Every finding on record at Greensboro Nursing Home

Based on observation, interview, and policy review, it was determined that the facility failed to store food in accordance with professional standards for food service safety. This has the potential to impact all residents. This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey dated 6/11/25. Findings include: During observations and interview on 5/19/26 at 2:49 PM, a dietary staff member confirmed there were no expiration dates for the following items:-Two six-pound ten-ounce cans of cream style corn in dry storage.-One six pound can of mandarin oranges in a light syrup in dry storage.-Twelve ounces of a turkey gravy mix in dry storage.-One gallon of buttermilk ranch dressing in the refrigerator.-One gallon of creamy Italian dressing in the refrigerator.-One sixteen-ounce container of a beef base in the refrigerator.During observations and interview on 5/20/26 at 10:51 AM with the kitchen manager, she stated that there are some food items that don't arrive with an expiration date. The kitchen manager then confirmed the following items:-Half gallon of 2% Hood milk that expired on 5/15/26 in the refrigerator.-Half gallon of 2% Hood milk that expired on 5/18/26 in the refrigerator.-Corn muffins without expiration or use by date in the freezer.-Pie crust without an expiration date or use by date in the freezer.Per review of the facility policy titled Food receiving and Storage, no date, it states that all foods stored in a refrigerator or freezer will be covered, labelled, and dated with a use by date. For dry foods (foods in dry storage) it states dry foods that are removed from their original packaging should be labeled and dated with a use by date.

Based on interview and record review, the facility failed to ensure a resident's medical record clearly communicated the resident's code status for 1 of 17 sampled residents (Resident #4). Findings include:Per record review, Resident #4 did not have a COLST (Clinician Orders for Life-Sustaining Treatment). The resident's profile page in the Electronic Health Record (EHR) stated Resident #4 was a full code. Resident #4 has a care plan intervention dated 2/26/26 that stated the resident was a DNR/DNI (Do not resuscitate/Do not intubate) and that care limiting orders were in place if the resident were to be found unconscious, without a pulse, or not breathing. Additionally, there was no code status order. A provider note from 3/12/26 states the resident code status is a full code (Cardiopulmonary Resuscitation and Intubation).Per interview with Resident #4's responsible party on 5/18/26, she reported that Resident #4 has a code status of a DNR.Per interview with the Nurse Manager on 5/19/26 at 9:09 AM and 10:04 AM, she confirmed that there should be a code status order for the resident and that there is a discrepancy between the profile page stating the resident is a full code, the residents care plan that states they are a DNR/DNI, and a provider note that states the resident is a full code.Per interview with the Social Worker on 5/19/26 at 9:58 AM, he stated Resident #4 was a DNR and that he had sent a COLST form to the provider to be filled out, but could not locate his copy of the form. The Social Worker stated the way the code status is stated in the medical record is confusing.Per interview with the Social Worker on 5/19/26 at approximately 2 PM, he provided the COLST form that he had received from the health office he had faxed it to. Review of the COLST reveals that the resident is a DNR/DNI with a provider signature and date of 2/23/26.Per review of the facility policy titled Advanced Directives Policy and Procedure, no date, it states that nursing will review physician's orders for congruity and if a discrepancy is identified between the resident's directive and physician orders, nursing will notify the physician of the discrepancy.

Based on interview and record review the facility failed to ensure that their policies related to screening for abuse via background checks had been implemented for 2 of 5 employees (LNAs #1 and #2). Findings include:Per record review of the facility policy titled Background Screening Investigations no date, it states Our facility Conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents ( direct access employees).Background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment.Per record review, LNA (Licensed Nursing Assistant) #1 was hired on 7/8/25 and LNA #2 was hired on 8/29/25. LNA #1 and LNA #2 did not have [NAME] State Criminal background checks prior to 5/19/26.Per interview on 5/20/26 at 10:02 AM, the Administrator confirmed that the [NAME] State Criminal background checks had been completed yesterday, 5/19/26, for two Licensed Nursing Assistant employees and that they don't have evidence of the [NAME] State Criminal Background checks being completed prior to survey.

Based on interview and record review, the facility failed to ensure one resident [Resident #28] of 17 sampled residents remained free from physical abuse regarding a resident-to-resident altercation. This is a repeat deficiency for this facility, with the violation cited during a previous partial survey dated 12/22/25. Findings include: Per record review, Resident #26 has diagnoses that include dementia with behavioral disturbance, visual hallucinations, Alzheimer's disease, anxiety disorder, and cognitive communication deficit. Review of Resident #26's Care Plan reveals the resident is identified as having the potential to be physically aggressive to other resident's related to Dementia, history of aggressive behaviors: resident to resident- [Resident #26] struck another resident [8/16/2024].Resident #26's Care Plan also identifies the resident as having a behavior problem related to inability to accept minor and major changes in h/her environment, poor impulse control manifested by pacing, yelling, history of hallucinations, swearing, muttering to self, refusing to participate in tasks s/he enjoys. Behaviors persist until resolved or until 1-1 intervention. The resident is further care planned as an elopement risk/wanderer related to disoriented to place, Impaired safety awareness, wanders aimlessly and has diagnosis of dementia not of new onset with severe impairment.Per record review of the facility's Summary Report: Resident to Resident Altercation, dated 5/14/26, on 5/12/2026 at approximately 6:40 PM [Resident #28] went into [h/her] room to find [Resident #26] going through [h/her] closet. [Resident #28] stated [s/he] became very upset seeing another person going through [h/her] belongings and started yelling at the other resident. [Resident #28] stated [Resident #26] allegedly reached out with one hand and pushed [Resident #28] in [h/her] face causing [h/her] glasses to fall on the floor. [Resident #28] then left [h/her] room and went to the nurse's station where the nurse in charge was and explained what had happened. The nurse in charge went back to [Resident #28's] room and found the other resident still in the closet and Resident #28's glasses were on the floor. Staff removed [Resident #26] from [Resident #28's] room. [Resident #28] had a slight red mark on the side of [h/her] nose which may have been caused by [h/her] glasses.Facility staff conducted an interview with Resident #28 on 5/13/26, the day after the incident.Resident #28 stated A strange [person] was in my room going through my clothes.[S/he] pushed me with [h/her] hand right in my face and knocked my glasses off to the floor. I couldn't see anything. Before I knew someone came and got [h/her] out of my room. I was pissed.Per review of a psycho-social note [regarding the interrelation of social factors and individual thought and behavior] for Resident #28, also dated 5/13/26, reveals [When staff asked] how [s/he] felt about the incident, [s/he] explained that .[s/he] does not like people touching [h/her] things and it startled [h/her] because [s/he] had no idea who [s/he] was.Further review of Progress Notes for Resident #28, 2 days later on 5/14/2026, include Monitor for increased behaviors or any apparent injuries resulting from when the resident was pushed in the face and their glasses knocked to the ground. Injury assessments reveal Small bruise under right eye where eyeglasses rest. A review was conducted of the facility's investigation report of the incident between Resident #26 and Resident #28, dated 5/12/26. [Exhibit 358 (Rev. 208; 10-21-22)]. The investigation report includes Abuse,' is defined as 'the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.' 'Willful,' in the definition of 'abuse,' 'means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.'Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. An example of a deliberate ( willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach. Neither physical marks on the body nor the ability to respond and/or verbalize is needed to conclude that abuse has occurred.An interview was conducted with the facility's Administrator [ADM] and Director of Nursing [DON] on 5/20/26 at 9:30 AM. Both ADM and DON confirmed that resident to resident abuse had occurred between Resident #26 and Resident #28 on 5/12/26 when Resident #26 struck Resident #28 in the face and knocked their glasses to the floor.

Based on interview and record review the facility failed to ensure documentation was accurate and true for one of three sample residents (Resident #1). Findings include:Per record review, Resident #1 has diagnoses of COPD [Chronic Obstructive Pulmonary Disease, Type II Diabetes, Atrial fibrillation [a condition in which the heart beats irregularly] and Parkinson's disease. Resident #1 had a BIMS [Brief Interview of Mental Status] score of 3 as of 1/15/26 indicating cognitive impairment; was dependent on staff for ADLs [Activities of Daily Living] and hygiene; and was at risk for falls related to deconditioning, gait/balance problems, and Parkinson's.Per review of a nursing progress from 2/19/26, it states, Pt [Patient] was trying to transfer self from [his/her] wheelchair to without assistance. This writer was in the room with [his/her] roommate and witnessed this. Pt stood up and sat back down on the floor on [his/her] rear. Once on [his/her] rear [s/he] started turning towards the nurse and laid out. Stated I was going to bed, but the floor misses me laughing and cracking jokes. Immediately assessed, no complaints of pain or discomfort noted. Helped up and wheeled to the nurses cart till dinner. Emotional support give, [given] but resident continued making jokes and laughing. HHC [home health care] notified, on call service and [family representative]. Further record review showed that there was no documentation of Resident #1's vital signs or neurological checks until 2/20/26.A review of the facility's investigation on 2/23/26 revealed the following: Nurse #1 filed an incident report that showed Resident #1 had a fall on 2/19/26 that was witnessed and their representative was notified. A risk management report demonstrated that the incident note and nursing progress note did not match the resident's physical capabilities. The Director of Nursing reported to the State Agency that the resident is incapable to rolling on the floor or anywhere else by him/herself. During their investigation, the facility determined that the resident's fall was unwitnessed and the resident's representative was not notified of the fall. During interviews with LNA #1 (Licensed Nursing Assistant) and LNA #2 it was discovered that Nurse #1 had asked the LNAs to change their witness statements about the resident's fall. Based on the staff interviews and chart reviews, the facility concluded that the information in the medical record was falsified. An interview was conducted with the DON [Director of Nursing] on 3/30/26 at 10:45 AM. The DON stated Nurse #1 was put on unpaid leave and then resigned from the position following this investigation. The DON confirmed that through the facility's internal investigation they found that the documentation of the fall had been falsified. At 11:49 AM, she further confirmed the nurse did not implement fall protocols and assess the resident's vital signs or do neurological checks when the resident fell stating, It would have been in [Resident #1]'s progress notes.Per review of the facility's Charting and Documentation policy [revised July 2017] it states, 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.Per review of the facility's Falls-Clinical Protocol policy [last revised March 2018) it states, 2. In addition, the nurse shall assess and document/report the following: a. vital signs b. recent injury, especially fracture or head injury; c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; D. change in cognition of level of consciousness; E. Neurological status; F. Pain; G. Frequency and number of falls since last physician visit; H. Precipitating factors, details on how fall occurred; I. All current medications, especially those associated with dizziness or lethargy; and J. All active diagnoses.

Based on interview and record review the facility failed to ensure three of three residents sampled (Resident#1, #2, and #3) were able to be informed to make treatment decisions by failing to have the resident or resident representative sign consent for prescribed psychotropic medication. Findings include:Per review of Resident #1's medical record, Resident #1 has a BIMS [Brief Interview of Mental Status] score of 3 as of 10/27/25 indicating they have cognitive impairment. Resident #1 is dependent on staff for ADLs [Activities of Daily Living] and hygiene. S/he has medical diagnoses of Alzheimer's Disease and peripheral vascular disease. On 12/11/25 Resident #1 was prescribed Quetiapine fumarate [an antipsychotic medication used to treat symptoms of psychosis] 25 mg [milligram] tablet: Give 25 mg by mouth one time a day related to Alzheimer's Disease with early onset.Per review of Resident #2's medical record, s/he has a BIMS of 0 as of 12/16/25, indicating severe cognitive impairment. They have medical diagnoses of Alzheimer's disease, epilepsy and depression. Resident #2 is dependent on staff for ADLs and hygiene. On 12/9/25 Resident #2 was prescribed Lorazepam [a medication used to treat anxiety] 0.5 [milligram][ tablet: Give 0.5 mg buy mouth every four hours as needed for anxiety, nausea, SOB [shortness of breath] for 30 days.Per review of Resident #3's medical record they have medical diagnoses of dementia and depression. Resident#3 has a BIMS of 2 as of 12/2/25 indicating cognitive impairment. They are dependent on staff for ADLs and hygiene. Per record review on 12/8/25 Resident #3 was prescribed Lorazepam 1 mg [milligram] tablet one tablet by mouth every four hours as needed for anxiety, DOE [dyspnea on exertion], or nausea for 30 days po [by mouth] or sl [sublingual]. Per record review, there were no psychotropic medication consent forms in the three residents' records. Per record review there was no policy identifying psychotropic medication consents from residents or resident representatives.An interview was conducted with the Director of Nursing on 12/22/25 at 10:18 AM. She confirmed the facility does not have signed psychotropic medication consents for the three residents. At 11:15 AM she confirmed the facility does not have a policy related to psychotropic medication consent forms stating, We'll make a policy.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of verbal abuse, send a summary of the investigation to the State Survey Agency, and take appropriate corrective action for 2 of 3 sampled residents (Resident #1 and Resident #3). Findings include:Per record review of Resident #1, a progress note written by the DON on 12/17/25 states, Visitor came to this writer and ADON [Assistant Director of Nursing] at 1:25 PM to report that resident's [spouse] was in the hallway next resident's room [ROOM NUMBER] when [Resident #3] was walking by with [her/his] walker. [Resident #1's spouse] per visitor statement got into [Resident #3's] space and pointed [her/his] finger at [Resident #3] and stated [He/she] is my [spouse] and you need to leave [him/her] alone. I do not want you around [him/her] at all. Per visitor [Resident #3] started to tear up and visitor intervened and asked [Resident #3] to walk into the main dining area and have a seat. [Resident #1's spouse] then took [Resident #1] into his/her room and shut the door. The visitor then reported incident to this writer and ADON [Assistant Director of Nursing]. This writer reported incident with social work and administrator.The visitor who witnessed the incident on 12/17/25 was interviewed on 12/22/25 at 10:35 AM. Per this interview, the visitor stated that the spouse of Resident #1 came over to Resident #3 and pointed his/her finger at Resident #3, stating Resident #1 was their spouse, and to leave him/her alone. [He/she] is my goddamn [spouse]. Resident #3 was very upset and started to cry. Visitor stated it was horrible how he/she treated him/her. The visitor stated that the spouse of Resident #1 had acted this way before and that everyone must walk on eggshells when the spouse visits. The visitor stated that Resident #1's spouse then took him/her to their room and closed the door. After the spouse had left the facility, the visitor observed Resident #1 coming to his door and peeking out and stating I want to come out of my room. The visitor described Resident #1 as walking around like an abused puppy dog after he/she left his/her room.Per record review of Resident #3, there was no notation in their medical record that s/he had been a part of an altercation with Resident #1's spouse. Upon further record review, there was no evidence that the altercation was thoroughly investigated, a summary of the investigation was sent to the State Licensing Agency, or that appropriate corrective action was taken to prevent further potential abuse. Per interview with the Administrator and the DON on 12/22/25 at 9:48 AM, the DON confirmed that the spouse of Resident #1 had yelled at him/her inside his/her room and that Resident #1 was very scared afterward. The DON confirmed that a report had been filed with APS (Adult Protective Services) about the incident between Resident #1 and his/her spouse but that no report had been filed with APS about the incident between Resident #1's spouse and Resident #3. The DON said regarding the incident between Resident #1's spouse and Resident #3 was that, it did not seem like a big deal. The DON confirmed that the incident involving Resident #3 had not been reported to the State Licensing Agency and had not been investigated as an allegation of abuse. The DON and the Administrator both stated they did not know that they had to report allegations of abuse to both APS as well as the State Licensing Agency.

Based on interview and record review, the facility failed to report incidences of abuse for 2 of 3 sampled residents (Resident #1 and Resident #3). This is a repeat deficiency for this facility, with violations cited during the previous recertification surveys dated 6/11/25. Findings include:Per record review of Resident #1's chart, progress note written by the Social Worker on 12/17/25 states, The Central Supply Manager came to staff and reported that this resident's [spouse] was being verbally abusive to this resident. Another family member of a different resident came to staff and told our DON [Director of Nursing] that this residents [spouse] confronted another resident and was verbally abusive. The staff member, central supply manager has put in a report to APS [Adult Protective Services].Per record review of Resident #1's chart, progress note written by the DON on 12/17/25 states, Visitor came to this writer and ADON [ Assistant Director of Nursing] at 1:25 PM to report that resident's [spouse] was in the hallway next resident's room [ROOM NUMBER] when [Resident #3] was walking by with [his/her] walker. [Resident #s'1 spouse] per visitor statement got into [Resident #3's] space and pointed [his/her] finger at [Resident #3] and stated [He/she] is my husband and you need to leave [him/her] alone. I do not want you around [him/her] at all. Per visitor [Resident #3] started to tear up and visitor intervened and asked [Resident #3] to walk into the main dining area and have a seat. [Resident #1's spouse] then took [Resident #1] into [his/her] room and shut the door. Visitor then reported incident to this writer and ADON. This writer reported incident with social work and administrator.The visitor who witnessed the incident on 12/17/25 was interviewed on 12/22/25 at 10:35 AM. Per this interview, the visitor stated that the spouse of Resident #1 came over to the table where they were sitting and pointed his/her finger at Resident #3, stating Resident #1 was their spouse, and to leave him/her alone. [He/she] is my goddamn [spouse]. Resident #3 was very upset and started to cry. The visitor stated it was horrible how he/she treated him/her. The visitor stated that the spouse of Resident #1 had acted this way before and that everyone must walk on eggshells when the spouse visits. The visitor stated that Resident #1's spouse then took him/her to their room and closed the door. After the spouse had left the facility, the visitor observed Resident #1 coming to his/her door and peeking out stating I want to come out of my room. The visitor described Resident #1 as walking around like an abused puppy dog after he/she left his/her room, subsequent to the spouse's visit. There is no evidence that the facility submitted incident reports to the State Licensing Agency related to the incident for either Resident #1 or Resident #3.Per an interview with the Administrator and the DON on 12/22/25 at 9:48 AM, the DON confirmed that the spouse of Resident #1 had yelled at him/her inside his/her room and the resident was very scared afterward. The DON confirmed that a report had been filed with APS about the incident between Resident #1 and his/her spouse but that no report had been filed with APS about the incident between Resident #1's spouse and Resident #3. The DON 's statement regarding the incident between Resident #1's spouse and Resident #3 was, it did not seem like a big deal. The DON confirmed that neither incident had been reported to State Licensing Agency. The DON and Administrator both stated they did not know that they had to report to both APS and the State Licensing Agency.

Based on interview and record review, the facility failed to protect the residents' right to be free from verbal abuse by a visitor for 2 of 3 sampled residents (Resident #1 and Resident #3). Findings include:Per record review of Resident #1, a progress note written by the Social Worker on 12/17/25 states, The Central Supply Manager came to staff and reported that this resident's [spouse] was being verbally abusive to this resident. Another family member of a different resident came to staff and told our DON [Director of Nursing] that this residents [spouse] confronted another resident and was verbally abusive. The staff member, central supply manager has put in a report to APS [Adult Protective Services].Per record review of Resident #1, a progress note written by the DON on 12/17/25 states, Visitor came to this writer and ADON [Assistant Director of Nursing] at 1:25 PM to report that resident's [spouse] was in the hallway next resident's room [ROOM NUMBER] when [Resident #3] was walking by with [her/his] walker. [Resident #1's spouse] per visitor statement got into [Resident #3's] space and pointed [her/his] finger at [Resident #3] and stated '[He/she] is my [spouse] and you need to leave [him/her] alone. I do not want you around [him/her] at all.' Per visitor [Resident #3] started to tear up and visitor intervened and asked [Resident #3] to walk into the main dining area and have a seat. [Resident #1's spouse] then took [Resident #1] into his/her room and shut the door. The visitor then reported incident to this writer and ADON [Assistant Director of Nursing]. This writer reported incident with social work and administrator.The visitor who witnessed the incident on 12/17/25 was interviewed on 12/22/25 at 10:35 AM. Per this interview, the visitor stated that the spouse of Resident #1 came over to Resident #3 and pointed his/her finger at Resident #3, stating Resident #1 was their spouse, and to leave him/her alone. [He/she] is my goddamn [spouse]. Resident #3 was very upset and started to cry. The visitor stated it was horrible how he/she treated him/her. The visitor stated that the spouse of Resident #1 had acted this way before and that everyone must walk on eggshells when the spouse visits. The visitor stated that Resident #1's spouse then took him/her to their room and closed the door. After the spouse had left the facility, the visitor observed Resident #1 coming to his door and peeking out and stating I want to come out of my room. The visitor described Resident #1 as walking around like an abused puppy dog after he/she left his/her room.Per record review of Resident #1's care plan, there are no interventions found in place to protect the resident and address the behavior of Resident #1's spouse.Per record review of Resident #3, there is no documentation of the incident between her/him and Resident #1's spouse on 12/17/25, including no mention of the psychosocial outcome of being upset and crying. Per record review, there is no evidence of the facility investigating the incident between Resident #3 and Resident #1's spouse. Per record review, there are no interventions found in place to protect Resident #3 from the potential of further abuse by Resident #1's spouse.Per an interview with the Administrator and the DON on 12/22/25 at 9:48 AM, the DON confirmed that the spouse of Resident #1 had yelled at him/her inside his/her room and that Resident #1 was very scared afterward.

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety and failed to maintain a sanitary kitchen. Findings include: Per observation on 6/11/25 at 9:08 AM, (4) 1 pound 12 ounce packages of cream of wheat were found in the dry storage with an expiration date of 4/1/25. On 6/11/25 at approximately 9:10 AM the food service staff member confirmed these were expired stating, Sorry, I'll get rid of these. Per observation of the kitchen on 6/11/25 at approximately 9:08 AM, there was melted plastic on the wall behind the toaster. The food service worker confirmed the condition of the wall 6/11/25 at approximately 9:10 AM, stating, It's been here for about a year .It's from the toaster. Per observation on 6/11/25 at approximately 9:12 AM a room with two large freezers had hats hanging from pipes on the ceiling. Per observation there were also coats hung up on the wall, and a dirty mop bucket with mop water in it on the floor. The food service staff member confirmed the condition of the freezer room on 6/11/25 at approximately 9:13 AM stating, Yeah, we usually just put everything in here.

Based on observations and interview, the facility failed to ensure medications were removed from the medication storage room when expiration dates were reached. Findings include: Per observation on [DATE] at 1:18 PM of the medication cart, an 8 oz [ounce] Spectrum Hand Sanitizer was found with an expiration date of [DATE]. A package of (3) Sani-cloth germicidal disposable wipes were found in the medication cart with an expiration date of 1/25. On [DATE] at 1:20 PM LPN#1(Licensed Practical Nurse) confirmed that these medications/biologicals were expired and stated, I'll get rid of these.

Based on interview and record review, the facility failed to implement an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections related to Legionella prevention. Findings include: Per record review of the facility's water management program, there was no risk assessment to identify areas in the building that could grow and spread Legionella in the facility water system. Per the facility's Legionella Water Management Program policy [Revised 7/2017] states, 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease .The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including: (1) Storage tanks; (2) Water heaters (3) Filters; 4) Aerators; (5) Showerheads and hoses; (6) Misters, atomizers, air washers and humidifiers ; (7) Hot tubs; (8) Fountains; and (9) Medical devices such as CPAP [Continuous Positive Airway Pressure] machines, hydrotherapy equipment, etc .E. Specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants); f. The control limits or parameters that are acceptable and that are monitored, g. A diagram of where control measures are applied, h. A system to monitor control limits and the effectiveness of control measures; i. A plan for when the control limits are not met/and or control measures are not effective; and j. Documentation of the program. An interview was conducted with the Administrator and Director of Maintenance on 6/11/25 at 1:16 PM. They confirmed that the facility did not complete a risk assessment, including identifying areas in the building where Legionella could grow or reside. The Director of Maintenance stated, We don't have any areas where Legionella could grow.

Based on interview and record review, the facility failed to provide one of two residents sampled (Resident #77) or the resident's representative with a bed-hold notice after discharge to the hospital. Findings include: Per record review Resident #77 was admitted on [DATE] and was transferred to the hospital on 5/9/2025. Per review of the Bed Policy [No date of revision] states, It is the policy of [the facility] to offer all residents who leave the facility for transfer to a hospital the right to return as soon as a bed is available, providing the nursing home is able to meet the medical needs of the resident and that the welfare of other residents will not be adversely affected .A copy of this policy would be sent to all residents or responsible party) at the time of transfer or leave, and documentation of such notification will be satisfied by any entry in the medical record indicating notification of the bed hold policy has been made. Further record review revealed that there was no documented evidence that a bed hold notice was provided to the Resident or their responsible party. An interview was conducted with the DON [Director of Nursing] on 6/11/25 at 10:00 AM. The DON confirmed the facility did not have a bed hold in place for Resident #77. When asked for documentation the DON confirmed that she could not find the bed hold document for Resident #77 stating, We are struggling to find it.

Based on interview and record review, the facility failed to coordinate and implement hospice care measures for 1 of 1 sampled resident (Resident #20). Findings include: Per record review, a Phycisian's order dated 6/10/2025 states Caledonia Home Health and Hospice services phone# . There were no other orders for hospice care, no progress notes from hospice, no updates to his/her care plan mentioning hospice care or interventions, and no way to identify when hospice provided care located in the Resident's medical record. Per review of the facility's Hospice Policy it states, .it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs .communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day .Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility . in order to maintain the resident's highest practicable physical, mental, and psychosocial well-being. Per interview with the Director of Nursing (DON) on 6/10/2025 at 3:57 PM she reported that Resident #20 has been on hospice services since 6/3/2025, and that the hospice provider, Caledonia Home Health and Hospice, provides the facility with their documentation when they get to it. The Director of Nursing stated that they didn'tt have any medical records from the hospice agency for Resident #20. When asked again on 6/11/2025 at 11:28 AM if she had received any records from Caledonia Home Health and Hospice, she said she hadn't and that it takes a while to get information from hospice. When asked how they know what hospice interventions to put in place for Resident #20 since receiving hospice services she stated that it's just through verbal communication.

Based on interview and record review, the facility failed to act on a pharmacist's Medication Regimen Review (MMR) that was then ordered by a physician for 1 of 5 Residents in the sample (Resident #20). The facility also failed to ensure that monthly MMRs were completed for 1 of 5 Residents in the sample (Resident #9). 1. Per record review there was no evidence that Monthly Medication Regimen Reviews were completed for Resident #9 for the month of March of 2025. Per interview on 6/11/2025 at 10:30 AM the Director of Nursing (DON) stated that the pharmacist sends the MMRs to her and she reviews them then follows up with the physician. The DON confirmed that there was no documented evidence in the record and that she could not produce the MMRs for March of 2025. 2. Per record review, on 11/11/2024, Resident #20 had a Medication Regimen Review (MMR) completed where the pharmacist identified the need for a one time digoxin level test. The physician reviewed and signed the document stating Ok to order x1 now and again yearly with their signature dated 11/14/2024. Per record review, on 12/6/2024, the pharmacist performed another Medication Regimen Review (MMR) where they stated Attn nursing: As a result of my consult last month, Dr. [facility doctor] ordered a one time Digoxin level on 11/14. As of 12/6/24, I do not see this scanned into PCC. Please obtain & scan in, so I can review next month. Per record review, on 1/14/2025, the pharmacist performed the monthly Medication Regimen Review (MMR) where they again stated Attn nursing: This is repeated from last month, as I do not see a Digoxin level scanned into PCC. The facility's Medication Regimen Reviews (MMR) policy states The MMR involves a thorough review of the resident ' s medical record to prevent, identify, report, and resolve medication related problems, medication errors and other irregularities, for example . inadequate monitoring for adverse consequences. Per interview with the Director of Nursing (DON) she reports the only digoxin level testing she has is from 1/28/2025. The Director of Nursing (DON) was unable to provide evidence that the facility acted on the pharmacists consult from the Medication Regimen Review, and the providers order for the 11/14/2024 digoxin testing. The facility failed to act upon the physician ' s order based on the Medication Regimen Review to monitor Resident #20 ' s digoxin levels to ensure they were in a therapeutic range.

Based on interview and record review, the facility failed to obtain laboratory services when ordered by a physician for 1 of 5 residents in the sample (Resident #20). The facility also failed to obtain laboratory results and promptly notify the ordering physician of laboratory results for 1 of 5 residents in the sample (Resident #9). Findings include: 1. Per record review the consulting pharmacist performed a Medication Regimen Review for Resident #9 dated 5/19/2025 states Resident has the following labs drawn on 5/12/2025 - BMP (basic metabolic panel) I do not see the results in Resident's chart yet. Please obtain & scan them into [Point Click Care, PCC is an electronic Health Record] for me to review next month. Further record review revealed that there was no evidence that the Resident's BMP results were obtained, reviewed, or acted on. Per interview on 6/11/2025 at 10:30 AM the Director of Nursing (DON) stated that the pharmacist sends the MMRs to her, she reviews them then follows up with the physician. The DON stated that she was unable to locate lab results for the 5/12/2025 lab draw in the record or through the laboratory's record system. The DON confirmed that there was no evidence in the record that the BMP results were obtained, reviewed, or acted on. 2. Per record review, on 11/11/2024, Resident #20 had a Medication Regimen Review (MMR) completed where the pharmacist identified the need for a one time digoxin level test. The physician reviewed and signed the document on 11/14/2024 stating Ok to order x1 now and again yearly. Per record review, on 12/6/2024, the pharmacist performed another MMR where they stated Attn nursing: As a result of my consult last month, Dr. [facility doctor] ordered a one time Digoxin level on 11/14. As of 12/6/24, I do not see this scanned into PCC. Please obtain & scan in, so I can review next month. Per record review, on 1/14/2025, the pharmacist performed the monthly MMR where they again stated Attn nursing: This is repeated from last month, as I do not see a Digoxin level scanned into PCC. Per interview with the Director of Nursing (DON) she reports the only digoxin level results that she can produce are from 1/28/2025. The DON was unable to provide evidence that the facility followed the Pharmasist recommendations made on 11/11/2024, 12/6/2024, and 1/14/2025, or implemented providers orders by obtaining laboratory services to determine Resident #20's digoxin levels on 11/14/2024.

Based on interview and record review, the facility failed to ensure that residents are free from chemical restraints for one of three sampled residents (Resident #4) as evidenced by administration of medications without proper indication for use and no discontinued date. Findings include: Per record review, Resident #4 has diagnoses that include: Alzheimer's dementia, major depressive disorder, and anxiety disorder. The MDS [Minimum Data Set, a comprehensive assessment of each resident's functional capabilities] record review assesses the resident is dependent on staff for activities of daily living, hygiene, and needs assistance with food and fluid intake. Per record review of a physician order on 4/10/25, it states please continue Ativan (generic name is lorazepam used to treat anxiety) in setting of hospice and comfort directed care to reduce anxiety/agitation. Risks of mood exacerbation if discontinued. Per record review there is no end date for the Lorazepam. The Director of Nursing (DON) entered the order for the Lorazepam on 4/16/25 into the electronic health record (EMR) as Lorazepam Oral Tablet 1 MG (milligram) Give 1 tablet by mouth every 4 hours as needed for anxiety, dyspnea on excretion, nausea until 7/10/25. The Psychotropic Medication Use policy (Revised 2025) states, 12a(1) For psychotropic medications that are NOT antipsychotics: if the prescriber or attending physician believes it is appropriate to extend the PRN (as needed) order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. An interview was conducted with the DON [Director of Nursing] on 6/11/25 at 10:06 AM. The DON stated the handwritten Physician's Orders are the justification for the medication, and the pharmacist recommendations are the physician orders that the MD documents. Per record review, there are no notes documented on the April 2025 MRR [Medication Regimen Review] in reply to the pharmacist recommendations and there are no recommendations about the Lorazepam. The DON was asked regarding the discrepancy between the physician order and the EMR. She stated the sheet labeled Physician's Orders isn't the order and the pharmacist monthly review is the order used. The DON was asked to provide the documentation with the order she entered into the EMR, and the document provided on 6/11/25 at approximately 10:30 AM was the April pharmacist review that doesn't address the Lorazepam. The DON stated the medication didn't need to have an end date since it had a justification for use per the pharmacist. DON was asked to provide documentation regarding this. The document was provided on 6/11/25 at approximately 10:30 AM. Per record review the document originated from the pharmacist titled Brief Summary of the Mega Rule - for reference for Skilled Facilities (Revised 11/1/2024) which states PRN Psychotropic orders are limited to 14 days, unless the prescriber believes it is appropriate to extend the order beyond 14 days & documents the reason & specific number of days (ie x 30, x 60 or x 90 days) to continue the order in the clinical record. The document also states, There is NOT an exception for comfort care / hospice / end of life orders.

Based on interview and record review the facility failed to ensure that an allegation of abuse was reported to facility administration, Adult Protective Services, and the State Licensing Agency. Findings include: Per record review Resident #77 was admitted in May of 2025 and began exhibiting aggressive behaviors requiring staff intervention and emergent transfer to the hospital. Review of the Accident/Incident witness interview tool dated 5/22/2025 that was completed by a Licensed Nursing Assistant (LNA) revealed that on 5/8/2025 she saw another LNA hit Resident #7 with a package of wipes. The interview tool states that the Resident was hitting the LNA and that the Resident stopped for a moment and lunged at the LNA. On 6/10/2025 at 2:15 PM the facility Administrator confirmed that the LNA who reported witnessing the other LNA hit Resident #77 with the package of wipes on 5/8/2025 failed to report it until 5/22/2025 and that she should have reported it at the time it occurred.

Based on interviews, observations, and record review, the facility failed to review, revise, and implement resident care plans for 1 of 5 residents in the applicable sample related to falls (Residents #4). Findings include: Per record review, Resident #4 has diagnoses that include: Alzheimer's dementia, major depressive disorder, and anxiety disorder. Review of the Resident's last MDS [Minimum Data Set, a comprehensive assessment resident's functional capabilities] dated 6/8/2025 reveals that the resident is dependent on staff for activities of daily living, hygiene, and needs assistance with food and fluid intake. Nursing Progress notes dated 9/4/24, 11/1/24, 1/13/25, 2/26/25, and 5/8/25 document that the Resident had falls on each of the dates. Per policy review of Falls and Fall Risk, Managing, under section Resident-Centered Approaches to Managing Falls and Fall Risk (Last revised 2018) it states The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. The policy also includes Monitoring Subsequent Falls and Fall Risk which states, The staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling. Included in the Fall Risk Assessment policy, item 4. includes if an individual continues to fall the staff and physician will reevaluate and reconsider the current interventions. Falls - Clinical Protocol policy under Treatment/ Management identification of pertinent interventions to prevent further falls and if a underlying cause of falls isn't identifiable various relevant interventions will be implemented to reduce or stop further falling. With continued record review, after the 9/5/24, 11/5/24, 2/24/25, and 5/8/25 falls, the screening, review, evaluation, and OT (Occupational Therapy) referral interventions have no documentation of being completed or further recommendations to assist residents in reducing falls. Per record review of Resident #4's care plan, an intervention of Non-skid strips placed by floor when in bed was documented on 12/27/24. On 1/4/25 an intervention was added that states, Fall mat placed on right side of bed. Per observation of the Resident's room on 6/9/25, 6/10/25 and 6/11/25 there were no non-skid strips on the floor by the bed or a fall mat on the right side of the bed. An interview was conducted with the DON [Director of Nursing] on 6/11/25 at 10:06 AM. The DON confirmed when the resident is in bed there should be a fall mat. On 6/11/25 at approximately 10:30 AM the DON provided a printed copy of the referral to OT and no further documentation was provided regarding the results of the assessments or referrals.

Based on interview, staff education record review, and the facility assessment, the facility failed to ensure that licensed nurses and licensed nursing assistants were assessed for competency and skill sets to provide care and respond to each resident's individualized needs. This has the potential to affect all residents. Findings include: Per review of 3 sampled Licensed Nursing Assistant's (LNA's) employee training files revealed 1 LNA file that lacked evidence of any competency evaluation required to demonstrate that they had the necessary skills to provide care needed. Review of the education and competency file for 3 Licensed Nursing Assistants (LNAs) revealed 1 LNA had no evidence that they were assessed for competency in the skills needed to care for the residents. 3. Review of the education and competency file for 3 Licensed Practical Nurse (LPN) revealed that 2 of the 3 had no evidence of annual competency evaluation of the skills needed to care for the residents. Per interview on 7/10/24 at 1:21 PM, the Administrator confirmed that there was no evidence of competency evaluation for the 3 staff members.