility failed to ensure nutrition assessments were being completed per facility policy and guidance. This was found to be true for four (4) of the seven (7) medical records reviewed under the nutrition pathway during the long-term care survey process. Resident identifiers: #8, #71, #74 and #78. Facility census: 90.Findings include: a) Policy for Medical Nutrition Therapy: Assessment and Care Planning reads in part. -The resident/patient nutrition status will be assessed upon admission and monitored at least quarterly thereafter. -Procedures 1. The Registered Dietician/Nutritionist (RDN) or other clinically qualified nutrition professional is responsible for the completion of the nutrition assessment (including the Minimum Data Sheet, Care area assessment and assessment) for all residents within 14 days of admission. -Procedures 2. The RDN or other clinically qualified nutrition professional will be responsible for the completion of a comprehensive assessment annually, upon referral, or as indicated by the clinical condition of the resident. -Procedures 4. The RDN or other clinically qualified nutrition professional may delegate tasks associated with the assessment process, such as data collection, data entry, etc. to the Diet Technician, Registered Diet Technician, or the Dining Service Director within the scope of their practice and validated competency. Including Admission, annual, quarterly and as indicated by the clinical condition of the resident. b) Resident #8 A review of Resident #8's medical record revealed: -admission date: 06/02/23 -Registered dietician assessments done: 06/26/23 admission assessment 08/08/23 quarterly assessment 09/14/23 quarterly assessment 05/01/24 quarterly assessment 08/01/24 quarterly assessment 11/24/24 annual assessment 02/04/25 quarterly assessment 5/12/25 quarterly assessment 12/08/25 annual assessment. -No annual assessments completed for 06/26/24 and 06/26/25 within a 30 day window. -Progress notes per Dietary Supervisor and or Registered Dietician 06/23/23 admission note from Supervisor 10/23/23 nutrition follow up from Registered Dietician 11/23/23 nutrition follow up from Registered Dietician 12/28/23 nutrition follow up from Registered Dietician 02/08/24 nutrition note from Dietary Supervisor c) Resident #71 A review of Resident #71's medical record revealed: -12/04/24- admission assessment -02/19/25- weight change -03/02/25-quarterley assessment -03/27/25- weight change -06/21/25- quarterly assessment -No annual assessment completed for 12/04/25 within a 30 day window. d) Resident #78 A review of Resident #8's medical record revealed: -08/23/22- admission assessment -08/14/23- annual assessment -10/31/23- weight change -05/13/24-quarterly assessment -08/09/24-annual assessment -11/24/24-quarterly assessment -02/11/25-quarterly assessment -05/12/25-quarterly assessment -No annual assessment completed for 8/09/25 within a 30 day window . e) Interview with Dietary Supervisor On 02/11/2026 at 8:42 AM, the State Agency (SA) interviewed the Dietary Supervisor and questioned the process for ensuring nutrition assessments for annual, quarterly etc. are done. The Dietary Supervisor reported, The dietician does all these, she is in house monthly and does remotely. When asked if she assisted the dietician with any of these the Dietary Supervisor reported, Oh no, she does them, I am not qualified. When the SA reviewed the above-mentioned policy with the Dietary Supervisor, she reported, Oh, I did not know that. f) During an interview on 02/11/2026 at 9:00 AM, the Registered Dietician was questioned how often nutritional assessments were being completed. She reported, Generally, we do assessments on admission and annually, sometimes quarterly. However, if a quarterly is done we do those in the progress notes. g) Resident #74 A review of the Resident #74's medical record outlined the resident had a weight loss of -11.1% over the past six months. On 08/26/2025, the resident weighed 326 pounds (lbs). On 02/03/2026, the resident weighed 289.8 lbs. The following pertinent diagnoses were found: - MORBID (SEVERE) OBESITY DUE TO EXCESS CALORIES - TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED - ANEMIA IN OTHER CHRONIC DISEASES CLASSIFIED ELSEWHERE - DEFICIENCY OF OTHER SPECIFIED B GROUP VITAMINS - VITAMIN D DEFICIENCY - ESSENTIAL (PRIMARY) HYPERTENSION - GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS n The resident had the following orders pertaining to diet: - Regular diet, Regular texture, Regular/Thin consistency Diet Active 2/18/2021 - Resident may participate in special activity, food/meals that may not adhere to diet. No directions specified for order. Other Active - Mounjaro Subcutaneous Solution Pen-injector 15 mg/.5 ml (Tirzepatide) Inject 0.5 ml (10 mg total) under the skin every 7 days The resident's care plan report stated, [First name of resident] wishes to lose weight, and rehabilitate to return home. She realizes that it will take awhile. However, her behaviors do not exhibit this desire. She is resistant to participate in therapy and she is not following her diet. Due to behaviors, this may be a long term placement. Under the focus of Diabetes Mellitus, the care plan states under intervention, dietary consult for nutritional regimen and ongoing monitoring PRN (as needed). According to the facility's policy entitled, Medical Nutrition Therapy: Assessment and Care Planning, developed on 05/2014 and last revised on 09/2017, .The resident/patient nutrition status will be assessed upon admission and monitored at least quarterly thereafter. A review of Resident #74's medical record revealed quarterly nutritional assessments completed on 09/01/24, 03/02/25, and 06/21/25. An annual assessment was completed on 12/24/25. There were no quarterly assessments after 06/21/25. At the 06/21/25 assessment, Dietician #174 documented insignificant weight changes with loss x 3 and 6 months and gain x 1 month. Goal for wt. loss to BMI < 40 Regular diet with diet condiments, regular texture, thin liquids Current interventions: diet condiments, fruit in place of dessert for L & D (lunch and dinner), fresh fruit all meals, hard boiled egg x 2 for L & D, banana, toast, bacon, yogurt, oatmeal, and scrambled eggs for B, and choc chip cookies for HS snack. Resident desires wt loss but requests high kcal items .Recommend continuing with physician prescribed wt loss regimen. During an interview with the Dietician on 02/11/26 at 8:55 AM, when asked about the time frames for completing her nutritional assessments on the residents, she responded, I try to do it at admission and annually. If I get time, I will do them quarterly. She further stated, Sometimes I just document in the resident's progress notes for the quarterly assessment. When surveyor indicated there was no nutritional assessments documented in the resident's record after June 2025 quarter, the Dietician had no response. A review of the resident's progress notes for the time period of 09/01/25 through 02/10/26, found no progress notes from the dietician.

Based upon record review and staff interview, the facility failed to post daily nurse staffing data containing all required regulatory data. This was found to be true for 17 days of 17 days reviewed during the long-term care survey process. Facility census: 90Findings included: Posted nurse staffing data was requested for 05/24/25, 05/25/25, 05/26/25, 05/27/25, 05/28/25, 05/2925, 05/30/25, 05/31/25, 07/04/25, 07/05/25, 09/03/25, 09/04/25, 09/05/25, 09/06/25, 10/30/25, 10/31/25, 12/26/25, and 12/27/25. Results included: 05/24/25 - the total hours worked were not included for Registered Nurses (RN), Licensed Practical Nurses (LPN) or Nurse Aides (NA).05/25/25 - the total hours were not included for RN, LPN or NA05/26/25 - the facility unable to locate the posted nursing staffing data for this day05/27/25 - the facility unable to locate the posted nursing staffing data for this day05/28/25 - the facility unable to locate the posted nursing staffing data for this day05/29/25 - the facility unable to locate the posted nursing staffing data for this day05/30/25 - the facility unable to locate the posted nursing staffing data for this day05/31/25 - the facility unable to locate the posted nursing staffing data for this dat.07/04/25 - the total hours worked were not included for RN, LPN or NA07/05/25 - the total hours worked were not included for RN, LPN, or NA09/03/25 - there was no staffing data completed for 7 AM to 11 PM; the total hours worked were not included for RN, LPN, or NA 09/04/25 - the total hours worked were not included for RN, LPN, or NA09/05/25 - there was no staffing data completed for 3 PM until 7 AM, the total hours worked were not included for RN, LPN or NA09/06/25 - the total hours worked were not included for RN, LPN or NA10/30/25 - the total hours worked were not included for RN, LPN or NA10/31/25 - the total hours worked were not included for RN, LPN, or NA12/26/25 - the facility unable to locate the posted nursing staffing data for this day12/27/25 - the total hours worked were not included for RN, LPN, or NA The missing total hours worked was reviewed with the Administrator on 02/11/26 at approximately 11:00 AM. The Administrator stated he did not know what had happened, but the posted nursing staffing data was missing for some days and he could not find it. He recognized the total hours worked was not present on the other dates that were supplied.

Based on observation, record review, and staff interview, the facility failed to ensure a medication error rate of less than five (5) percent. Of 29 medication observations, three (3) errors were observed. This was a medication error rate of 10.34%. Resident identifier: #58. Facility census: 90. Findings included: On 02/10/26 at 9:58 AM, Licensed Practical Nurse (LPN) #80 was observed administering medications to Resident #58. The resident took her meds crushed and placed in pudding. Three (3) of the medications are not recommended to be crushed. These medications were pantoprazole sodium [Protonix], potassium micro extended release, and iron (ferrous sulfate). The National Institutes of Health Daily Med Website gave the following instructions for these three (3) medications: - pantoprazole sodium: Do not split, chew, or crush pantoprazole sodium for delayed-release oral suspension.- potassium: Swallow tablets whole without crushing, chewing or sucking.- iron: Do not crush or chew tablets. Review of Resident #58's physician's orders, showed the following order written on 04/12/24, May crush meds or open capsules as needed unless on DO NOT CRUSH list. May mix with food or fluids. On 02/10/2026 at 1:01 PM, the Director of Nursing (DON) provided the Do Not Crush list. Pantoprazole sodium, potassium, and iron salts were medications on the list. The DON also provided an e-mail from Pharmacist #175 which stated as follows:Ferrous sulfate immediate-release (IR) tablets generally should not be crushed or chewed; they are designed to be swallowed whole to prevent teeth staining, irritation, and to ensure proper absorption. While some specific immediate-release brands (like Feosol) may be crushed if necessary, most guidelines recommend against it. Potassium: Should not be crushed to powder but are made to dissolve or cut in half because the tablet is so large to swallow.Potassium extended-release (ER) tablets, specifically micro-encapsulated formulations like Klor-Con M, can generally be broken in half to make them easier to swallow or dissolved in water. They should not be chewed or sucked, as this can cause severe stomach irritation. Pantoprazole should generally not be crushed but there is data that exists that it can for feeding tube patients:Feeding Tube Use: While the tablets are generally not for crushing, some clinical guidance suggests they can be administered through a feeding tube if done properly by a healthcare provider.Additionally, the DON stated she had received an order from the physician stating to crush the resident's potassium and iron. She stated she also received an order to change pantoprazole to omeprazole. The DON provided the following nursing note written on 2/10/26 at 12:44 PM, Called [physician] regarding crushing certain meds. [Physician] stated we could continue to crush potassium and iron. He would like to switch protonix to omeprazone [sic]. Clarified with pharmacy. Attempted to notify POA [power of attorney], no answer. Left message for POA to call me back regarding med changes.

Based on observation, record review, and staff interview, the facility failed to ensure storage and labeling of medications within accepted standards of practice. An expired multiuse bottle of medication was available for use. Additionally, three (3) multi-use insulin pens were not dated when first accessed. These were random opportunities for discovery during the medication storage and labeling facility task. Resident identifiers: #58, #31, #87, and #4. Facility census: 90.Findings included: a) Expired Medication The facility's policy titled, Administering Medications, with no implementation date given and a revision date of [DATE], stated the expiration/beyond use date on the medication label was to be checked prior to administering the medication. On [DATE] at 8:24 AM, Licensed Practical Nurse (LPN) #80 was observed preparing medications for Resident #58. The resident was ordered cyanocobalamin (Vitamin B12) 500 mcg. LPN #80 got a bottle of cyanocobalamin out of the medication cart and poured out a tablet into the medication cup containing the other medications for the resident. The surveyor observed the expiration date on the cyanocobalamin bottle was [DATE]. LPN #80 confirmed the medication was past its expiration date. She removed the cyanocobalamin tablet from the resident's medication cup. She obtained a new bottle of cyanocobalamin from the medication room and dispensed a tablet from this bottle into the resident's medication cup. b) Undated insulin pens The facility's policy titled Administering Medications, with no implementation date given and a revision date of [DATE], stated when opening a multi-use medication, the date opened would be recorded on the container. On [DATE] at 8:35 AM, the 100 hallway medication cart was inspected with LPN #80 in attendance. Three (3) multi-dose insulin pens in the cart were not dated to indicate when the pens were first accessed. Recording the opening date is important to determine when the pens need to be discarded. These undated insulin pens were as follows: -Humalog insulin pen for Resident #31. The label indicated the pen had been filled by pharmacy on [DATE].-Lantus insulin pen for Resident #87. The label indicated the pen had been filled by pharmacy on [DATE]. -Novalog insulin pen for Resident #4. The label indicated the pen had been filled by pharmacy on [DATE]. LPN #80 confirmed the three (3) insulin pens had not been dated when first accessed to indicate when the pens would need discarded.

Based on observation, staff interview, and resident interview, the facility failed to ensure food temperatures were at a safe and palatable temperature. This was a random opportunity discovered throughout the Long-Term Care Survey Process. Resident identifiers: #1, #2, #6, and #8. Facility census: 90. Findings include: a) Policy for Food preparation and Service reads in part:-1. Danger zone means temperatures above 41 degrees and below 135 degrees that allow the rapid growth of pathogenic, microorganisms that can cause foodborne illness.-3. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, potentially hazardous foods must be maintained at or below 41 degrees or at or above 135 degrees. b) Resident interviewsOn 02/09/2026 at 10:00 AM, Resident #1 reported food is sometimes cold, it takes a while to get to us, the aides don't get in a hurry.On 02/09/2026 at 10:30 AM, Resident #2 reported food is generally not good, need more variety. Cold at times.On 02/09/2026 at 9:30AM, Resident #6 reported, The food is usually cold especially with breakfast, seems like it takes them a good bit to get the food to us.On 02/09/2026 at 2:03 PM, Resident #8 reported, I don't like a lot of the food here, usually it's cold when we get it.c) Food Temperatures The following test tray temperatures were obtained per Dietary Supervisor on 02/10/26 at 12:35 PM:-Taco meat 128.3 degrees Fahrenheit (F)-Rice 128.3 degrees F-Lemonade 43.0 degrees F-Mandarin oranges 51.8 degrees F During an interview with the Dietary Supervisor on 02/10/26 at 12:40PM, she reported, Whenever I do these, we always fail. It takes them too long to pass.

Based on observations and staff interview, the facility failed to ensure food was labeled, dated, and stored in accordance with professional food standards. This was found during the Long Term Care survey process. This deficient practice had the potential to affect more than a minimal number of residents who received nutrition from the kitchen. Facility Census 90.Findings include: a) Policy for tracking temperatures read in part: 2. monthly tracking sheets for all refrigerators and freezers are posted to record temperatures.4. Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening. b) Policy for Refrigerated/Frozen storage reads in part.1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date).4. Refrigerators/walk-ins are not overcrowded. Foods in walk-in are stored off the floor.5. Functioning of the refrigeration and food temperatures are monitored daily and at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements.7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded c) Policy for Food receiving and Storage reads in part under section for Employee Food Storage:-1. Separation from Residents: Food and drink for staff should not be stored in patient care refrigerators or on counters where patient food is prepared. d) Policy for Foodborne Illness-Employee Hygiene and Sanitary Practices reads in partHair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep fair from contacting exposed food, clean equipment, utensils and linens. e) Initial kitchen walkthrough During an initial kitchen walk-through, completed on 02/09/26 at 8:40 AM, the following issues were found: -Food temperature log missing: 02/02/26-dinner temperatures. 02/03/26-breakfast, lunch and dinner temperatures. 02/04/26-breakfast, lunch and dinner temperatures. 02/05/26 breakfast, lunch and dinner temperatures. 02/06/26 dinner temperature. 02/07/26 dinner temperature. 02/08/26 dinner. Dietary Supervisor reviewed with surveyor and verified, reporting, I just can't get them to do these. -Four-door reach in refrigerator temperature log missing: 02/02/26- PM temperature, 02/03/26 AM and PM temperatures, 02/04/26 AM and PM temperatures, 02/05/26 PM temperature, 02/06/26 PM temperature, 02/07/26 PM temperature, and 02/08/26 PM temperature. Dietary supervisor reviewed with surveyor and verified, reporting, I just can't get them to do these -Walk in refrigerator temperature log missing: 02/02/26 PM temperatures. 02/03/26 AM and PM temperatures. 02/04/26 AM and PM temperatures. 02/05/26 PM temperature. 02/06/26 PM temperature. 02/07/26 PM temperature. 02/08/26 PM temperature. Dining supervisor reviewed with surveyor and verified reporting ,I just can't get them to do these. -Ice cream freezer temperature log missing: 02/02/26 PM temperature. 02/03/26 AM and PM temperatures. 02/04/26 AM and PM temperatures. 02/05/26 PM temperature. 02/06/26 PM temperature. 02/07/26 PM temperature. 02/08/26 PM temperature. Dining supervisor reviewed with surveyor and verified reporting, I just can't get them to do these. -Meat freezer temperature log missing: 02/02/26 PM temperature. 02/03/26 PM temperature. 02/04/26 AM and PM temperatures. 02/05/26 PM temperature. 02/06/26 PM temperature. 02/07/26 PM temperature. 02/08/26 PM temperature. Dining supervisor reviewed with surveyor, verified and reported, I just can't get them to do these. - Three (3) bowl sink temperature log missing: 02/02/26 dinner temperature. 02/03/26 breakfast and dinner temperatures. 02/04/26 breakfast and dinner temperatures. 02/05/26 dinner temperatures. 02/06/26 dinner temperature. 02/07/26 dinner temperature. 02/08/26 dinner temperature. Dining supervisor reviewed with surveyor, verified, and reported, I just can't get them to do these. -Dessert temperature log missing: 02/02/26 lunch temperature. 02/03/26 lunch temperature. 02/04/26 lunch temperature. 02/05/26 lunch and dinner temperatures. 02/06/26 dinner temperatures. 02/07/26 dinner temperature. 02/08/26 lunch and dinner temperatures. Dining supervisor reviewed with surveyor, verified, and reported, I just can't get them to do these. -Drink temperature log missing: 02/02/26 breakfast and lunch temperatures. 02/03/26 breakfast and lunch temperatures. 02/04/26 breakfast and lunch temperatures. 02/05/26 breakfast and lunch temperatures. 02/06/26 lunch temperature. 02/08/26 breakfast temperature. Dining supervisor reviewed with surveyor, verified, and reported, I just can't get them to do these. -Walk in refrigerator: no pull date on small totinos pizza, bologna in packet no open or use by date. Container of bacon grease no use by date. X2 employee meals in containers. Ham salad no use by date. Container of red sauce no label or date. Jar of jelly no open or use by date. Container of cream cheese no open or use by date. Dining supervisor with surveyor during tour, verified no dates, and reported, I have never added pull dates on anything. -Walk in freezer #1 (vegetable etc.) box on floor open to air. Chunks of ice on floor under fans. No dates on the cases with exception of us foods deliver tag. Cup of parmesan cheese outdated, dates were: 12/19/25-01/19/26. Dining supervisor with surveyor during tour and informed this surveyor, We never add a receive date, we just use the tags from the vendor, and just know when to remove. e) On 02/09/2026 at 12:45 PM, Dietary Employee #110 was observed preparing food items without beard guard. Dining supervisor verified, informing this surveyor, He usually has one on. She then reminded him to ensure a beard guard was on. f) Kitchen revisit On 02/10/2026 at 10:47 AM, a revisit of the kitchen was completed. The following wet nesting issues were identified: -Six 6) of (12) drinking glasses sitting on a tray no mat in place to allow for air flow-Four (4) of (12) soup bowls sitting on tray no mat in place to allow for air flow- Three (3) of (12) coffee mugs sitting on a tray no mat in place to allow for air flow. The Dietary supervisor was with surveyor during this time, verified the wet nesting, and reported, We leave them on the trays to dry. The reach in refrigerator had a tray of dessert (lemon pie) without a prep date or use by date. The dining supervisor verified this and reported, We will toss after today as they were made on Saturday. The walk in freezer ice build up on floor remained. A case of product was found sitting on the floor. There was no received dates on any cases in the freezer. Dining supervisor with surveyor during this round, verified, and reported, We use the label from the food vendor.

Based upon resident interview, staff interviews, and record review, the facility failed to honor a resident's right for toileting assistance during meal periods. This was a random opportunity for discovery during the long-term care survey process. Resident identifier: #74. Census: 90.Findings included: a) Resident #74 During an interview with Resident #74, on 02/09/26 at 08:45 AM, the resident expressed a concern about nurse aides not wanting to toilet her if it was during meal times. The resident stated staff tell her she will just have to wait until someone is finished with feeding other residents. A review of the resident's care plan under the focus care area of Activities of Daily Living (ADL), documents, .Needs Assist of 2 [two] with most ADLs, bed mobility, transfers, toileting and grooming Transfer with mechanical lift x 2 [two] .Frequent bladder incontinence, occasionally incontinent of bowel. Uses bedpan. Does not ambulate. There were several progress notes in the resident's medical record regarding toileting during meal periods or feeding time. These included: A progress note written by Social Worker (SW) #83 on 01/15/26 at 7:10 PM stated, This SW and ADON [Assistant Director of Nursing] met with this resident to discuss with her a plan of care related to her using the bathroom. ADON discussed with the resident her need to use the bathroom at the start of meals. This resident was aware staff were not able to stop passing trays and feed. The resident reported that she was aware but said she couldn't control when she had to use the bathroom. Another progress note written by Social Worker #83 on 01/19/26 at 12:14 PM stated, Alert made on 01/15/26. Staff reported that this resident reported she was unhappy with the facility and dayshift staff. She told staff, I'm going to get better so I can get out of this damn place. You can't have any privacy. She said They went and told on me for wanting to get changed during meals. There are five or six of them out there on the floor. That's plenty. Social Worker #83, on 01/19/26 at 12:32 PM, wrote a progress note which stated, Alert made on 01/14/26. Staff reported that this resident requested to be changed during tray pass. The CNA [Certified Nursing Assistant] informed this resident that staff were passing out trays and let her know it would be a little bit before they could change her. Staff reported that this resident demanded to be changed now, or she was not eating. A orogress note written by the Social Services Director #118 on 01/22/26 at 4:27 PM stated, Met with [first name, last name of resident]. She admits to feeling upset. She reported that ADON [Assistant Director of Nursing] and SW [Social Worker] came and met with her last week and informed her that she couldn't put her call light on during the lunch break. Explained to Ms. [last name of resident] that it was worker's understanding that they discussed putting her on the bedpan prior to lunch, because there had been several days in a row that resident had a bowel movement during lunch, and staff were unable to meet her needs due to feeding other residents. In an interview with Social Worker #83 at 02/11/26 at approximately 11:10 AM, a question was asked What is the facility's policy or practice as it relates to providing toileting assistance during meal pass? The Social Worker responded, we try to toilet before meals, but, you should probably ask the ADON that question as she oversees the CNAs. During an Interview on 02/11/26 at approximately 1:00 PM, the ADON was asked about the facility's policy or practice if a resident uses their call bell for toileting assistance during meal pass. The ADON stated if they are feeding someone, the resident would have to wait until feeding is finished, then they would respond to the call light. Interpretative Guidance on Regulation 483.10, resident rights provided:Refraining from practices demeaning to residents such as leaving urinary catheter bags uncovered, refusing to comply with a resident's request for bathroom assistance during meal times, and restricting residents from use of common areas open to the general public such as lobbies and restrooms, unless they are on transmission-based isolation precautions or are restricted according to their care planned needs. The practice of refusing the resident to toilet when needed has the potential to impact a resident's psychosocial and physical well being.

Based upon record reviews and staff interviews, the facility failed to inform the resident or resident's representative of the benefits and risk of treatment, as well as a change in medication. This was found to be true for two (2) of five (5) resident records reviewed under the unnecessary drug pathway during the long term care survey process. Resident identifiers: #4, #5. Census: 90. Findings included: a) Resident #4 During a review of Resident #4's medical record, it was determined that Resident #4 did not have capacity to make their own medical decisions. The resident had the following diagnosis, given on 11/12/25, Unspecified Dementia, Unspecified Severity, with Agitation. For this brain disorder, the physician ordered the following medications: Lorazepam Oral Concentrate 2 MG/ML (Lorazepam)Give 0.25 ml by mouth in the morning every Mon, Thu for give prior to resident shower, usually shower is given at 10 AMPharmacy Active prescribed on 11/14/2025 Lorazepam Oral Concentrate 2 MG/ML (Lorazepam)Give 0.25 ml by mouth in the evening for agitationPharmacy Active prescribed on 11/10/2025 Rexulti Oral Tablet 1 MG (Brexpiprazole)Give 1 mg by mouth one time a day related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY Pharmacy Active Prescribed on 10/14/2025 Seroquel Oral Tablet 25 MG (Quetiapine Fumarate)Give 25 mg by mouth two times a day related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETYPharmacy Active Prescribed on 3/21/2025 A review of the Medication Administration Records in the resident's medical record revealed the resident had been receiving these medications as prescribed. The progress notes and miscellaneous documents were reviewed to determine if the resident's representative had been informed of the benefits and risks of the use of these medications (Rexulti, Seroquel and Lorazepam) prior to the resident being provided the medications. There was no evidence that informed consent forms had been signed by resident's representative and scanned into the electronic health record. During an interview on 02/10/26 at 11:00 AM, Medical Records staff #46 stated she could not locate these informed consents. No further documentation was provided prior to surveyor's exit from the building. b) Resident #5 During a review of Resident #4's medical record. the following issues were found: -Resident #5 did not have capacity to make his own medical decisions -The physician altered the resident's order for Seroquel (changing the dosage) on 01/06/2026 -There was no evidence that Resident #4's medical power of attorney (MPOA) was notified of the change in the medication dosage and treatment. During an interview on 02/10/26 at 2:40 PM, the Director of Nursing (DON) stated, The nurses should always notify the resident / power of attorney for any changes to their care / medications, and they must have missed this one.

Based on medical record review and staff interview, the facility failed to follow their policy and procedure on preventing adverse consequences that can occur when two (2) or more medications are combined during treatment that could have adverse consequences that have a negative impact on the residents health, resulting in an hospitalization. This was true for one (1) of three (3) residents reviewed for hospitalizations. Resident identifier: #12. Facility census: 90.Findings include: a) Review of the facility's policy and procedure entitled, Medication monitoring, preventing and detecting adverse consequences and medication errors found the following details:When a resident receives a new medication, the medication order is evaluated for the following:The resident is not taking other medications, nutritional supplements, including herbal products, or foods that would be incompatible with the prescribed medication.Facility staff monitor the resident for possible medication related adverse consequences, including mental status changes and / or changes in level of consciousness, when the following conditions occur:A clinically significant change in condition or statusA worsening of an existing problem or conditionAcute onset of signs or symptoms or worsening of a chronic problem or condition.Addition or discontinuation of medications and / or non-pharmacologic interventions.When any of the above occurs, the prescriber and / or staff rule out medication as a cause and document it in the residents clinical recordThe facility staff monitors residents on the following combinations for possible adverse consequences and / or the need to modify the dose of one or more medications. The prescriber documents why or how these combinations of medications benefits outweigh their risks in the residents clinical record.Anticoagulant meds such as Eliquis and NSAID such as Motrin that are taken together, can cause serious gastrointestinal bleeding In the event of a significant medication error or adverse consequence, immediate action is taken, as necessary, to protect the resident's safety and welfare. Significant is defined as:Requiring medication discontinuation or dose modificationRequiring hospitalization, or extending a hospitalization.The attending physician is notified promptly of any significant error or adverse consequences.The physician's orders are implemented, and the resident is monitored closely for 24 to 72 hours, or as directedThe incident is described on the shift change report to alert staff of the need to monitor the residentThe following information is documented in an incident report and in the resident's clinical recordEach incident report is forwarded to the director of nursing, quality assurance nurse, medical director, consultant pharmacist and the director of the pharmacyResident #12 was given two (2) medications at the same time that can thin the blood and promote unwanted bleeding. On 12/06/2025 at 7:50 AM, Resident #12 went to the nurses desk stating that she was not feeling good. She was complaining of shortness of breath, back pain, and nausea. The nurse stated in her note that Resident #12 was showing signs of distress at this time. On 12/06/2025 at 8:05 AM, the physicians was informed of Resident #12 concerning vital signs and condition. The resident requested to be sent to the emergency room. Her blood pressure was 88/50 and her heart rate was 116. She continued to have pain in her back. On 12/06/2025 at 3:16 PM the nurse call the hospital to follow up on Resident #12's condition. A CT scan showed that she had a pulmonary embolism on the right side and a 6 mm renal stone was found on the left side. On 12/10/2025 at 2:55 PM, Resident #12 was readmitted to the facility from the hospital. She had a physician's order for the anticoagulant (AC) Apixaban oral tablet 5 MG and the nonsteroidal anti-inflammatory drug (NSAID) Ibuprofen 400 MG oral tablet. On 12/10/2025 at 3:12 PM, after the orders were entered into Point Click Care (PCC), the system issued a possible moderate drug to drug interaction, warning of the NSAID Ibuprofen may enhance the AC effect of the Apixaban. The Assistant Director of Nursing (ADON) signed off on this warning on 12/10/2025. On 12/11/2025 at 9:53 PM, a nurse documented in PCC that Resident #12 is very weak and has a small amount of blood in her brief. She also refused all evening meals, fluids and snacks. On 12/12/2025 at 4:37 AM, a nurse notified the physician and documented in PCC that Resident #12 is continuing to have Hematuria (blood in urine) and possible Rectal bleeding in small to moderate amounts. At the time, Resident #12 was receiving 10 MG of Eliquis twice per day (BID) until 12/15/2025 but was also receiving 400 MG of Motrin once per day (QD) which increased the effect of her Eliquis. The nurse asked the physician if they could hold her Motrin for now? There was no evidence the physician responded to the nurse's question or documentation. On 12/12/2025 at 3:38 PM, a nurse documented in the medical record that a Certified Nurse Assistant (CNA) notified them that Resident #12 had a gross amount of red blood in her brief. That same nurse went and observed Resident #12 and noted it to be a gross amount of blood, congruent with a gastrointestinal (GI) bleed. The nurse notified the physician and Resident #12's power of attorney (POA) that they were sending Resident #12 out to the hospital emergency room for treatment. On 12/12/2025 at 3:44 PM, the physician gave the order to send Resident #12 to the ER for a GI bleed. On 12/13/2025 at 3:01 AM, a nurse called the hospital to get an update on Resident #12. The hospital let the nurse know that Resident #12 has a GI bleed and her hemoglobin went from 11.3 to 10.8 while there. On 12/15/2025 at 2:02 PM, the physician at the facility discontinued the order for Motrin 400 MG. On 12/19/2025 at 7:45 PM, Resident #12 was readmitted to the facility from the hospital with diagnosis of pulmonary embolism, acute blood loss anemia, severe dementia, atrial fibrillation, and acute GI bleeding. On the discharge summary from the hospital, the attending physician discontinued the orders for tramadol and NSAID for bleeds. On 02/11/2026 at 10:40 AM, the State Agency (SA) asked the Director of Nursing (DON) for the policy and procedure on preventing and detecting adverse consequences and medication errors. The DON gave the requested information at 10:45 AM. During an interview on 02/11/2026 at 10:50 AM, the ADON was asked what a nurse should do if they receive a drug to drug interaction warning on PCC? The ADON stated that if it was mild to moderate they wouldn't do anything. If it was moderate to severe then they would notify the physician. The ADON read the progress notes from the nurse on 12/12/2025 at 4:37 AM, in which the nurse documented they notified the physician and documented in the electronic medical record that Resident #12 is continuing to have hematuria (blood in urine) and possible rectal bleeding in small to moderate amounts. Resident #12 is receiving 10 MG of Eliquis twice per day (BID) until 12/15/2025, but is also receiving 400 MG of Motrin once per day (QD) which increases the anticoagulant effects of her Eliquis. The nurse asked the physician if they could hold her Motrin for now? After the ADON read the note, the SA asked how long should it take for the physician to answer the nurses question and concern about the drug interaction. She answered, I don't know.

Based upon record review and staff interview, the facility failed to perform a drug regimen at least once a month by a licensed pharmacist. This was found to be true for one (1) of five (5) residents reviewed under the unnecessary drug pathway during the long-term care survey process. Resident identifier: #4. Facility census: 90. Findings included: a) Policy Review The facility policy entitled, Monitoring Medication Regimen Review, dated 12/17, stated, The ACP (AlixaRx Clinical Pharmacist) performs a comprehensive review of each resident's medical record at least monthly. The medication regimen review (MRR) is a thorough evaluation of the medical regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. b) Resident #4 A record review revealed the facility did not have documentation in the electronic medical record showing the necessary monthly drug regimen reviews had been completed for the following months: -January 2025-February 2025-March 2025-April 2025-May 2025-June 2025-July 2025-August 2025-September 2025-October 2025-November 2025-December 2025-January 2026 These missing reports were requested from the facility on 02/09/25 at approximately 4:00 PM. Medical Records Employee #46, on 02/10/26, provided completed monthly medication regimen reviews for April 2025 through January 2026, but failed to provide anything for January 2025, February 2025, and March 2025. Evidence that monthly medication regimen reviews had been completed for January through March 2025 was requested again on 2/10/25 at 11:15 AM. The Medical Records Employee #46 provided a copy of the completed March 2025 review on 02/10/26 at 11:30 AM. Then the medical records employee reported she could not locate the reports for January 2025 or February 2025. No further information / documentation was provided prior to the end of the survey.

Based on record review and staff interview, the facility failed to ensure dietary staff had the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. The facility did not ensure all Dietary Staff received their food handlers card within 30 days after being hired. This was found during the Annual Long-Term Care Survey Process. Facility census: 90.Findings include: a) Guidelines Per local health department guidelines for Grant County, the employee should earn a food handlers card within 30 days of starting work. b) Review of Staff Records Two (2) of (15) dietary records reviewed found the food handler cards were not obtained within the (30) day guideline after hire date. - Dietary Employee #71 had a hire date of 07/23/25. A food handlers card was obtained on 09/16/25. - Dietary Employee #119 had a hire date 08/18/25. A food handler card was obtained on 10/14/25. c) Interview with Dietary Supervisor During an interview, on 02/10/26 at around 1:30PM the Dietary Supervisor verified the food handler cards for the above-mentioned employees were not obtained within the 30 day timeline per health department recommendations. The Dietary Supervisor reported, We missed these prior.

Based on observation and staff interview, the facility failed to ensure all garbage and dumpsters were properly contained and that the dumpsters were covered with lids (or otherwise covered.) This was true for three (3) of the four (4) dumpsters observed. This was a random opportunity for discovery during the Long-Term Care Survey Process. Facility Census 90.Findings include: a) Policy Review The policy for Sanitation reads in part under interpretation and Implementation-14. Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactors with lids (or otherwise covered.)-15. Areas used for garbage disposal are free from odors and waste fats, and maintained to prevent pests. Guidelines for garbage and refuse containers reads in part:-Garbage and refuse containers need to be in good condition (no leaks) and is waste properly contained in dumpsters with lids or otherwise covered. b) Observations and Interview On 02/10/2026 at 8:30 AM, three (3) of the four (4) dumpsters observed were found with lids open and trash hanging over the edges. On 02/10/2026 at 10:30 AM, three (3) of the four dumpsters observed were found with lids open and trash hanging over the edges. On 02/10/2026 at 10:45 AM, the Dining manager observed and verified the lids for three (3) of four (4) dumpsters were open with trash hanging over the edges. The Dining manager closed the lids and reported, I have told everyone these need to stay closed.

Based on facility record review and staff interview, the facility failed to complete final internal food temperatures and ensure food was held prior to food service at appropriate temperatures. This has the potential to affect all residents that receive their nutrition form the kitchen. Facility census: 82 Findings include: a) Food tempetures On 04/15/24 at12:20 PM during a tour of the kitchen it was discovered the Food temperatures were not completed on: -evening meal 04/01/24 -evening meal 04/02/24 -evening meal 04/03/24 -evening meal 04/04/24 -all meals 04/05/24 -all meals 04/08/24 -evening meal 04/10/24 -all meals 04/11/24 -evening meal 04/12/24 -all meals 04/13/24 -evening meal 04/14/24 During an interview on 04/15/24 at 12:23 PM the Certified Dietary Manager verified the food temperatures were not being completed daily as required.

Based on observation and staff interview the facility failed to complete labeling and dates in a unit refrigerator and complete refrigerator temperature log unit refrigerator and freezers on the 100, 200 and Sub halls and main dining room in accordance with professional standards for food service safety related to storage. This has the ability to affect all Residents that get their nutrition from the kitchen. Facility Census: 82. Findings Include: a) 100 Hall Unit Refrigerator Observation during the Unit tour on 04/15/24 at 12:44 PM found 3 sodas open, cherry pie, and plastic container in the resident refrigerator with no labeling or dates. During an interview on 04/15/24 at 11:44, the Dietary Manager (DM) verified there was no labeling or dates on the items in the 100-hall resident refrigerator. b) Refrigerator / Freezer Temperature Log On 04/15/24 at 12:58 PM facility record review of the refrigerator temperature log for unit refrigerator and freezers on the 100, 200 and Sub halls and main dining room found the temperatures was not completed on the log at this time on: -04/01/24 -04/06/24 -04/07/24 -04/11/24 -04/14/24 -04/15/24 On 04/15/24 at 12:58 PM during an interview the DM verified that the refrigerator temperatures should have been completed.

Based on record review and staff interview, the facility failed to implement appropriate interventions for quality deficiencies of which it was aware. This deficient practice had the potential to affect all residents residing in the facility. Facility census: 82. Findings included: a) Skin assessments. On 04/16/24 at 3:40 PM, the Director of Nursing (DON) was interviewed and asked about the facility form called a, SHOWER BODY AUDIT for Residents. The DON said the Nurse Aides do skin assessments when they give showers. If they find a concern, they mark it on the shower body audit sheet and the nurse will go and assess it, then sign the shower body audit. The DON was asked if a Licensed Nurse does routine skin assessments on everyone. The DON said no they go by what the Aides find. Also, at this same time the Licensed Practical Nurse/Treatment Nurse (TN) #120 was present for this interview via phone. TN #120 stated she does not do routine skin assessments. The DON agreed that while it is good practice for the Nurse Aides to report any skin issues they find, a licensed nurse has the training to assess skin issues. During the above interview the DON confirmed routine and/or weekly skin assessments are not being done by a licensed nurse. From the website. NCBI (National Institutes of Health) A complete skin assessment is essential for holistic care and must be completed by nurses and other health professionals on a regular basis. Providing patients and relatives with information on good skin hygiene can improve skin integrity and reduce the risk of pressure damage and skin tears. The assessments need to be repeated on a regular basis to determine whether any changes in skin condition have occurred. In Long term care facilities, comprehensive skin assessment should be performed by a unit nurse on admission to the unit, daily, and on transfer or discharge. This includes assessment of skin color, moisture, temperature, texture, mobility and turgor, and skin lesions. Inspect and palpate the fingernails and toenails, noting their color and shape and whether any lesions are present. b) Interview On 04/17/24 at 12:49 PM, the Administrator and Corporate Compliance Officer were interviewed. The Administrator and Corporate Compliance Officer stated a Performance Improvement Project (PIP) had been done regarding pressure ulcers. An intervention had been implemented for Nursing Aides (NAs) to perform skin assessments during resident bathing activities. The Administrator and Corporate Compliance Officer confirmed no measures had been implemented for routine skin assessments by licensed nursing staff.

Based on record review and staff interview, the facility failed to document the attendance of the Medical Director or designee at all quarterly Quality Assurance Performance Improvement (QAPI) meetings. This deficient practice had the potential to affect all residents residing in the facility. Facility census: 82. Findings include: a) Meeting attendance by medical director On 04/16/24 at 4:21 PM, the Administrator stated Quality Assurance Performance Improvement (QAPI) meetings were held every month. The Administrator stated the facility's Medical Director attended the quarterly meetings held on January, April, July, and October. However, the Administrator was unable to locate the QAPI attendance record for April 2024 to document the Medical Director's attendance at the meeting. No further information was provided through the completion of the survey process.

Based on record review and staff interview, the facility failed to ensure a new Preadmission Screening and Resident Review (PASARR) was completed for Resident #68, #67, and #18 when the residents developed a new mental illness diagnosis during their stay at the facility. This was true for three (3) out of five (5) residents reviewed for care area of PASARR during the long term care survey process. Resident Identifier: #68, #67, and #18. Facility census: 82. Findings include: A) Resident #68 At approximately 2:30 PM on 04/15/24 a record review was conducted for Resident #68. The record noted the resident was admitted to the facility with a PASARR dated 09/01/23. A review of Resident #68's diagnoses noted the resident was diagnosed with Major Depressive Disorder on 10/30/23. Further review indicated the facility had not completed a new PASARR for Resident #68. At approximately 2:01 PM on 04/16/24, the Director of Nursing (DON) acknowledged the facility had not yet completed a new PASARR for Resident #68 after the diagnosis was added. The DON stated they were not aware a new PASARR needed to be completed after a new diagnosis of a major mental illness. B) Resident #67 At approximately 3:00 PM on 04/15/24 a record review was conducted for Resident #67. The record review noted the resident was admitted to the facility with a PASARR dated 11/23/22. A review of Resident #67's diagnoses noted the resident was diagnosed with Major Depressive Disorder on 08/07/23. Further review indicated the facility had not completed a new PASARR for Resident #67. At approximately 2:01 PM on 04/16/24, the Director of Nursing (DON) acknowledged the facility had not yet completed a new PASARR for Resident #67 after the diagnosis. The DON stated they were not aware a new PASARR needed to be completed after a new diagnosis of a major mental illness. c) Resident #18 Review of Resident #18's medical records showed the resident was admitted to the facility in 2017. Further review of Resident #18's medical records showed a PASRR was completed on 05/22/17. The resident was noted to have a diagnosis of major depression. PASRR Level II screening was recommended. However, PASRR Level II desk review determined Resident #18 was not in the Level II screening population and nursing home placement was determined to be appropriate. On 06/05/18, Resident #18 received a diagnosis of bipolar disorder. An updated PASRR was not completed for the resident to determine whether nursing home placement continued to be appropriate for the resident. On 04/16/24 at 3:49 PM, the Director of Nursing confirmed Resident #18's most recent PASRR was performed on 05/22/17 and an updated PASRR was not completed when the resident received a new diagnosis of bipolar disorder in 2018. No further information was provided through the completion of the survey process. 49467

Based on observation, medical record review and staff interview the facility failed to ensure skin assessments were done at a professional standard of practice and failed to administer Immunizations recommended by the CDC in a timely manner. This failed practice had the potential to affect more than a limited number of residents who currently reside at the facility. Resident Identifier: #52, #19, #18, and #12. Facility census 82. Findings include: a) Skin assessments. On 04/16/24 at 3:40 PM, the Director of Nursing (DON) was interviewed and asked about the facility form called a, SHOWER BODY AUDIT for Residents. The DON said the Nurse Aides do skin assessments when they give showers. If they find a concern, they mark it on the shower body audit sheet and the nurse will go and assess it, then sign the shower body audit. The DON was asked if a Licensed Nurse does routine skin assessments on everyone. The DON said no they go by what the Aides find. Also, at this same time the Licensed Practical Nurse/Treatment Nurse (TN) #120 was present for this interview via phone. TN #120 stated she does not do routine skin assessments. The DON agreed that while it is good practice for the Nurse Aides to report any skin issues they find, a licensed nurse has the training to assess skin issues. During the above interview the DON confirmed routine and/or weekly skin assessments are not being done by a licensed nurse. From the website. NCBI (National Institutes of Health) A complete skin assessment is essential for holistic care and must be completed by nurses and other health professionals on a regular basis. Providing patients and relatives with information on good skin hygiene can improve skin integrity and reduce the risk of pressure damage and skin tears. The assessments need to be repeated on a regular basis to determine whether any changes in skin condition have occurred. In Long term care facilities, comprehensive skin assessment should be performed by a unit nurse on admission to the unit, daily, and on transfer or discharge. This includes assessment of skin color, moisture, temperature, texture, mobility and turgor, and skin lesions. Inspect and palpate the fingernails and toenails, noting their color and shape and whether any lesions are present. b) Facility Immunizations On 04/17/24 at 8:30 AM, a record review found the facility failed to provide information and/or administer the Respiratory Syncytial Virus (RSV), Pneumococcal, the Recombinant Zoster Vaccine (RZV)/Shingrix and the Moderna/Pfizer Fall 2023 immunization per recommendation of the CDC in a timely manner. The Centers for Disease Control and Prevention (CDC) Respiratory Syncytial virus, or RSV, is a common respiratory virus that usually causes mild, cold-like symptoms. Most people recover in a week or two, but RSV can be serious. Infants and older adults are more likely to develop severe RSV and need hospitalization . Vaccines are available to protect older adults from severe RSV. Monoclonal antibody products are available to protect infants and young children from severe RSV. CDC recommends RSV vaccines to protect adults ages 60 and older from severe RSV, using shared clinical decision-making. According to the CDC the RSV vaccine was made available on early August of 2023. In general, simultaneous administration of vaccines remains a best practice. Providers should continue to simultaneously administer the vaccines for which a patient is eligible, including COVID-19, influenza, and pneumococcal vaccines. Simultaneous administration of RSV vaccine with other vaccines for older adults is also acceptable. When deciding whether to simultaneously administer other vaccines with RSV vaccine on the same day, providers should consider whether the patient is up to date with recommendations for currently recommended vaccines, the feasibility of administering additional vaccine doses later, risk for acquiring vaccine-preventable disease, vaccine reactogenicity profiles, and patient preferences. .recommendations specify the use of either PCV20 alone or PCV15 in series with PPSV23 for all adults aged =[AGE] years and for adults aged 19-[AGE] years with certain underlying medical conditions or other risk factors who have not received a PCV or whose vaccination history is unknown. In addition, ACIP recommends use of either a single dose of PCV20 or =1 dose of PPSV23 for adults who have started their pneumococcal vaccine series with PCV13 but have not received all recommended PPSV23 doses. Shared clinical decision-making is recommended regarding use of a supplemental PCV20 dose for adults aged =[AGE] years who have completed their recommended vaccine series with both PCV13 and PPSV23 . Above information was taken from the website: Centers for Disease Control and Prevention (.gov) A random sample of five (5) residents were chosen to review immunizations. Resident #12 had consented to the Pneumococcal (PCV 20), Respiratory Syncytial Virus (RSV), and the Recombinant Zoster Vaccine (RZV)/Shingrix vaccinations on 02/29/24. As of 04/17/24 none of the above vaccines had been administered. Resident #18 had consented to the Pneumococcal (PCV 20), Respiratory Syncytial Virus (RSV), the Recombinant Zoster Vaccine (RZV)/Shingrix and the Pfizer Fall 2023 vaccinations on 04/17/24 (the date of the interview with the Infection Preventionist). As of 04/17/24 none of the above vaccines had been administered. Resident #19 had consented to the Respiratory Syncytial Virus (RSV) and the Recombinant Zoster Vaccine (RZV)/Shingrix vaccinations on 02/16/24. As of 04/17/24 none of the above vaccines had been administered. Resident #52 had consented to the Pneumococcal (PCV 20), Respiratory Syncytial Virus (RSV), and the Recombinant Zoster Vaccine (RZV)/Shingrix vaccinations on 04/10/24. As of 04/17/24 none of the above vaccines had been administered. On 04/17/24 at 11:45 AM during an interview with the Infection Preventionist (IP), she stated she had not given the RSV vaccines yet because she had not received them from the pharmacy. When ask when she ordered them, she responded a few days ago. When asked what the plan was to administer the vaccines that were not complete yet, she stated she planned to administer the RSV when they come in, the COVID 2023 fall vaccination two (2) weeks after the RSV, the Recombinant Zoster Vaccine (RZV)/Shingrix vaccine two (2) weeks after the COVID, and the Pneumococcal vaccines two (2) weeks after the RZV. She plans to have all vaccines up to date in six (6) to eight (8) weeks. She states she has not administered any RSV or RZV vaccinations for the [AGE] year. The IP stated she did not know the guidelines for CDC in administering the vaccinations as it pertains to seasons it is to be administered in. On 04/17/24 at 12:30 PM the above information was confirmed with the IP at which time she stated, I agree the vaccines should have already been administered in order to be completed in a timely manner. 45171

Based on observation and staff interview the facility failed to ensure the resident environment over which it had control was as free of accident hazards as is possible . These failed practices were random opportunities for discovery and was true for Resident #65 and #26. Resident identifiers: #65 and #26. Facility census 82. Findings include: a) Resident #65 Resident #65 was observed on 04/16/24 at 11:55 AM, being lifted from his Geri chair in the Day room by Nurse Aide (NA) #50 and #55. It was noted the residents' pants were not pulled up over his brief and he was exposed to everyone in the Day room. There were 14 residents in the day room and two (2) visitors. The white brief on Resident #65 appeared to be very heavy and was hanging very low, while the resident was hanging in the air being pushed to the bathroom. Resident #65 was transported approximately 10-12 feet into the bathroom via a mechanical lift. The two (2) NA's used the lift to transport Resident #65 to the bathroom. At 12:02 PM the same two (2) NA's pushed Resident #65 out of the bathroom with the lift back to the chair. A brief interview on 04/16/24 at 12:06 PM, NA #50 was asked about providing privacy for Resident #65. NA #50 stated, she did not know his pants were pulled down. NA #50 stated using the lift to take residents to the bathroom is what they have always done. NA#50 went on to say Resident #65 had a brief on, so he was not really exposed. b) Resident #26 Review of the facility's policy titled Self-Administration of Medications with initiation date 2001 and revision date of February 2021 stated as follows: - The Intradisciplinary Team (IDT) would determine whether residents had the cognitive and physical abilities to safely self-administer medications. - If it was deemed safe and appropriate for a resident to self-administer medications, this would be documented in the medical record and care plan. - Residents who are identified as being able to self-administer medications would be asked if they wished to do so. On 04/17/24 at 7:50 AM, Licensed Practical Nurse (LPN) #104 was observed administering medications to Resident #26. LPN #104 placed the following oral medications into a medication cup: - Amiloride for hypertension - Colace for constipation - Cranberry tablet for history of urinary tract infections - Gabapentin for diabetic neuropathy (Gabapentin is also a controlled substance, kept in a special drawer of the medication cart. Administration of controlled substances is carefully monitored.) - Synthroid for hypothyroidism - Lasix for edema - Lisinopril for hypertension - Prilosec for gastro-esophageal reflux disease - Magnesium for vitamin deficiency - Ferrex for anemia - Famotidine for gastro-esophageal reflux disease - Fiber capsule for constipation - Buspar for anxiety disorder - Metformin for diabetes mellitus - Prozac for major depressive syndrome - Senna for constipation - Multivitamin for vitamin deficiency - Vitamin B12 for deficiency - Vitamin D3 for deficiency - Zyrtec for chronic sinusitis - Trajenta for type II diabetes mellitus Miralax powder for constipation was also placed in a cup. LPN #104 stated Resident #26 liked to mix the Miralax with coffee she already had in her room. LPN #104 entered Resident #26's room with the medications. Resident was lying in bed with the overbed table across the bed. LPN #104 placed Resident #26's oral medications on the overbed table. LPN #104 stated the resident had capacity and would take the medications on her own. LPN #104 then left the resident's room. In the hallway, LPN #104 was questioned about leaving Resident #26's medications in her room for the resident to take independently. LPN #104 stated Resident #26 was care planned to self-administer medications. Review of Resident #26's medical records showed a form titled Self-Administration of Drugs. The form had been signed on 03/13/18 and Resident #26 indicated I do not wish to exercise my right to self-administer my own medications to keep any medications at bedside. Review of Resident #26's comprehensive care plan contained no indication the resident was care planned to self-administer medications. On 04/17/24 at 9:12 AM, the Director of Nursing agreed Resident #26's medications should not have been left at the resident's bedside for the resident to take independently. No further information was provided through the completion of the survey. 39571

Based on observation, resident interview, staff interview, record review and policy review, the facility failed to ensure a resident was free from neglect. Resident #85, assessed as a high fall risk, was left unattended while on the toilet resulting in a fall with a fracture. This failed practice caused actual physical harm to Resident #85 when she was left unsupervised (in violation of her care plan) and sustained a fall that resulted in a broken arm. Resident identifier: #85. Facility census: 102. Findings included: a) Resident #85 An observation of the Resident, on 08/12/19 at 1:45 PM, revealed the Resident had her right arm in a sling. An interview with the Resident, on 08/12/19 at 1:47 PM, revealed she had fallen in the bathroom a few weeks ago when I was left alone on the toilet. The Resident stated I broke my arm when I fell . A review of the Resident's Care Plan, on 08/12/19 at 1:55 PM, revealed the following focus area: --The resident is athigh risk for falls with injury related to gait and balance problems, incontinence, psychoactive drug use, and attempting to transfer alone without the intervention. --Intervention was noted as the assistance of 1 to 2 staff to transfer to the bathroom --Further intervention was noted as the staff were to not leave the resident alone on the commode This care plan had an initiation date of 07/26/19. A review of the Resident's Admission Minimum Data Set (MDS) Resident Assessment and Care Screening, on 08/12/19 at 2:10 PM, revealed the MDS Assessment was completed on 07/19/19. The functional status in Section G concerning toilet use assessed the Resident as extensive assistance with two plus person assistance when the resident uses the toilet. A review of the Resident's Progress Notes, on 08/12/19 at 2:30 PM, revealed the Resident was admitted to the facility on [DATE]. A Progress Note stated the Resident was sent to an acute care hospital on [DATE]. The note further stated the Resident returned from the hospital with an immobililzer to the right arm. A progress note dated 08/04/19 stated the emergency room discharge instructions included the Resident being diagnosed with [REDACTED]. The progress notes did not include why the Resident was sent to the hospital or any falls at that time. Further review of the medical record, on 08/12/19 at 3:00 PM, revealed an X-Ray Report dated 08/03/19 that was taken at the acute care hospital. The report stated the an acute comminuted [MEDICAL CONDITION] proximal humerus. An interview with the Director of Nursing (DON), on 08/13/19 at 1:00 PM, revealed the Resident had fallen on 08/03/19 and broke her arm. The DON stated there are no Progress Notes concerning the fall. The DON stated the only place the fall is documented is on the Incident Report. The DON stated this fall as well as all other falls should be documented in the Progress Notes. A review of the Incident Report, on 08/13/19 at 1:15 PM, revealed an unwitnessed fall occurred for the Resident on 08/03/19. The incident description stated the Certified Nursing Assistant was in bathroom with the Resident and needed a brief so she ran down the hall to get one. The Resident fell on to the floor and was found on her right side with her right arm under her. A further interview with the DON, on 08/13/19 at 1:30 PM, revealed the Nurse Aide taking care of the Resident should have never left her alone to get supplies. The DON confirmed the Resident's Care Plan stated to not leave the Resident alone in the bathroom and that the Resident was assessed on the MDS as requiring extensive assistance involving two staff members with toileting. The DON did confirm the resident sustained [REDACTED]. The DON stated this incident would be considered neglect on the part of the nurse aide caring for the Resident at the time of the fall. A review of the (undated) facility policy titled Abuse and Neglect, on 08/13/19 at 1:55 PM, revealed the policy stated Neglect means the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. This failed practice caused actual physical harm to Resident #85 when she was left unsupervised (in violation of her care plan) and sustained a fall that resulted in a broken arm.

Based on observation, resident interview, record review, and staff interview, the facility failed to provide an environment free from accident hazards over which it had control. Resident #85, assessed as a high fall risk, was left unattended while on the toilet resulting in a fall with a fracture. This failed practice caused actual physical harm to Resident #85 when she was left unsupervised (in violation of her care plan) and sustained a fall that resulted in a broken arm. The facility also failed failed to store chemical substances, razors, scissors, and equipment securely on the 100 Hall, 200 Hall, and 300 Hall. Medication carts on the 100 Hall and 300 Hall were also observed to be unlocked. These practices affected more than a limited number of residents. Resident identifier: #85. Facility census: 102. Findings included: a) Resident #85 An observation of the Resident, on 08/12/19 at 1:45 PM, revealed the Resident had her right arm in a sling. An interview with the Resident, on 08/12/19 at 1:47 PM, revealed she had fallen in the bathroom a few weeks ago when I was left alone on the toilet. The Resident stated I broke my arm when I fell . A review of the Resident's Care Plan, on 08/12/19 at 1:55 PM, revealed the following focus area: --The resident is athigh risk for falls with injury related to gait and balance problems, incontinence, psychoactive drug use, and attempting to transfer alone without the intervention. --Intervention was noted as the assistance of 1 to 2 staff to transfer to the bathroom. --Further intervention was noted as the staff were to not leave the resident alone on the commode. This care plan had an initiation date of 07/26/19. A review of the Resident's Admission Minimum Data Set (MDS) Resident Assessment and Care Screening, on 08/12/19 at 2:10 PM, revealed the MDS Assessment was completed on 07/19/19. The functional status in Section G concerning toilet use assessed the Resident as extensive assistance with two plus person assistance the the resident uses the toilet. A review of the Resident's Progress Notes, on 08/12/19 at 2:30 PM, revealed the Resident was admitted to the facility on [DATE]. A Progress Note stated the Resident was sent to an acute care hospital on [DATE]. The note further stated the Resident returned from the hospital with an immobililzer to the right arm. A progress note dated 08/04/19 stated the emergency room discharge instructions included the Resident being diagnosed with [REDACTED]. The progress notes did not include why the Resident was sent to the hospital or any falls at that time. Further review of the medical record, on 08/12/19 at 3:00 PM, revealed an X-Ray Report dated 08/03/19 that was taken at the acute care hospital. The report stated the an acute comminuted [MEDICAL CONDITION] proximal humerus. An interview with the Director of Nursing (DON), on 08/13/19 at 1:00 PM, revealed the Resident had fallen on 08/03/19 and broke her arm. The DON stated there are no Progress Notes concerning the fall. The DON stated the only place the fall is documented is on the Incident Report. The DON stated this fall as well as all other falls should be documented in the Progress Notes. A review of the Incident Report, on 08/13/19 at 1:15 PM, revealed an unwitnessed fall occurred for the Resident on 08/03/19. The incident description stated the Certified Nursing Assistant was in bathroom with the Resident and needed a brief so she ran down the hall to get one. The Resident fell on to the floor and was found on her right side with her right arm under her. A further interview with the DON, on 08/13/19 at 1:30 PM, revealed the Nurse Aide taking care of the Resident should have never left her alone to get supplies. The DON confirmed the Resident's Care Plan stated to not leave the Resident alone in the bathroom and that the Resident was assessed on the MDS as requiring extensive assistance involving two staff members. The DON did confirm the resident sustained [REDACTED]. This failed practice caused actual physical harm to Resident #85 when she was left unsupervised (in violation of her care plan) and sustained a fall that resulted in a broken arm. b) Medication Carts An observation of the 300 Hall, on 08/12/19 at 11:25 AM, revealed the medication cart was in the hallway. The medication cart was unlocked from 11:25 AM to 11:30 AM. Seven (7) residents were observed to be in the hallway in close proximity to the medication cart. The nurse in charge of the medication cart was in the Medication Storage Room and could not visibly see the cart while it was unlocked. An interview with Licensed Practical Nurse (LPN) #54, on 08/12/19 at 11:30 AM, revealed she only walked away from the medication cart for a few minutes. The LPN stated the medication carts should always be locked. An observation of the 100 Hall, on 08/13/19 at 10:25 AM, revealed the medication cart was in the hallway. The medication cart was unlocked from 10:25 AM to 10:30 AM. The nurse in charge of the medication cart was in the Shower Room and could not visibly see the cart while it was unlocked. An interview with LPN #78, on 08/13/19 at 10:30 AM, revealed the medication cart should have been locked before she walked away from it. c) 300 Hall Chemicals An observation of the 300 Hall Shower Room, on 08/12/19 at 11:35 AM, revealed the door to the room was propped open and accessible to anyone. The Shower Room contained the following items in unlocked drawers and baskets: --Two (2) bottles of Scruples Shampoo with the warning Keep out of reach of children-If swallowed get medical help or contact a Poison Control Center. --Three (3) containers of Remedy Phytoplex Cleanser with the warning For external use only. --One (1) container of Vitamin A & D Ointment with the warning Keep out of reach of children-If swallowed get medical help or contact a Poison Control Center. --One (1) container of Lysol Disinfectant Spray with the warning Causes moderate eye irritation. --One (1) container of Hydrogen Peroxide Wipes with the warning Causes moderate eye irritation. --One (1) container of Scent-Sational Odor Elimininator with the warning Causes serious eye damage/eye irritation. --Twelve (12) capped shaving razors. --One (1) pair of scissors. An interview with LPN #54, on 08/12/19 at 11:40 AM, revealed the shower room door should not have been propped open. The LPN stated she had no idea the items found in the shower room needed locked up. d) Soiled Utility Room- Wing one (1) An observation, on 08/12/19 at 12:00 PM, revealed an opened soiled utility room with a red biohazard sticker on the door. The room contained multiple chemicals with warnings. The chemicals found were: Penner Patient Care Whirlpool Disinfectant Cleaner with a warning that stated, Keep out of reach of children. Clorox spray bottle Disinfectant Cleaner with Bleach Keep out of reach of children and Warning: Eye and Skin Irritant. Use only in well-ventilated areas. Spartan Mild Acid Cleaner spray bottle that stated, Danger: Causes irreversible eye damage and skin burn. Two (2) full red sharps containers filled with used needles laying on the floor. An interview, with Maintenance Supervisor, #20, on 08/12/19 at 12:05 PM, confirmed the door was not broke but was not shut securely. A second observation, on 08/13/19 at 10:25 AM, revealed an opened soiled utility room with a red biohazard sticker on the door. The room contained multiple chemicals with warnings. The chemicals found were: Penner Patient Care Whirlpool Disinfectant Cleaner with a warning that stated, Keep out of reach of children. Clorox spray bottle Disinfectant Cleaner with Bleach Keep out of reach of children and Warning: Eye and Skin Irritant. Use only in well-ventilated areas. Spartan Mild Acid Cleaner spray bottle that stated, Danger: Causes irreversible eye damage and skin burn. Two (2) full red sharps containers filled with used needles laying on the floor. An interview with Licensed Practical Nurse (LPN) # 78, on 08/13/19 at 10:32 AM, confirmed the soiled utility door was open. LPN # 78 stated, the door is normally shut and locked. LPN # 78 stated, the door did not shut correctly and stated, I need to call the maintenance man the door normally closes and locks e) Dayroom Wing one (1) An observation in Wing one (1) dayroom, on 08/12/19 at 1:35 PM, contained a 32 ounce spray bottle of Lysol All Purpose Cleaner in an unlocked cabinet. An interview with Activities Staff # 69, on 08/12/19 at 1:38 PM, confirmed bottle should not have been in the unlocked cabinet and stated, usually the bottle is on the maintenance cart. f) Medical Equipement on the 100 and 200 Hallways 1. 200 Hallway Observation of the 200 Hallway revealed on 08/12/19 at 1:16 PM, finds there were two (2)total lift chair with the base legs spread apart unlocked, one (1) sit to stand lift unlocked, and two (2) wheelchair with their leg rests extended unlocked. In an observation and interview on 08/12/19 at 3:13 PM, with Licensed Practical Nurse (LPN ) # 135 observed the two total(2) lift chair with the base legs spread apart unlocked, one (1) sit to stand lift unlocked, and two (2) wheelchair with their leg rests extended on the 200 corridor Hallway unlocked. LPN #135 said they have no where to store the lifts and wheel chairs. The LPN acknowledged that the residents were at risk for accidents related to the medical equipment sitting in the corridor Hallway unlocked. 2. 100 Hallway Observed on 08/12/19 at 2:50 PM, of the 100 Hallway finds one (1) trash receptacle, and one (1) linen bin with roller wheels in the corridor of the 100 Hallway unlocked. There were two (2) wheelchairs unlocked with the leg rest extend, two (2)total lifts with the base spread apart unlocked, and one(1) sit to stand lift in the corridor of the 100 Hallway unlocked. In an interview on 08/12/19 at 2:58 PM, with Nursing Aide (NA) #3, when she asked why is the one (1) trash receptacle, and one (1) linen bin with the roller wheels unlocked on the corridor of the 100 Hallway, and why there are two (2) wheelchairs unlocked with the leg rest extend, two (2)total lifts that was unlocked with the base spread apart , and one(1) sit to stand lift unlocked in the corridor of the 100 corridor Hallway. NA #3 revealed they have no where to place their equipment, so they have to place the equipment in the hallway. NA #3 made no comment on why the medical equipment was left unlocked on the corridor. In an interview and observation with LPN #135 on 08/12/19 at at 3:00 PM, of the 100 Hallway, finds one (1) trash receptacle, and one (1) linen bin with roller wheels in the Hallway unlocked. There were two (2) wheelchairs with the leg rest extend, two total (2) lifts with the base spread apart, and one(1) sit to stand lift in the corridor of the 100 Hallway unlocked. LPN agreed the trash and linen receptables wheelchairs, and the lifts in the corridor of the 100 Hallway were an accident hazard for the residents, especially if they were not being locked. During this observation and interview with the LPN, observe NA #3 removed the trash receptacle and the linen bin out of the 100 corridor of the hallway. On 08/13/19 01:56 PM, two (2) wheelchairs unlocked, two ( 2) total lifts unlocked, one (1) sit to stand lift unlocked on the 100 corridor Hallway. The facility failed to removed the medical equipement on the corridor of the 100 Hallway, in which this deficient practice creates a potential for accident hazard for their residents. g) Chemical in the Hallway within residents reach. Observation of the 200 hallway revealed on 08/12/19 at 1:18 PM, finds there is two (2) 16 fluid ounces (OZ) Epi Clenz 70% Ethyl Alchol (Hand Sanitizers), and skin repair cream four (4) fluid OZ. laying on a bedside table, prior to entering the 200 hallway shower room. The Epi Clenz and the Skin repair is accessible to the residents on the 200 Hallway. In an interview with LPN #135 on 08/12/19 at 1:22 PM, agreed the above items should have been in a locked receptacle. On 08/13/19 at 1:40 PM revealed the one bottle Epi Clenz 16 Fluid OZ on the over the bed table entering the 200 Hallway shower room. LPN #135 was informed following the above observation and she stated that, she will put the Epi- Clenz away. The Safety Data Sheets finds the Epi-Clenz is acute toxicity to dermal (skin)and oral (if swallowed. It is also causes eye damage/irrigation, flammable liquid and sensitive to the skin. The Safety Data Sheet for the skin repair cream toxicity to the oral may be harmful if swallowed, causes eye damage/irritation.