Every finding on record at Havencare at Filosa

Based on observation, review of the clinical record, facility documentation, facility policy, and interview, the facility failed to ensure that the residents' personal and confidential medical information was not accessible for 1 of 3 units, The findings include:Upon entrance to the facility for a recertification survey on 4/6/26, the survey team was provided with the resident roster lists for 3 resident units. Review of the 2nd floor unit resident roster list included a list of names of the 23 residents who reside on the unit. The list also included the residents' diagnosis, TBP, medical devices etc. The list was divided over 2 pages, front and back, with rooms 201D - 206W located on the front page, and rooms 207D - 213P located on the back page.Observation on 4/6/26 at 9:23 AM identified the medication cart was positioned in front of Resident #60's room. A clip board was attached to the medication cart with the front page of the 2nd floor unit roster list on the clip board and visible. During this observation, RN #1 and APRN #1 were observed in Resident #60's room, speaking to the resident. RN #1 and APRN #1 were observed with their backs to the medication cart. At 9:27 AM, RN #1 was observed exiting the room and at the medication cart.Observation and interview with RN #1 immediately following this observation identified that she was not aware that the unit roster was visible on the cart while she stepped away. RN #1 identified she should not have left the resident roster list visible on the cart but wanted to speak with APRN #1 about Resident #60's medications and subsequently entered the resident's room with her back to the cart for several minutes. RN #1 identified she typically flipped the clipboard over when she was not at the cart but was unable to identify why she did not do that during this observation. Interview with the DNS on 4/7/26 at 9:30 AM identified all personal and medical information related to residents of the facility should not be accessible to any visitors or other residents of the facility.The facility policy on resident rights directed that residents had the right to privacy and confidentiality regarding all personal and health information kept by the facility pertaining to the residents, as provided by federal and state laws governing the facilities use and disclosure of this information.

Based on observation, review of the clinical record, facility documentation, facility policy, facility assessment and interview the facility failed to maintain infection control standards as follows.a. The facility failed to ensure the line list for residents on transmission based precautions (TBP) and enhanced barrier precautions (EBP) was complete and accurate. b. The facility failed to ensure that the line list for infection outbreaks was complete and accurate.c. The facility failed to ensure that environmental rounds were completed for multiple months in 2025.d. The facility failed to ensure that tracking and statistical data regarding facility infection rates was maintained for July/August/[DATE].e. For 1 of 3 residents (Resident #5) reviewed for pressure ulcers, the facility failed to ensure that infection control measures were adhered to during a dressing change. f/g. For 2 of 3 residents (Resident #46 and Resident #47) reviewed TBP, the facility failed to ensure that TBP were maintained. The findings include. a. During entrance conference on 4/6/26 at 8:05 AM as part of an annual recertification survey with the Administrator and DNS, the DNS identified that the facility did not have any residents on TBP and that there were no current outbreaks. Interview with the DNS on 4/6/26 at 10:00 AM identified she was recently made aware that Resident #69 was on contact precautions, but no other residents in the facility were on any TBP. The DNS also identified that multiple residents were on EBP and she would have LPN #1 provide a list of the residents to the survey team.Review of an undated facility document labeled EBP/Isolation List provided to the survey team on 4/6/26, identified 5 residents on unit 1, 5 residents on unit 2, and 7 residents on unit 3 were on precautions. The list failed to identify what specific precautions each resident required (EBP or TBP).Review of Resident #46's clinical record identified he/she had been placed on Droplet Precautions due to suspected RSV with pending test results on 4/6/26.Review of Resident #47's clinical record identified a 4/6/26 insolation progress note which identified Resident #47 was on Contact Precautions for suspected scabies. Further review of the record identified Resident #47 was initially identified with suspected scabies on 3/16/26.Subsequent to surveyor inquiry, the facility provided additional documentation on 4/7/26 at 6 AM for review. Review of an undated document labeled Enhanced Barrier Precautions on 4/7/26 identified a total of 6 residents on unit 1, 5 residents on unit 2, and 7 residents on unit 3. Resident #47 was identified as a resident who required EBP due to a history of ESBL in the urine, Resident #67 was identified as a resident who required EBP related to an IV in place, and Resident #69 was identified as a resident who required EBP for an indwelling catheter and enteral feeding.Review of an undated document labeled Transmission Based Precautions identified Resident #67 required contact precautions related to MRSA bacteremia, and Resident #69 required contact precautions due to pseudomonas. Review of the list failed to identify any additional residents on any type of TBP or dates TBP was initiated.Observation on 4/7/26 at 9:22 AM identified a Droplet Precautions and Enhanced Barrier Precautions signage posted outside the room of Resident #46 and #47. Interview with LPN #1 and RN #5 on 4/7/25 at 10:30 AM identified that Resident #46 was on droplet precautions due to possible RSV, and that Resident #47 was on contact precautions for scabies. LPN #1 identified and she was unsure why there was no signage related to contact precautions. LPN #1 identified she had not updated the TBP list with either resident. LPN #1 and RN # 5 identified initiation and discontinuation of TBP at the facility was a nursing measure and did not require a physician's order.The facility policy for isolation precautions directed that it was the policy of the facility when necessary to prevent the transmission of infections within the facility through use of isolation precautions. The policy directed that transmission-based precautions would be deployed for known or suspected infections for which the rate of transmission and prevention was known and transmission-based categories included airborne, droplet, and contact precautions. The policy further directed that the isolation precautions may be instituted by a physician, the IP, the DNS, the ADNS, or the nursing supervisor and may be discontinued by only one of the above.The policy for Respiratory Syncytial Virus (RSV) outbreak management plan directed that the purpose of the policy was to detail specific response measures required for a confirmed or suspected RSV outbreak, prioritizing the protection of high-risk elderly residents. The policy further directed that the facility was to immediately place any resident with new onset respiratory symptoms on droplet and contact precautions due to the high risk of RSV transmission via direct contact with respiratory secretions and contaminated surfaces.The facility policy for scabies - procedure for positive or suspected rash, directed that the procedure included starting a line list related to possible or confirmed scabies. The policy further directed that the resident should be placed on contact precautions with gown and gloves applied upon entry to the resident's room and that the resident would remain on contact precautions for 24 hours after the initiation of effective therapy, and a line list should be maintained and updated for a period of 6 weeks or more.The facility policy on Outbreak Response Plan directed that the facility would promptly identify and respond appropriately to decrease the risk of transmission to residents and staff which had the potential to pose a significant public health threat and danger of infection to the residents, resident representatives, and staff of the facility.The facility assessment directed that infection prevention nurse would continuously monitor and assess the risk for the acquisition and transmission of infectious agents on a regular and ongoing basis, which included handwashing observations, environmental rounds, sharps safety monitoring, infection line listings, and monitoring of employee and resident illnesses and appropriate isolation procedures, including appropriate donning and doffing of PPE. b. Review of a reportable event form, submitted to the state agency on 7/28/25 by the Administrator, identified that a staff member tested positive for Covid. The form identified that the onset of symptoms was 7/23/25 and that 1 of 3 units was affected. The form also identified exposure testing had been initiated and a total of 9 covid tests had been completed at the time of the report.Review of infection outbreak line lists for all of 2025 failed to identify documentation related to the 7/28/25 covid outbreak including any documentation related to the covid outbreak line list for staff and residents, circumstances regarding the 9 covid tests reported as completed, or when the outbreak resolved.Review of a reportable event form, submitted to the state agency on 10/28/25 identified that a staff member tested positive for Covid. The form identified the staff member last worked on 10/27/25 and tested positive on 10/28/25 and was out of work on that date. The form also identified no residents were affected.Review of the staff covid outbreak line list dated 10/28/25 identified a staff member became symptomatic on 10/28/25 and last worked on 10/29/25 and tested positive on that date. Review of a resident covid outbreak line list dated 10/28/25 identified a total of 17 residents on unit 1 who had a covid exposure date of 10/30/25 and that all residents were asymptomatic. The line list failed to identify additional information including need for testing, or when the outbreak resolved.Review of a reportable event form, submitted to the state agency on 10/30/25 identified that a resident tested positive for RSV on that date. The form identified that 1 of 3 units was affected and that symptoms first began on 10/26/25 (4 days prior to the positive test result). The form also identified that a total of 19 RSV tests were completed.Review of the facility infection outbreak line list for October 2025 failed to identify documentation related to the 10/30/25 RSV outbreak including any documentation related to the outbreak line list for staff and residents, circumstances regarding the 19 RSV tests reported as completed, or when the outbreak resolved.Review of staff line lists for scabies exposure dated 11/24/25 - 11/28/25, 11/30/25 and 12/1/25 - 12/3/25 identified facility staff with recent exposure to scabies. The line list failed to identify any documentation when the scabies outbreak was identified, the nature of the outbreak, information regarding exposure to any residents of the facility, or when the outbreak was resolved.Review of the facility outbreak line list failed to identify documentation related to Resident #46's suspected RSV or Resident #47's suspected scabies.Interview with LPN #1 and RN #5 on 4/7/25 at 10:30 AM identified that LPN #1 had been in the role as the facility IP since 9/29/25 and was also the facility staff development nurse. LPN #1 identified that prior to her employment at the facility, she had one other position as an IP in a different facility for approximately 6 months and did not receive any training for the role. LPN #1 identified that since she became the IP of the facility, outside IP staff from a nearby affiliated facility would periodically come to assist her with the program, but identified that while she was certified, she was the only IP certified nurse in the building and was learning the position on the job, including initiating and maintaining line lists and outbreak tracking. RN #5 identified she had been providing oversight and assisting LPN #1 with the infection control program regularly and had been in the building at least twice weekly since January 2026. The facility assessment directed that infection prevention nurse would continuously monitor and assess the risk for the acquisition and transmission of infectious agents on a regular and ongoing basis, which included infection line listings, monitoring of employee and resident illnesses, and appropriate isolation procedures, including appropriate donning and doffing of PPE.The facility policy on Outbreak Response Plan directed that the facility would promptly identify and respond appropriately to decrease the risk of transmission to residents and staff which had the potential to pose a significant public health threat and danger of infection to the residents, resident representatives, and staff of the facility. The policy also directed that an outbreak was defined as any unusual occurrence of disease or any disease about background or endemic levels. The policy also directed that the IP would initiate a line list as a mechanism to track any specific infectious disease and symptoms in residents and employee illness related to absenteeism increases that might indicate the early cases of a facility outbreak. The policy also directed that the IP would direct the facilities planning and response efforts and was responsible for surveillance of an outbreak. The policy also directed that line listings would be utilized as mechanisms for tracking facility admissions and discharges of suspected or laboratory confirmed cases of specific disease outbreaks in residents.The facility policy on the infection prevention program directed it was the goal of the Infection Prevention program to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. The facility also directed that the responsibility for ongoing collection and analysis of data and required follow-up is assigned to the Infection Preventionist and elements included monitoring and documenting infections, tracking and analyzing outbreaks of infections, managing resident health initiatives and provision of early, uniform identification and reporting of infections. The policy further directed that the facility would designate an individual as the Infection Prevention and Control Officer, who has or will receive specialized training in infection control, and the IP will participate on the quality assessment and assurance committee and will report to the committee on the Infection Prevention and Control Program (IPCP) on a regular basis. The policy also directed the IP would perform surveillance and investigation of infections to prevent, to the extent possible, the onset and spread of infection; promote antibiotic stewardship and ensure residents received the right antibiotic, at the right dose, at the right time, and for the right duration; provide education to staff, residents and families on antibiotic stewardship to reduce antibiotic usage in the facility and decrease the risk for development of antibiotic resistive organisms within the facility; analyze trends and clusters of infection, and any increase in the rate of infection or resistant organisms, in a timely manner; maintain the monthly infection reports by unit to record each resident infection; monitor community-associated (CA) infections in residents admitted to the facility and attempt to obtain results and diagnosis of infection when residents are transferred back from an acute care hospital; prevent and control outbreaks and cross contamination using transmission-based precautions in addition to standard precautions; decide what procedures, such as transmission-based precautions, should be applied to an individual resident; ensure compliance in reporting of communicable diseases by maintaining the most updated list of reportable diseases and demonstrating knowledge of when and whom to report the disease to; and ensure compliance with state and federal regulations related to Infection Control and prevention.The facility policy on Antibiotic Stewardship directed it was the policy of the facility to treat only symptomatic infections meeting criteria, and to promote antibiotic stewardship to reduce inappropriate antimicrobial use, improve patient care outcomes and reduce possible consequences of antimicrobial use, and all infections will be tracked [NAME] the IP or designee and reviewed for trends. c. A review of the environmental rounding logs for 2025 failed to identify documentation that environmental rounds had been completed for the facility by any staff from January 2025 - September 2025, 9 months. Review of the facility records failed to identify a designated IP from 11/22/24 - 2/9/25, 3/20/25 - 4/27/25, and 7/26/25 - 9/28/25.Interview with LPN #1 and RN #5 on 4/7/25 at 10:30 AM identified that LPN #1 had been in the role as the facility IP since 9/29/25 and was also the facility staff development nurse. LPN #1 identified she was unable to locate any documentation of environmental rounds from January 2025 - September 2025, 9 months. The facility assessment directed that the infection prevention nurse would continuously monitor and assess the risk for the acquisition and transmission of infectious agents on a regular and ongoing basis and this included environmental rounds. The facility policy on general infection control nursing policies directed it was the policy that all nursing activities would be performed in a manner to minimize the potential of infection in residents, staff and visitors. The policy directed that guidelines included: All resident personal items will be appropriately labeled with resident name and stored in bedside stands or other designed resident storage areas and cleaned and disinfected as indicated. All residents will be provided with personal items necessary for adequate personal hygiene. These personal items will be kept in bedside stands, unless preferred by residents. Residents will be educated on Infection Control practices regarding storage. All residents will be encouraged to maintain adequate personal hygiene; if they are unable to do so, the facility staff will provide or assist with personal care. Resident rooms will be clean and orderly, with consideration given to the preferences and rights of the individual residents to maintain their environment as they desire (personal furniture, items from home) if those preferences do not infringe upon the rights of others. All resident common areas will be maintained in a clean and orderly manner and will be free of obvious hazards such as fall hazards, chemical hazards, etc. All resident care will be provided in the privacy of the resident's room or other designated area, with cubicle curtains drawn to further provide privacy within the room. Infection surveillance will be targeted toward high risk of infection for the population served. Data will be reported internally, monthly, quarterly, or as indicated at the quality improvement meeting d. During a review of the facility's infection control program, review of the facility infection line lists failed to identify documentation of infection data tracking or infection rates for any residents of the facility from July 2025 - September 2025, 3 months. Review of the facility records failed to identify a designated IP from 7/26/25 - 9/28/25.Interview with LPN #1 and RN #5 on 4/7/25 at 10:30 AM identified that LPN #1 had been in the role as the facility IP since 9/29/25 and was also the facility staff development nurse. LPN #1 identified she was unable to locate any documentation of infection data tracking or infection rates for any residents of the facility from July 2025 - September 2025, 3 months. Interview with RN #5 on 4/7/26 at 2:00 PM identified she was the VP of Clinical Services for all of 2025 and was not aware that the facility did not have a designated IP in place for multiple time periods from November 2024 until LPN #1 took over the role on 9/29/25. The facility policy on the infection prevention program directed the goal of the Infection Prevention program was to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. The facility also directed that the responsibility for ongoing collection and analysis of data and required follow-up is assigned to the Infection Preventionist and elements included: monitoring and documenting infections, tracking and analyzing outbreaks of infections, managing resident health initiatives and provision of early, uniform identification and reporting of infections, analyzing trends and clusters of infection, and any increase in the rate of infection or resistant organisms, in a timely manner, and maintaining the monthly infection reports by unit to record each resident infection. The policy further directed that the facility would designate an individual as the Infection Prevention and Control Officer, who has or will receive specialized training in infection control.The facility assessment directed that staff involved with infection prevention, along with the infection preventionist and medical director, would conduct an annual assessment of the infection control risks by utilizing sources such as history of the facility, reports from CDC, and the Department of Health to identify infections that might be acquired in healthcare settings. Data would be collected monthly, and infection rates would be monitored to assess for changes. High risk and high-volume patient groups would be identified and assessed for their risk level in developing HAIs on an annual basis utilizing a risk analysis decision matrix and used as a basis for evaluation of the infection control program and developing objectives for the following year. The policy also directed that the infection prevention nurse would continuously monitor and assess the risk for the acquisition and transmission of infectious agents on a regular and ongoing basis, which included infection line listings and monitoring of employee and resident illnesses.The facility policy on general infection control nursing policies directed was the policy that all nursing activities would be performed in a manner to minimize the potential of infection in residents, staff and visitors. The policy directed that guidelines included infection surveillance that would be targeted toward high risk of infection for the population served and data will be reported internally, monthly, quarterly, or as indicated at the quality improvement meeting. e. Resident #46 was admitted to the facility in September 2023 with diagnoses that included Alzheimer's dementia, repeated falls, and insomnia.The quarterly MDS dated [DATE] identified Resident #46 had severely impaired cognition, occasionally continent of bowel, frequently incontinent of bladder, and was dependent on staff to assist with dressing, toileting, and transfers.The care plan dated 3/25/26 identified Resident #46 had functional deficits related to comorbidities resulting in a deconditioned state and required max to total assistance with ADLs. Interventions directed to provide the resident with the level of assistance applicable for all ADL activities. A nurse's note dated 4/6/26 at 12:55 PM by LPN #3 identified Resident #46 had been placed on droplet precautions pending swab results for covid, flu, and RSV due to congestion and cough.Review of the physician's orders failed to identify an order for Droplet precautions. f. Resident #47 was admitted to the facility in September 2020 with diagnoses that included Alzheimer's dementia, aphasia, and atopic dermatitis.The quarterly MDS dated [DATE] identified Resident #47 had severely impaired cognition, always continent of bowel, frequently incontinent of bladder, was dependent on staff to assist with dressing, and required partial assistance from staff with bathing and toileting. A care plan dated 3/10/26 identified Resident #47 was at risk for skin impairment due to decreased mobility and incontinence. Interventions included to monitor skin impaired sites for healing/worsening per facility policy and report to PCP when applicable. An outside provider consult note dated 3/16/26 identified Resident #47 was seen by a dermatologist on that date for a rash. The note identified Resident #47 had a skin biopsy completed and new medication orders for topical Permethrin (a medication used to treat scabies) applied from the neck down and repeat treatment one week later and to follow up in 2 weeks.The physician's order dated 3/16/26 directed to apply Permethrin 5% cream from the neck down and rinse off at 8:00 am on 3/17/26. The physician's order dated 3/17/26 directed Contact Precautions every shift for possible scabies and document an isolation progress note every shift.The physician's order dated 3/26/26 directed to apply Permethrin 5% cream from the neck down and rinse off at 8:00 am on 3/27/26. Review of the clinical record identified Resident #47 was discontinued from contact precautions by APRN #1 on 3/27/26 with a note that treatment had been completed.An isolation progress note dated 4/6/26 by LPN #3 identified Resident #47 was on contact precautions for possible scabies. The note identified Resident #47 had a roommate, did not stay in his/her room during the isolation period, and had scabbed sites on observation. Observation on 4/7/26 at 9:22 AM identified a Droplet Precautions and Enhanced Barrier Precautions sign posted outside the room of Resident #46 and #47. Review of the droplet precautions sign directed (STOP, everyone must clean their hands, including before entering and when leaving the room. Put on a fit tested N-95 or higher respirator before room entry. Remove respirator after exiting the room and closing the door. Door to the room must remained closed). During this observation, entrance door was fully open. Resident #46 was observed sitting in a wheelchair near the window. The curtain between the residents' beds was pulled back to the wall, allowing full view of the room. NA #4 was observed in the room gathering soiled linens from Resident #47's bed, (near the door). NA #4 was observed with disposable gloves on but lacking PPE per the signage outside the door. NA #4 had a short sleeve scrub top on with her arms exposed. NA #4 was observed holding the linen, which was bundled into a ball and not contained in any type of bag, against her torso, and carrying the linen to a soiled lined hamper outside the room entrance. NA #4 then exited the room at 9:26 AM.Review of the TBP signage and interview with NA #4 immediately following this observation identified she only applied gloves because the droplet precautions were in place for Resident #46, and since she was not helping Resident #46, NA #4 identified she was not required to wear PPE. A review of the droplet precautions signage with NA #4 identified she was aware that Resident #46 required droplet precautions, and she identified that while the signage did not specify that she did not have to wear an N-95 if she was not providing care to the resident, that's what she believed the signage was directing. NA #4 also identified she was not aware which resident required EBP.Interview with the DNS on 4/7/26 at 9:30 AM identified that anyone entering Resident #46 and Resident #47's room should have applied an N-95. The DNS further identified that she was not sure if Resident #47 was on contact precautions but was likely still on them due to the need to follow up with dermatology to evaluate the treatment for scabies. The DNS identified she would have to look into the matter and would discuss PPE use with NA #4. Interview with LPN #1 and RN #5 on 4/7/25 at 10:30 AM identified that Resident #46 was on droplet precautions due to possible RSV, and that Resident #47 was on contact precautions for scabies. LPN #1 identified and she was unsure why there was no signage related to contact precautions. LPN #1 and RN #5 identified initiation and discontinuation of TBP at the facility was a nursing measure and did not require a physician's order, and that staff were notified via the unit report sheets which were updated with TBP if initiated. Interview with APRN #1 on 4/8/26 at 9:55 AM identified that EBP and TBP orders were a nursing intervention at the facility and did not require a physician's order. APRN #1 identified that LPN #1 was responsible for determining the need for EBP and TBP and would update the resident's clinical record and also was responsible for discontinuing the order. APRN #1 identified she would discontinue an order for TBP but typically she would just notify the DNS verbally, or the nursing staff would be notified if they read her clinical note regarding the need for TBP. Interview with NA #11 on 4/8/26 at 10:14 AM identified she regularly worked on Unit #1, where Resident #46 and Resident #47 resided. NA #11 identified that the nurse aide staff were notified regarding TBP by signage outside the resident's room, the unit report sheets, or if verbally told by the nurse. NA #11 then provided the unit #1 report sheet, dated 4/2/26, which did not include any documentation that Resident #46 or Resident #47 required TBP. The facility policy for isolation precautions directed that it was the policy of the facility when necessary to prevent the transmission of infections within the facility through use of isolation precautions. The policy directed that transmission-based precautions would be deployed for known or suspected infections for which the rate of transmission and prevention was known and transmission-based categories included airborne, droplet, and contact precautions. The policy further directed that staff and visitors would be informed of the need for isolation precautions. The policy facility policy for Respiratory Syncytial Virus (RSV) outbreak management plan directed that the purpose of the policy was to detail specific response measures required for a confirmed or suspected RSV outbreak, prioritizing the protection of high-risk elderly residents. The policy further directed that the facility was to immediately place any resident with new onset respiratory symptoms on droplet and contact precautions due to the high risk of RSV transmission via direct contact with respiratory secretions and contaminated surfaces.The facility policy scabies - procedure for positive or suspected rash, directed that the procedure included starting a line list related to possible or confirmed scabies. The policy further directed that the resident should be placed on contact precautions with gown and gloves applied upon entry to the resident's room and that the resident would remain on contact precautions for 24 hours after the initiation of effective therapy, and a line list should be maintained and updated for a period of 6 weeks or more.The facility policy on Outbreak Response Plan directed that the facility would promptly identify and respond appropriately to decrease the risk of transmission to residents and staff which had the potential to pose a significant public health threat and danger of infection to the residents, resident representatives, and staff of the facility.The facility assessment directed that infection prevention nurse would continuously monitor and assess the risk for the acquisition and transmission of infectious agents on a regular and ongoing basis, which included handwashing observations, environmental rounds, sharps safety monitoring, infection line listings, and monitoring of employee and resident illnesses and appropriate isolation procedures, including appropriate donning and doffing of PPE.The facility policy on the infection prevention program directed the goal of the Infection Prevention program was to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. The policy also directed that the responsibility for ongoing collection and analysis of data and required follow-up was assigned to the Infection Preventionist and elements included: monitoring and documenting infections, tracking and analyzing outbreaks of infections, managing resident health initiatives and provision of early, uniform identification and reporting of infections; prevent and control outbreaks and cross contamination using transmission-based precautions in addition to standard precautions; deciding what procedures, such as transmission-based precautions, should be applied to an individual resident; ensure compliance in reporting of communicable diseases by maintaining the most updated list of reportable diseases and demonstrating knowledge of when and whom to report the disease to; and ensure compliance with state and federal regulations related to Infection Control and prevention. g. Resident #5 was admitted to the facility in March 2024 with diagnoses that included intestinal obstruction, diabetes, and anemia.The annual MDS dated [DATE] identified Resident #5 had moderately impaired cognition, was occasionally incontinent of bowel and bladder, was dependent on staff to assist with bathing, and required partial assistance from staff with toileting and dressing.The care plan dated 12/31/25 directed that Resident #5 was at risk for skin impairment due to decreased mobility and hammer toes. Interventions directed to apply lambs' wool in between toes as ordered. A nurse's note dated 3/23/26 at 10:28 PM identified Resident #5 had a pressure injury to the right 2nd toe. Treatment orders for daily cleanse with saline, apply skin prep to peri wound and apply silver alginate to the wound bed and a dry dressing daily.A physician's order dated 3/31/26 directed to cleanse 2nd metatarsal with normal saline, apply skin prep to peri wound, apply silver alginate to the wound bed and a dry dressing and apply lamb's wool between toes twice daily (every day and evening shift).A facility wound list dated 4/2/26 identified Resident #5 had a facility acquired stage 2 pressure ulcer at the 2nd toe. Review of an undated document labeled Enhanced Barrier Precautions on 4/7/26 identified Resident #5 required EBP due to history of MDRO including MRSA and ESBL.Observation on 4/7/26 beginning at 12:05 PM of Resident #5's dressing change identified the following: LPN #2 had donned a gown prior to entering the resident's room and was observed washing her hands and donning her gloves and the resident's bathroom. LPN #2 proceeded to the resident's bedside and had the resident's dressing materials on the bedside table. The bedside table was observed to be nearly full of Resident #5's personal items. LPN #2 identified she had brought in and prepared the dressing items prior to surveyor observation, a[TRUNCATED]

Based on review of the clinical record, facility documentation, facility policy, and interviews, the facility failed to ensure antibiotic use and surveillance tracking was ongoing from July 2025 - September 2025. The findings include:A review of the facility's antibiotic stewardship program was completed on 4/7/26. Infection line lists failed to identify documentation or tracking infections or antibiotic use for any residents of the facility from July 2025 - September 2025. Review of the facility records failed to identify any designated IP from 7/26/25 - 9/28/25.Interview on 4/7/26 at 11:55 AM with the prior DNS identified that she was employed at the facility as the DNS from 2022 until the beginning of July 2025 and began her new job on 7/7/25. The DNS identified that she continued to work at the facility in a per diem role on Saturdays, beginning 7/13/25, for 6 hours to assist with the infection control program by reviewing orders for new admissions to ensure that antibiotics were ordered and tracked and immunizations were in place but did not provide any other assistance and she resigned from the facility effective 8/17/25. The prior DNS identified that RN #9 (prior IP) left on 7/25/25 and the facility did not have an IP in place. Interview with LPN #1 and RN #5 on 4/7/25 at 10:30 AM identified that LPN #1 had been in the role as the facility IP since 9/29/25 and was also the facility staff development nurse and she began tracking monthly infection and antibiotic use since that time, and identified she was unable to locate any documentation of antibiotic use or statistical tracking, including any documentation from July 2025 - September 2025. Interview with RN #5 on 4/7/26 at 2 PM identified she was the VP of Clinical Services for all of 2025 and was not aware that the facility did not have a designated IP in place for multiple time periods from November 2024 until LPN #1 took over the role on 9/29/25. The facility policy on Antibiotic Stewardship directed it was the policy of the facility to treat only symptomatic infections meeting criteria, and to promote antibiotic stewardship to reduce inappropriate antimicrobial use, improve patient care outcomes and reduce possible consequences of antimicrobial use. The policy further directed the facility would establish an antimicrobial stewardship team (AMS) dedicated to improving antimicrobial use. The core members of the AMS team will include, but not be limited to the Medical Director, Pharmacy Consultant, Director of Nurses and Infection Preventionist (IP), that all infections will be tracked [NAME] the IP or designee and reviewed for trends, that audits will be done randomly to ensure antibiotic orders are complete and are reassessed as noted above. The policy also directed the AMS team would review ABT usage, MDRO data and ABT usage audit tool results and provide feedback at the quarterly medical staff meeting.The facility policy on the infection prevention program directed the goal of the Infection Prevention program was to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. The facility also directed that the responsibility for ongoing collection and analysis of data and required follow-up is assigned to the Infection Preventionist and elements included promoting the use of standard precautions for all resident care unless a resident had a known or suspected infectious agent (infected or colonized) including certain epidemiologically important pathogens, which might require additional control measures to effectively prevent transmission; prevent and control outbreaks and cross contamination using transmission-based precautions in addition to standard precautions; decide what procedures, such as transmission-based precautions, should be applied to an individual resident; ensure compliance in reporting of communicable diseases by maintaining the most updated list of reportable diseases and demonstrating knowledge of when and whom to report the disease to; and ensure compliance with state and federal regulations related to Infection Control and prevention.The facility assessment directed that the infection prevention program would include antibiotic stewardship throughout the facility, including monitoring of antibiotic usage, including indication for usage, appropriateness of antibiotic, and number of days of therapy.

Based on review of facility documentation, facility policy, and interviews, the facility failed to designate an individual (s) as the infection preventionist (IP) for multiple time periods between 7/26/25 - 9/28/25. The findings include:During entrance conference on 4/6/26 at 8:05 AM as part of an annual recertification survey with the Administrator and DNS, the DNS identified she began working at the facility on 9/2/25 and identified LPN #1 was the facility IP (this is in conflict with the interview with LPN #1 who identified she assumed the role of IP on 9/29/25). The DNS identified she provided oversight to LPN #1 but was not IP certified. Interview with LPN #1 on 4/7/26 at 10:00 AM identified she had been the IP for the facility since 9/29/25. LPN #1 identified she was not sure who was covering the position prior to her start.Interview with RN #5 (Corporate VP of Clinical Services) on 4/7/26 at 10:30 AM identified she had been providing oversight and assisting LPN #1 (who assumed the IP role 9/29/25) with the infection control program regularly and had been in the building at least twice weekly since January 2026. RN #5 identified that prior to September 2025, the facility also had consistent IP coverage (this is in conflict with review of personnel file review). RN #5 identified that until the beginning of 2025, LPN #5 was the facility IP, (this is in conflict with LPN #5's employee file that identified her last day at the facility was 11/21/24). RN #5 indicated RN #8 worked at the facility for a couple of months, (this is in conflict with review of RN #8's employee file that identified she worked at the facility 2/10/25 - 3/19/25, 5 weeks). RN #8 identified RN #9 was the IP until just prior to LPN #1 taking over the position (this is in conflict with RN #9's employee file that identified her last day worked was 7/18/25, 10 weeks before LPN #1 took over). RN #5 identified that she would have to check with HR regarding the specific dates of employment but identified that in addition to the facility having regular IP coverage, the prior DNS and IP staff from a nearby affiliated facility also provided periodic assistance with the IP program during all of 2025. RN #5 was unable to identify the timeframes or specific hours worked by the outside IP staff or provide documentation showing the coverage. RN #5 identified that the prior DNS had an IP certification but that no other facility nursing staff were certified.Review of employee files for LPN #1, LPN #5, RN #8, and RN #9 identified the following:LPN #5 was employed as the facility IP from 11/7/23 - 11/21/24. LPN #5's employee file identified she had completed prerequisites courses needed to test for a Long Term Care Certified IP exam on 2/15/24, however the HR file failed to identify that LPN #5 obtained any IP certification. Review of the facility records failed to identify any designated IP from 11/22/24 - 2/9/25.RN #8 was employed as the facility IP from 2/10/25 - 3/19/25. Review of RN #8's time card identified that her last day worked was 3/12/25, and she did not work from 3/13/25 - 3/19/25. Review of RN #8's employee file failed to identify any prior specialized education, training, certifications, or employment as an IP prior to RN #8's employment at the facility. Further review of RN #8's file also failed to identify any specialized training, education, or certification as an IP or related to infection control for the duration of her employment at the facility.Review of the facility records failed to identify any designated IP from 3/20/25 - 4/27/25.RN #9 was employed as the facility IP from 4/28/25 - 7/25/25. Review of RN #9's timecard identified that her last day worked was 7/18/25, and she did not work from 7/19/25 - 7/25/25. Review of RN #9's file identified she held an IP certification since December 2019.Review of the facility records failed to identify any designated IP from 7/26/25 - 9/28/25.Interview on 4/7/26 at 11:55 AM with the prior DNS identified that she was employed at the facility as the DNS from 2022 until the beginning of July 2025 and held an IP certification. The prior DNS identified that she left the facility and began her new job on 7/7/25. The DNS identified that she continued to work at the facility in a per diem role on Saturdays, beginning 7/13/25, for 6 hours to assist with the infection control program by reviewing orders for new admissions to ensure that antibiotics were ordered and tracked and immunizations were in place but did not provide any other assistance. The prior DNS identified she resigned from the facility effective 8/17/25. The prior DNS identified that the dates of employment for LPN #5, RN #8, and RN #9 were correct that she had an IP certification and assisted with the IP program while she was the DNS when she was able. The prior DNS identified the facility did not have a designated IP in place from 11/22/24 - 2/9/25 and 3/20/25 - 4/27/25, and identified since she had already left by the time RN #9 left the role, she could not confirm how long the position remained open, but identified that when RN #9 left on 7/25/25 the facility did not have an IP in place. The prior DNS identified that during the gaps in coverage, she assisted with the program along with other facility nursing staff as she and the staff were able.Interview with RN #5 on 4/7/26 at 2:00 PM identified she was the VP of Clinical Services for all of 2025 and was not aware that the facility did not have a designated IP in place for multiple time periods from November 2024 until LPN #1 took over the role on 9/29/25. The facility assessment directed staff needed to provide support and care for residents including Infection Prevention. The policy further directed the infection program was under the direction of the registered infection prevention nurse who had completed both required and enhanced training in infection prevention and control.The facility policy on the infection prevention program directed the goal of the Infection Prevention program was to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. The facility also directed that the responsibility for ongoing collection and analysis of data and required follow-up was assigned to the Infection Preventionist and elements included monitoring and documenting infections, tracking and analyzing outbreaks of infections, managing resident health initiatives and provision of early, uniform identification and reporting of infections. The policy further directed that the facility would designate an individual as the Infection Prevention and Control Officer, who had or would receive specialized training in infection control.Please cross reference F880 and F881.

Based on observation, review of the clinical record, facility policy, and interview for 1 resident (Resident #27) reviewed for position/mobility/range of motion, the facility failed to follow the physician's order for an orthotic. The findings include: Resident #27 was admitted to the facility in February 2018 with diagnoses that included dementia, and contractures and pain of the right and left hands. The Occupational Therapy (OT) Evaluation and Plan of Treatment dated 2/25/25 identified Resident #27's objective progress and short-term goals included: Resident #27 would tolerate 10 minutes of [NAME] passive range of motion (PROM) of the bilateral upper extremities (BUE) in order to prevent further contracture, would tolerate wearing elbow splints for 2 hours, and hand splints for 2 hours in order to prevent further contractures with a target date of 2/26/25. The OT Evaluation and Plan of Treatment further identified objective progress/long-term goals included: Resident #27 would tolerate 20 minutes of [NAME] PROM of the BUE in order to prevent further contracture, would tolerate wearing elbow splints for 8 hours in order to prevent further contracture, and would tolerate hand splints for 8 hours in order to prevent further contracture with a target date of 4/28/25. A physician's order dated 8/26/25 directed to place inflatable carrots to both hands during AM care, as tolerated and palm protectors placed at PM care to be worn overnight. The Restorative Nursing Instruction Form (located in the Restorative Nursing Documentation Log binder at the nurse's station) dated 11/17/25 identified Resident #27 had the following programs, which should be performed for at least 15 minutes: PROM to the bilateral hands and elbows with care and bilateral carrot orthotic and elbow orthotic, on with AM care and off with PM care, gentle PROM prior to donning, and OOB in wheelchair. The care plan goals were to maintain upper extremity ROM and to prevent further contractures. The OT Discharge summary dated [DATE] for the dates of service 2/5/25 through 11/26/25 identified Resident #27 was at functional baseline with no significant changes, contractures were stable and the resident had reached maximum potential with OT services, at this time, on-going needs could be met by nursing staff with established care. The quarterly MDS dated [DATE] identified Resident #27 had severely impaired cognition, had upper and lower extremity impairments on both sides, and had not participated in OT for at least 15 minutes a day on one or more days in the last 7 days. The care plan dated 1/21/26 identified Resident #27 had the need for total assistance with all ADL's, had left and right hand contractures, with interventions that included inflatable carrots placed to both hands during AM care, as tolerated by the resident, and palm protectors placed at PM care to be worn overnight. The Restorative Nursing Flow Sheets (located in the Restorative Nursing Documentation Log binder at the nurse's station) dated 3/21/26 through 4/5/26 directed staff document the number of minutes Resident #27 was provided restorative therapy each shift for each checked area (PROM and splint/brace assistance). The logs identified the following. 3/21/26 no documentation for any shift. 3/22/26 no documentation for any shift.3/23/26 11:00 PM-7:00 AM-15 minutes PROM and 0 minutes splint/brace assistance. No other documentation was noted.3/24/26 11:00 PM-7:00 AM-15 minutes PROM and 0 minutes splint/brace assistance. No other documentation was noted 3/25/26 11:00 PM-7:00 AM-15 minutes PROM and 0 minutes splint/brace assistance. No other documentation was noted.3/26/26 no documentation for any shift. 3/27/26 no documentation for any shift. 3/28/26 11:00 PM-7:00 AM-15 minutes PROM and 0 minutes splint/brace assistance. No other documentation was noted.3/29/26 11:00 PM-7:00 AM-15 minutes PROM and 0 minutes splint/brace assistance. No other documentation was noted.3/30/26 no documentation for any shift. 3/31/26 11:00 PM-7:00 AM-15 minutes PROM and 0 minutes splint/brace assistance. No other documentation was noted.4/1/26 11:00 PM-7:00 AM-15 minutes PROM and 0 minutes splint/brace assistance. No other documentation was noted.4/2/26 11:00 PM-7:00 AM-15 minutes PROM and 0 minutes splint/brace assistance. No other documentation was noted.4/3/26 11:00 PM-7:00 AM-15 minutes PROM and 0 minutes splint/brace assistance. No other documentation was noted. 4/4/26 no documentation for any shift. 4/5/26 no documentation for any shift. Observation on 4/6/26 at 8:40 AM identified Resident #27 was in bed without the benefit of a palm guard or carrot in place. Observation on 4/6/26 at 10:30 AM identified Resident #27 was out of bed to a wheelchair, without the benefit of a palm guard or carrot in place, bilateral elbow splints were in place. Observations on 4/7/26 at 7:50 AM and 4/7/26 at 9:42 AM identified Resident #27 was out of bed to a wheelchair, without the benefit of a palm guard or carrot in place, bilateral elbow splints were in place. Observation with LPN #2 on 4/7/26 at 2:10 PM identified Resident #27 was in bed without the benefit of a palm guard or carrot in place. Observation of Resident #27's left and right hands with LPN #2, identified his/her skin was clean, dry, and intact, nails were trimmed, and he/she tolerated PROM to all 10 digits without the appearance of pain. During an interview with LPN #2 and NA #1 on 4/7/26 at 2:15 PM, NA #1 identified that Resident #27 is ordered to have a palm guard, but she could not recall the last time Resident #27 had worn the palm guard because it had worn out and needed replacement. NA #1 indicated that she had let one of the rehabilitation therapists know that the palm guard had worn out, and she was told that they would need to order a replacement because it was not something that was in stock, NA #1 could not recall when she had made the notification. LPN #2 indicated that she was aware that Resident #27 had not been wearing the palm guards and could not recall the last time he/she had worn them. LPN #2 identified that sometimes palm guards get lost in the laundry, and she thought this was the case for Resident #27. LPN #2 further identified that she completed skin checks of both hands, palms, and fingers and cleaned the area daily. Subsequent to surveyor inquiry the palm guards and carrots were located in Resident #27's bedside table. Interview with the DNS on 4/7/26 at 2:31 PM identified that it was her expectation that Resident #27's has the palm guards and carrots applied according to the physician's order and it is the responsibility of the nurse or the nurse aide to place the carrot and/or palm guard in Resident #27's hands. During an interview with the DNS, NA #1, and LPN #2 on 4/7/26 at 2:36 PM, NA #1 identified that she was not sure which orthotic device was the carrot or who would be responsible to place it in Resident #27's hand. LPN #2 identified that she was not sure who was responsible for placing the carrot in Resident #27's hand, but the nurse aide would put the palm guards in his/her hand. Interview and clinical record review with the Director of Rehabilitation Services on 4/7/26 at 3:17 PM identified that Resident #27 had received OT services from 2/2025 - 11/2025 for bilateral contractures of the elbows and hands, and per the OT recommendations, Resident #27 was ordered to wear bilateral palm protectors at night and bilateral carrots and elbow splints during the day; the ongoing orders were to prevent any decline in ROM of the hands or fingers and should be followed as a preventative measure. Interview with OT #1 on 4/8/26 at 10:32 AM identified that she had begun working at the facility in October 2025, and the process for educating nursing staff on a resident's rehabilitation treatment plan was for the OT or PT to review the individualized plan with the resident's nurse and nurse aide, with the expectation that they would carry over the education to the next shift and all nursing care providers, additionally the individualized Restorative Nursing Instruction Form was stored at the nurses' station in the Restorative Nursing Documentation Log binder, providing a reference for the instructions to the nursing staff, along with the Restorative Nursing Flow Sheets, which required a sign-off, every shift. OT #1 further indicated that Resident #27's Restorative Nursing Flow Sheets did not reflect updated documentation that Resident #27 was consistently wearing palm guards at night and the carrots during the day. OT #1 identified that she screened Resident #27's right and left hand contractures on 4/8/26, subsequent to surveyor inquiry, and the contractures did not worsen; Resident #27's right hand was a little tight but he/she was able to tolerate holding the carrots, bilaterally without pain, and in the same way he/she was able to hold them prior. Although requested the OT screening completed on 4/8/26 was not provided. The Splint/Orthotics/Prosthetics policy directs for residents to receive splint, orthotic, or prosthetic devices as deemed appropriate by the physician and rehabilitation services. Staff will monitor the circulation and skin integrity of residents using these devices at least every shift as part of routine care, or more often, as ordered by the physician. Nursing staff will apply/remove the designated device during scheduled wearing times and should also notify the rehabilitation department of any worn or ill-fitting devices. If the resident refuses to wear the device, notify the physician, rehabilitation department, and responsible party.

Based on review of the clinical record, facility documentation, facility policy and interview for 2 of 6 residents (Resident #10 and 22) reviewed for accidents, for Resident #10 who had a diagnosis of dementia and dysphagia, poor eating strategies, ongoing coughing and signs of aspiration (inhalation of foreign material into the airways) the facility failed to supervise the resident during meals. Further, despite these risks, the facility allowed Resident #10 to continue to eat the same meal after experiencing a coughing episode without further evaluation for safety in November 2025. Resident #10 subsequently experienced a choking episode in December 2025 which required the Heimlich maneuver. After the airway was cleared, the resident again was allowed to continue to eat the same meal. For Resident #22 who had a fall during a staff assisted transfer, the facility failed to use a gait belt during the transfer according to facility policy. The findings include: 1. Resident #10 was admitted to the facility in September 2022 with diagnoses that included dementia and dysphagia. The quarterly MDS dated [DATE] identified Resident #10 had severely impaired cognition and was independent/set up assist with eating. Physician's order dated 10/22/25 directed a no added salt, mechanically altered texture, thin consistency diet. A Speech Therapy Evaluation dated 10/17/25 identified Resident #10 had a diagnosis of dysphagia, was at risk for aspiration, and was being referred for evaluation and development of compensatory strategies to improve oral intake. Recommendations included thin liquids, regular textures, alteration of liquids and solids and upright position during meals and 30 minutes after. Speech therapy (ST) services were scheduled to continue until 1/7/26. A Speech Therapy Encounter Note dated 11/5/25 identified a diet texture analysis was conducted with mechanically altered consistencies and thin liquids. Resident #10 reported he/she just had a coughing attack. ST instructed Resident #10 in completing a hard throat clear and re-swallow, which were weak. Thin liquids were trialed with no overt signs of aspiration but Resident #10 continued with a gurgled vocal quality. ST discussed recommendations with the responsible party for nectar thick liquids to determine increased swallowing safety in the next few days. A physician's order dated 11/5/25 directed a no added salt, mechanically altered texture, nectar thick consistency diet. The care plan dated 11/12/25 identified Resident #10 was at risk for weight loss and decline in swallowing function. Interventions included reporting difficulties in chewing, swallowing, eating upright and chewing slowly/thoroughly. A Speech Therapy Encounter Note dated 11/14/25 identified Resident #10 was evaluated by speech therapy during snack. ST initiated thin liquids which were tolerated well. Resident #10 required occasional verbal cues for rate and intake modification with solids. Fluctuating carryover was noted. Resident #10 consumed the whole snack without difficulty. ST to continue the plan of care to determine the safest and least restrictive diet. No precautions, contraindication or barriers were present and Resident #10 was actively participating with skilled interventions. A Speech Therapy Encounter Note dated 11/18/25 identified Resident #10 was evaluated during lunch. The resident consumed the mechanically altered solids with adequate bolus size/rate intake and adequate clearance post swallow with no signs/symptoms of aspiration. Resident #10 consumed approximately 1/3 of the meal with nectar thick liquids in single cup sips followed by ST facilitated trial of thin liquids. There was one episode of coughing post swallow with 8 oz. of thin liquids. Staff reported ongoing coughing with thin liquids (family provided) which currently ended due to severe coughing episodes. ST provided Resident #10 with nectar thick liquids again who demonstrated no difficulty and was able to tolerate 4 oz. via single cup sips with relative ease. Nursing staff were notified of Resident #10's performance. The care plan included to continue with nectar thick liquids with mechanical ground textures. No precautions, contraindication or barriers were present and Resident #10 was actively participating with skilled interventions. A Speech Therapy Encounter Note dated 11/19/25 identified staff reported Resident #10 was gagging on dinner every night and reported drinking regular liquids at times. ST provided Resident #10 with nectar thick liquids with good movement of food/liquid from the front to the back of the mouth. Resident #10 also reported he/she drinks regular liquids at times. ST provided education (the note failed to identify what education was provided and to whom). A Speech Therapy Encounter Note dated 11/21/25 identified Resident #10 was evaluated during a meal of mechanically altered solids with nectar thick liquids. Resident #10 tolerated the meal well with set up assistance, however demonstrated residual at the base of the tongue post swallow, cleared with verbal cues and liquid washes. Education was provided for consistent liquid washes, with Resident #10 reporting understanding (despite having a BIMS of 4 and severely impaired cognition). Resident #10 had a missing dental bridge therefore unable to tolerate a diet advancement. ST to continue current plan of care with ongoing trials of thin liquids to determine candidacy for safe diet advancement. No precautions, contraindication or barriers were present and Resident #10 was actively participating with skilled interventions. A Speech Therapy Encounter Note dated 11/24/25 identified Resident #10 was evaluated sitting in the dining room during supper eating a mechanically altered diet with nectar thin liquids. Resident #10 was observed with occasional coughing episodes. ST provided cues for liquid washes due to a buildup of residue on the base of the tongue with Resident #10 showing improved performance given ongoing verbal/visual cues, as Resident #10 demonstrated poor carryover strategies. Resident #10 consumed 100% of the meal land 8oz. of nectar thick liquids via single cup sips with no difficulty noted with liquid intake. ST to continue the plan of care. No precautions, contraindication or barriers were present and Resident #10 was actively participating with skilled interventions. Nurses note dated 12/2/25 at 11:37 PM (entered by RN #3) identified at 6:15 PM during dinner, Resident #10 was unable to clear their airway and began to choke during the meal. The Heimlich maneuver was performed with success. Macaroni was dislodged from the airway. Resident #10's airway with no obstruction observed. A speech evaluation sheet was sent to rehabilitation services to evaluate. A reportable event summary dated 12/11/25 at 9:00 AM identified Resident #10 experienced a choking episode requiring immediate initiation of abdominal thrusts, which successfully cleared the airway. Resident #10 was eating the prescribed diet at the time of the event. An x-ray showed no acute changes, and an evaluation was completed by speech therapy. Resident #10's diet was downgraded to puree with nectar thick liquids. Aspiration precautions were implemented, and Resident #10 began receiving supervision during meals to ensure small bites/sips and adequate oral clearance between bites. No further choking episodes have been reported. The corrective action plan included staff education related to the recent diet downgrade, review of speech therapy recommendations regarding aspiration precautions, supervised meals and guidelines. Staff to receive abdominal thrust competency training, education on timely reporting and appropriate chain of custody procedures. Interview with the Director of Rehabilitation on 4/7/26 7:39 AM identified Resident #10 was independent with set up assistance and did not require supervision prior to the choking event of 12/3/25. Resident #10 has since been downgraded to a puree diet with nectar thick liquids. Interview with RN #3 on 4/7/26 at 8:57 AM identified he entered Resident #10's room and observed the resident sitting upright in the wheelchair exhibiting stridor (high-pitched breathing sound caused by obstruction). RN #3 stood behind Resident #10, placed his arms around the resident's abdomen, and delivered 2-3 upward abdominal thrusts. Food was successfully dislodged and the resident's respiratory status returned to baseline. RN #3 indicated he allowed Resident #10 to complete the meal supervised, with smaller bites and pacing between sips and bites as a nursing measure. Resident #10 was referred to speech therapy and the diet was downgraded. Interview with SLP #1 on 4/7/26 at 9:36 AM identified while she did not provide services to Resident #10 prior to the choking episode, Resident #10 was demonstrating safe eating strategies and did not require supervision prior to the choking incident. SLP #1 indicated that a diet should be downgraded for any resident following a choking episode. SLP #1 further identified allowing a resident to complete a meal they had just choked on places them at risk for further choking. Interview with NA #4 on 4/7/26 at 10:41 AM identified she was the assigned aide on 12/2/25 during the 3:00 PM to 11:00 PM shift. NA #4 indicated Resident #10 was normally independent with eating requiring set up assistance only. NA #4 provided Resident #10 a meal tray in his/her room sitting in a wheelchair, set the resident up to eat, and returned to the hall to continue to serve food trays for dinner. When passing Resident #10's room a short time later, NA #4 observed Resident #10 still in the wheelchair, gesturing with his/her hand towards the mouth and neck, unable to speak, purple in color and not coughing. NA #4 immediately notified the nurse who entered Resident #10's room and delivered the Heimlich maneuver where the food was successfully dislodged. An interview with APRN #2 on 4/07/2026 at 12:40 PM identified while he recalled reading about Resident #10 experiencing a choking episode, he was not consulted on the details and the allowance of continuing the meal after the choking episode. APRN #2 indicated he would have ordered Resident #10 to have nothing by mouth until evaluated by speech therapy. Interview with NA #3 on 4/7/26 at 3:15 PM identified on a separate occasion, sometime in November 2025 during dinner between 5:30 PM and 6:00 PM in the dining room, Resident #10 began to cough repeatedly during the meal and was pointing to his/her neck. Resident #10 never changed color or stopped coughing and eventually spit out a small 'rice' like food bolus. NA #3 was alone in the dining room at the time and allowed Resident #10 to resume eating after the significant coughing episode with no further issues. NA #3 reported the incident to the charge nurse after dinner and an assessment was completed. NA #3 was instructed by the nurse to be notified if the resident experienced any more coughing. There was no documentation in the clinical record related to the coughing episodes during meals. Interview with the DNS on 4/8/26 at 10:31 AM identified that while she determined Resident #10 consumed macaroni and cheese resulting in a choking episode as the root cause, she did not thoroughly examine Resident #10's diet consistency prior to the incident or determine if the wrong consistency was served. The DNS indicated she did learn Resident #10 ate fast during her analysis. The DNS implemented staff education in Resident #10's diet downgrade, speech therapy recommendations, competency in Heimlich thrusts and timely reporting of incidents. 2. Resident #22 was admitted to the facility in May 2025 with diagnoses that included dementia, dorsalgia, repeated falls, and abnormalities of gait and mobility. The care plan dated 12/13/25 identified Resident #22 was at risk for falls related to deconditioning, unsteady gait, impaired mobility, diagnoses of orthostatic hypotension, poor safety awareness and self-transferring. Interventions included providing reminders to use call bell prior to rising as warranted, provide a motion sensor, and transfers the resident with the assistance of one staff with a rolling walker. The care plan failed to reflect documentation of the use of a gait belt with transfers. The fall risk evaluation form dated 12/13/25 at 11:19 PM identified Resident #22 was at risk for falls. The quarterly MDS dated [DATE] identified Resident #22 had moderately impaired cognition and required partial/moderate assistance with lying to sitting on side of bed, sitting to stand, and toilet transfer with a walker. Further, Resident #22 has a history of falls and fall with injury. The physician's order dated 3/1/26 directed staff to provide assistance of one for transfers and ambulate Resident #22 to the bathroom with a rolling walker and the assistance of one. The order failed to include the use of a gait belt as part of the resident's transfer and ambulation assistance. Although NA #5 completed a safety and transfer orientation and demonstrated competency on 3/21/26, review of the orientation packet dated 3/21/26 indicated that NA #5 was educated on patient safety, transfer techniques, and the use of a gait belt for residents who require assistance with transfers. A reportable event form dated 3/30/26 at 3:30 PM identified Resident #22 had a witnessed fall in his/her room. An RN assessment was performed and Resident #22 was alert and oriented to self, reported pain in the right upper arm and demonstrated limited range of motion. The APRN was notified and a new order was obtained for a STAT x-ray of the right humerus. The risk analysis/investigative report form dated 3/30/26 identified Resident #22 was last toileted at 3:20 PM. The nurse's note dated 3/30/26 at 8:07 PM identified RN #7 was notified by LPN #4 that NA #5 observed Resident #22 fall and land on his/her right side while standing next to the bed. There was no reported head strike. The APRN was notified with orders for post-fall monitoring, STAT x-ray of the right humerus, and a one-time dose of Metoprolol 25mg for blood pressure of 157/96 and irregular apical pulse of 116 beats per minute. STAT x-ray was obtained with result pending. The fall risk evaluation form dated 3/30/26 at 11:07 PM identified Resident #22 was at risk for falls. The nurse's note dated 3/30/26 at 11:16 PM identified x-ray of the right humerus with negative results for injury. The care plan dated 3/30/26 identified Resident #22 was at risk for falls related to deconditioning, unsteady gait and impaired mobility, diagnoses of orthostatic hypotension, poor safety awareness and self-transferring. Interventions included physical therapy evaluation. A written statement by NA #5 dated 3/30/26 identified she was assisting Resident #22 to the bathroom when the resident fell. NA #5 indicated she assisted Resident #22 to a standing position and asked Resident #22 to wait while she turned off the bed alarm. NA #5 indicated she doesn't think Resident #22 heard her because as she turned to turn off the bed alarm, Resident #22 stepped forward and lost his/her balance. NA #5 indicated Resident #22 landed on his/her right side and rolled onto his/her back. NA #5 indicated she removed the walker from around the resident's body and called for the nurse. The APRN note dated 3/31/26 at 1:37 PM identified Resident #22 was assessed following a fall on 3/30/26 with complaints of right upper arm pain. Resident #22 was alert, followed commands, and demonstrated equal strength bilaterally in the upper extremities. No evidence of pain or acute injury noted to either limbs at the time of assessment. Tylenol as needed for pain. The physician's order dated 4/1/26 directed staff to provide assistance of one for transfers from bed to wheelchair with rolling walker and no ambulation at this time. The order failed to include the use of a gait belt as part of the resident's transfer. Interview with RN #7 on 4/8/26 at 10:15 AM identified she was the supervisor on duty on 3/30/26 during the 3:00 PM – 11:00 PM shift when she was called to Resident #22's room and observed the resident lying on the floor, alert and verbally responsive, without a gait belt in place. RN #7 assessed Resident #22 on the floor, obtained vital signs, and Resident #22 complained of right upper arm pain. RN #7 indicated she applied a gait belt prior to assisting the resident off the floor with NA #5. RN #7 indicated NA #5 identified she was standing next to Resident #22 and turned to reach to turn off the bed alarm when the resident fell. RN #7 indicated gait belts are usually available in the resident rooms and are always available on the unit. Interview with the DNS on 4/8/26 at 10:54 AM identified during her investigation, NA #5 was assisting Resident #22 from the bed to the bathroom using a rolling walker when the resident fell. The DNS indicated NA #5 did not use a gait belt during the transfer and turned to the left to turn off the bed alarm when Resident #22 took a step forward, lost his/her balance, and fell. The DNS indicated NA #5 should have used a gait belt during the transfer. The DNS indicated that NA #5 was re-educated on proper use of a gait belt for resident transfers. The DNS identified NA #5 should have followed the facility gait belt policy and indicated gait belts are available on the unit. Interview with the Rehabilitation Director on 4/8/26 at 11:05 AM identified prior to the fall Resident #22 required assistance of one person with transfers and a rolling walker. The Rehabilitation Director indicated that staff are expected to use a gait belt during all transfers. The Rehabilitation Director indicated assistance of one means hands-on assistance, and the expectation is to have one hand on the gait belt during transfers. The Rehabilitation Director indicated the nurse aide should have been using the gait belt during the transfer. Interview with LPN #4 on 4/13/26 at 9:06 AM identified while receiving change of shift report, she heard a loud bang and ran to Resident #22's room. LPN #4 indicated when she entered the room, RN #7 (supervisor) and two nurse aides were present, and Resident #22 was observed lying on the floor without a gait belt in place. LPN #4 indicated RN #7 obtained the resident vital signs and then retrieved and applied a gait belt before the resident was lifted off the floor. Interview with MD #1 on 4/14/26 at 3:32 PM identified the nurse aide should have followed the facility protocol and utilized a gait belt when transferring Resident #22. Although attempts were made, an interview with NA #5 was not obtained. Review of the facility gait belt policy identified gait belts will be used to assist in transferring or ambulating designated residents to ensure safety of resident and staff members and the use of proper body mechanics. Once in a standing position, while still holding the gait belt, help the resident to ambulate or turn slowly toward the new surface. Review of the falls management policy identified the facility will utilize all resident/patient related information made available upon admission and ongoing to determine resident/patient at -risk for fall status. A fall is defined as any incident in which a resident/patient unintentionally has a change in elevation/plane, an occasion where the residents would have lost their balance without staff intervention, or an incidence where residents roll off a bed or mattress close to the floor. Unless there is evidence suggesting otherwise, anytime a resident is found on the floor, a fall is considered to have occurred.

Based on review of the clinical record, facility policy, and interviews for 2 of 2 residents (Resident #31 and 69) reviewed for urinary catheter/UTI, for Resident #31, who had a supra pubic tube and a history of UTIs with hospitalizations, the facility failed to ensure a recommended urology follow up was obtained, and for Resident #69 the facility failed to consistently monitor and document urine output in accordance with physician's orders. The findings include: 1. A urology telehealth visit note dated 9/22/22 identified Resident #31 presented with complaints of urinary retention, had progressive advanced multiple sclerosis, had been followed by a urologist out of state, and recently moved back to the area. Resident #31 had developed urinary retention for which he/she had been managed with a suprapubic catheter since 2016, had a history of recurrent urinary tract infections (UTI) and sepsis in the distant past for which he/she was followed by an out of state urologist and infectious disease services, and the decision was made to continue prophylactic Amoxicillin 500 mg daily. Since starting the therapy approximately 2 years ago, he/she has not had any urinary tract infections. Resident #31 was doing well with 2–3-week suprapubic tube changes, draining clear urine, had not had any recent UTIs, and desired a refill for Penicillin for prophylaxis, which he/she has been tolerating for some time, in the more distant past he/she had been on Amoxicillin. The plan for Resident #31's urinary retention included refilling Penicillin V potassium tablet, 500 mg daily, calling with hematuria or issues changing the catheter, and reevaluation in the office in a few months, as he/she has not been seen for over one year. Resident #31 was admitted to the facility in November 2022 with diagnoses that included neuromuscular dysfunction of the bladder, progressive multiple sclerosis (MS), and urinary tract infections. The physician's note dated 11/7/23 identified Resident #31 reported no complaints of abdominal pain, chest pain, or shortness of breath, assessment and plan for flaccid neuropathic bladder included management of the suprapubic catheter and continuing with Penicillin and Vitamin C. The Discharge Documentation Attending Attestation dated 11/24/23 identified Resident #31 presented to the emergency department on 11/22/23 with a fever, fast heart rate, hypotensive, and was admitted for management of severe sepsis secondary to UTI. Urine culture showed Pseudomonas, sensitive to fourth-generation cephalosporins and fluoroquinolones; the antibiotic therapy was adjusted and Resident #31 was started on Levofloxacin. Resident #31 was medically stable for discharge, recommended follow up with primary care physician, in the next few days for reevaluation, and will continue Levofloxacin for 6 more days; once completed antibiotic therapy, consider the patient on prophylactic therapy given the recurrent UTI. The physician's admission note dated 11/28/23 identified Resident #31's assessment and plan for sepsis management included PT/OT and antibiotics. The APRN note dated 4/11/24 at 6:30 PM identified Resident #31 had a past medical history of MS and was seen to review the need for a suprapubic catheter, which was in place for neurogenic bladder. Resident #31 was hospitalized in November 2023, for UTI, which grew Pseudomonas, and he/she finished a course of Levofloxacin, at that time. A recommendation was given, at that time, to continue on prophylactic antibiotics for UTI prevention, per notes it was recommended that Resident #31 be changed from the Penicillin which he/she has always been on prophylactically to something that would cover Pseudomonas moving forward, in light of his/her recent infection. The plan to discontinue Penicillin and start Ciprofloxacin 125 mg, daily, to cover pseudomonas, was discussed with Resident #31 and he/she was in agreement. A physician's order dated 4/11/24 directed to administer Ciprofloxacin 250mg, give 0.5 tablet by mouth, daily, related to a personal history of UTIs. The quarterly MDS dated [DATE] identified Resident #31 had intact cognition and had an indwelling suprapubic catheter. The care plan dated 3/3/26 identified Resident #31 had a suprapubic catheter, has a diagnosis of neuromuscular dysfunction of the bladder and a history of recurrent UTIs, with interventions that included cleaning and changing suprapubic catheter as ordered and observing for signs and symptoms of UTI, reporting changes to the physician, and medicate as ordered with antibiotic prophylaxis. Interview with Resident #31 on 4/6/26 at 8:35 AM identified that he/she had no concerns with the management of his/her neurogenic bladder or suprapubic catheter, and that he/she had not had any recent UTIs. Interview with the Infection Control Nurse (LPN #1) on 4/7/26 at 7:35 AM identified that she had worked at the facility for 6 months and was not sure if Resident #31 had been under the service of a consulting Urologist, and she was unsure if the order for prophylactic Ciprofloxacin had been reviewed by the Interdisciplinary Team (IDT) since it was ordered in April 2024 but she would look into both and follow-up. Interview with APRN #1 on 4/7/26 at 8:30 AM identified that she had worked at the facility since 2023, and that she was unable to access Resident #31's clinical record prior to June 2024, as the facility had changed electronic health record systems, and she did not have full access to the old system. APRN #1 indicated that Resident #31 was on prophylactic Ciprofloxacin and that recommendation came from the Urologist. The resident had been taking Penicillin, but when it was identified that the regimen needed to cover Pseudomonas, the Penicillin was discontinued and Ciprofloxacin was ordered. APRN #1 indicated that she could not recall the last time Resident #31 had a consultation with the Urologist and that she was not sure who would have coordinated that appointment. APRN #1 indicated that she would work with the facility staff to assist with gaining access to Resident #31's clinical record prior to June 2024 for a more comprehensive review. Interview with the VP of Clinical Services (RN #5) on 4/8/26 at 10:30 AM identified that she was able to access the Resident #31's clinical record in the old system, as well as progress notes from the prior Medical Director that supported the justification Resident #31's on-going prophylactic antibiotic order but was unable to located documentation that Resident #31 had been seen by his/her Urologist since the visit in September 2022. Interview with the DNS on 4/8/26 at 1:19 PM identified that she did not work at the facility when Resident #31 was admitted so she could not speak to the process on following up with the consultant Urologist's 9/22/22 recommendation for follow-up in a few months, but she would expect recommendations from consulting medical provider to be followed and follow-up appointments scheduled, per the recommendations. The DNS further indicated that she would have a conversation with Resident #31 and his/her medical providers regarding Urology follow-up. The Consultation Services policy directs the facility to identify and facilitate consultant services to meet the resident's needs, to ensure optimum care for each resident/patient through consultant services. 2. Resident #69 was admitted to the facility in February 2026 with diagnoses that included urinary retention, urinary tract infection, and acute kidney failure. The care plan dated 2/19/26 identified Resident #69 had an indwelling urinary catheter. Interventions included to monitor urinary output and catheter patency as per facility protocol. The admission MDS dated [DATE] identified Resident #69 had severely impaired cognition, an indwelling catheter, and was totally dependent for toileting hygiene. The physician's order dated 3/9/26 directed to document urinary drainage bag output every shift. Review of the Treatment Administration Record (TAR) dated 3/9/26 – 3/25/26 failed to reflect documentation of the amount of urinary output. The clinical record indicated Resident #69 was hospitalized [DATE] – 3/31/26. Review of Resident #69 hard copy and electronic medical records dated 3/9/26 – 3/25/26 failed to reflect documentation of urinary output amounts. The physician's order dated 4/1/26 directed to document urinary drainage bag output every shift. Review of the April 2026 TAR dated 4/1/26 – 4/7/26 failed to reflect documentation of the amount of urinary output. Review of Resident #69's hard copy and electronic medical records dated 4/1/26 – 4/7/26 failed to reflect complete documentation of urinary output amounts. Interview with the DNS on 4/8/26 at 11:30 AM identified she was not aware that urinary output amounts were not being documented. The DNS indicated both nurse aides and licensed nursing staff are responsible for documenting the urinary output amounts in the resident's clinical record. Interview with RN #2 on 4/8/26 at 12:00 PM identified she was not aware the physician's order was not being followed as urinary output was not being documented. Interview with RN #5 (Vice President Clinical Services) on 4/8/26 at 12:15 PM identified she was not aware the facility was not following the physician's order for documenting the urinary output amounts in Resident #69 clinical record. RN #5 indicated she will educate the nursing staff regarding documenting urine output. Interview with MD #1 on 4/14/26 at 3:32 PM identified he was not aware that staff were not following the physician's order for documenting the urinary output amounts from the foley catheter. MD #1 indicated his expectation would be that the nurses follow the physician's order. Review of the urinary catheter policy identified the purpose was to establish standardized procedures for urinary catheter insertion, maintenance, and removal to minimize the risk of catheter-associated urinary tract infections and promote resident comfort and well-being. Acceptable indications in a nursing home setting may include urinary retention that causes significant discomfort or complications. Accuracy monitoring of urine output in critically ill or unstable residents. Accurate and thorough documentation is essential. Documentation should include urine output and characteristics. Document the maintenance care provided, urine output, and any observations or complications.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #69) reviewed for tube feeding, the facility failed to ensure consistent monitoring and documentation of intake for a resident with a feeding tube in accordance with physician's order. The findings include:Resident #69 was admitted to the facility in February 2026 with diagnoses that included dysphagia, diverticulitis of intestine, dementia, and gastroesophageal reflux disease. The care plan dated 2/19/26 identified Resident #69 has the need for enteral feeding via a tube. Interventions include nothing by mouth and tube feeding as tolerated. Follow order for type of formula, rate, tube feedings continuously or intermittently via pump. Monitor input as ordered.The admission MDS dated [DATE] identified Resident #69 had severely impaired cognition, and a feeding tube.The physician's order dated 4/1/26 directed to administer Osmolite 1.5 at 50 ml per hour for 22 hours via pump. On at 7:00 AM and off at 5:00 AM every shift and Resident #69 was ordered nothing by mouth (NPO).The physician's order dated 4/1/26 directed to document the amount of formula and water administered via feeding tube every 8 hours and to record the total intake every 24 hours. Further, to administer water flush with 200 ml every 6 hours via feeding tube. Review of the MAR dated 4/1/26 - 4/7/26 failed to reflect documentation of the amount of intake of the Osmolite and water flushes via feeding tube (21 shifts). Review of Resident #69's hard copy and electronic medical records dated 4/1/26 - 4/7/26 failed to reflect documentation of intake of the Osmolite and water flushes via feeding tube. The nutrition note dated 4/6/26 at 4:35 PM identified Resident #69 was NPO and receiving Osmolite 1.5 at 50 ml an hour via feeding tube for 22 hours a day, with 200 ml water flushes every 6 hours. The nurse's notes indicated Resident #69 was tolerating the feeding tube at this time. The feeding tube regimen supplies 1650 kcal per day. Interview with the DNS on 4/8/26 at 11:30 AM identified she was not aware the feeding tube intake was not being documented in Resident #69's clinical record. The DNS indicated the licensed nursing staff are responsible for documenting the feeding tube amounts in the resident's clinical record.Interview with RN #2 on 4/8/26 at 12:00 PM identified she was not aware the feeding tube intake was not being documented in Resident #69 clinical record. RN #2 indicated she was not aware that the physician's orders were not being followed. Interview with RN #5 (Vice President Clinical Services) on 4/8/26 at 12:15 PM identified she was not aware the facility was not following the physician's order for documenting the feeding tube intake amounts in Resident #69 clinical record. RN #5 indicated she will educate the licensed staff regarding documenting the feeding tube intakes.Interview with MD #1 on 4/14/26 at 3:32 PM identified he was not aware the facility was not following the physician's order for documenting the feeding tube intakes. MD #1 indicated his expectation would be that the nurses follow the physician's order.Review of the facility enteral feeding provides an alternative method of nutritional support via gastrostomy or jejunostomy tube and is used to enhance and maintain nutritional status when there is an inability to take adequate nutrients orally. Document and record intake, flush and free water volume administered.

Based on review of facility documentation, facility assessment, and interviews for 2 of 2 licensed nurses (RNs #3 and 8) and 2 of 3 nurse aides (NA #1 and 12), the facility failed to ensure annual competencies necessary to care for resident's needs were completed. The findings include:Review of the Annual Education Schedule identified the following competencies for licensed nurses were to be completed: hand hygiene/PPE in January, glucometer use and cleaning in February, IV in March, and Lifts in July. RN #3 was hired on 10/11/22. Review of RN #3's competency documentation for 2025 and 2026 failed to identify routine competency evaluations were completed for hand hygiene/PPE, glucometer use and cleaning, and lifts.RN #8 was hired on 1/18/18. Review of RN #8's competency documentation for 2025 and 2026 failed to identify routine competency evaluations were completed for hand hygiene/PPE, glucometer use and cleaning, and lifts.Review of the Annual Education Schedule identified the following competencies for nurse aides were to be completed: hand hygiene/PPE in January, Heimlich in May, lifts in June, and transfers in November.NA #1 was hired on 6/15/05. Review of NA #1's competency documentation for 2025 and 2026 failed to identify a routine competency evaluation was completed for transfers.NA #12 was hired on 1/3/25. Review of NA #12's competency documentation for 2025 and 2026 failed to identify routine competency evaluations were completed for lifts and transfers.Interview with the Staff Development Nurse (LPN #1) on 4/8/26 at 9:30 AM identified that she began working in the facility in October 2025, and she could not speak to the oversight of the program prior to her hire, but every month there is a calendar for staff education and competencies, that the facility follows, and that she has been completing the 2026 competencies with nursing staff.Interview with the VP of clinical services (RN #5) on 4/8/26 at 9:35 AM identified that in collaboration with LPN #1 and the DNS, both of which were recent hires, the staff development program was in the process of being reorganized and improvements were already underway. RN #5 indicated that she believed that the annual competencies for nursing staff had been completed, but they were unable to locate all the documentation.Interview with the DNS on 4/8/26 at 1:04 PM identified that she began working at the facility in September 2025, and the staff development position had been vacant for a while prior to LPN #1's hire in October 2025, which would have contributed to competency evaluations not being completed consistently. The DNS indicated that she expected competencies to be completed on operating lifts, transfers, and glucometer use and cleaning for applicable nursing staffing on orientation and annually.The Facility Assessment identified there were 22 residents requiring assistance of 1-2 staff members for transfers and 16 residents that were dependent on staff for transfers. The Facility Assessment further identified education, training, and job competency evaluation begins upon hire, in general orientation with every new employee in every department. The orientation job competency checklist is job specific and is part of the orientation of every employee. After orientation is completed, every employee will be evaluated for competencies in their job on a regular basis.

Based on review of facility documentation, employee handbook, the facility assessment, and interviews for 3 of 6 nurse aides (NAs #6, 9, and 10) the facility failed to ensure performance reviews were completed, at least every 12 months. The findings include:Review of NA #6's personnel file identified that she was hired on 5/2/19 and failed to identify documentation that an annual performance review had been completed since 10/31/22.Review of NA #9's personnel file identified that she was hired on 8/30/21 and failed to identify documentation that an annual performance review had been completed since 8/2/23.Review of NA #10's personnel file identified that she was hired on 5/1/23 and failed to identify documentation that a performance review had been completed since hire.Interview and personnel file review with the HR Director on 4/8/26 at 10:00 AM identified NAs #6, 9, and 10 did not have an up-to-date annual performance review on file. The HR Director indicated that the process for the completion of annual nursing staff performance reviews would be that the receptionist, who no longer worked at the facility as of a few weeks ago, would notify the appropriate department head of who was due for their annual review monthly, the DNS would be notified of upcoming nursing staff performance reviews, and once the review was completed the department head would return it to the receptionist, who would return it to HR; she would sign the review and put it in the personnel file. The HR Director indicated that she was aware that there were incomplete annual performance reviews, and she had conversations with the prior receptionist.Interview with the DNS on 4/8/26 at 1:04 PM identified that she began working at the facility in September 2025 and that the process for completing annual performance reviews was that at the beginning of each month, she would be notified of which employees were due for their annual performance review, based off of their hire date anniversary, she would complete the evaluation with the nursing staff member, and return the completed review to the HR Director. The DNS indicated that she was unaware that some nurse aide performance reviews had not been completed annually. The DNS indicated that she would work closely with the HR Director to tighten up the process for completing annual performance reviews and ensure all nursing staff were up to date.The Employee Handbook: Performance Reviews identified that the facility endeavors to conduct written performance reviews of each staff member's performance annually.The Facility Assessment identified that additional training for nurse aides may be added to address areas of weakness determined in the nurse aide's performance review.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 residents (Resident #10) reviewed for unnecessary medications, the facility failed to ensure pharmacy recommendations were addressed in a timely manner: The findings include:Resident #10 was admitted to the facility in September 2022 with diagnoses that included hydronephrosis (swelling of the kidneys), dementia dysphagia, (swallowing disorder).The quarterly MDS dated [DATE] identified Resident #10 was severely cognitively impaired, incontinent of urine and required two person assist with toileting.The care plan dated 11/12/25 identified Resident #10 was experiencing functional deficits related to comorbidities/health conditions. Interventions included assistance with toileting ensuring dignity through the ADL process completion to the extent possible.Physician's order dated 12/3/25 directed to administer Tamsulosin HCL (medication used to relax the muscles in the bladder to improve urinary flow) 0.4mg (milligrams) one capsule by mouth daily for incontinence and to crush all medications unless contraindicated. Pharmacy Medication Regimen Review dated 12/4/25 identified Tamsulosin (Flomax) 0.4mg should not be crushed, chewed or opened. With an order to crush medications, please evaluate and consider discontinuing if no longer needed or switch to Silodosin (medication used to improves urinary flow) 4mg once daily after dinner which may be opened and the powder sprinkled whole in applesauce if appropriate. The review was marked as agreed with a notation of (will do) and signed on 2/11/26, 70 days after the recommendation was made. The request was marked 'done.'Physician's order dated 2/12/26 directed to administer Tamsulosin HCL 0.4mg one capsule by mouth in the evening for incontinence. Review of the clinical record did not identify clinical rationale pertaining to the continued use of the Tamsulosin. Interview with APRN #1 on 4/8/26 at 10:07 AM identified she reviews, responds to and signs the pharmacy recommendations once received by nursing. Once signed, it is her expectation that nursing makes the necessary changes as indicated. APRN #1 agreed to the medication change and signed the review on 2/11/26 when received.Interview and clinical record review with the DNS on 4/08/26 at 10:22 AM identified she received the monthly pharmacy medication reviews. The DNS and RN #4, the ADNS were responsible for reviewing the recommendations. The DNS would place the recommendations in the APRN communication book. Once responded to, the DNS and RN #4 make changes in the system. The DNS further indicated she recalled an issue related to the medication change for Resident #10 but needed to refer to RN #4 for details that it should have been addressed and documented. Interview with RN #4 on 4/8/26 at 11:00 AM identified there was a problem with the formulary and availability through the pharmacy but was unable to explain how the issue was addressed. RN #4 further indicated, subsequent to surveyor inquiry, she would determine the status now. Review of the facility policy for Monthly Drug Regimen Review directed the pharmacist is to perform a medication regimen review at least monthly and provide written documentation of all recommendations to be submitted monthly to the facility for the attending prescriber or designee to review and respond. The written documentation is considered part of the clinical record. The facility is required to act upon the medication regimen review findings/recommendations timely within 7-14 days or less. The provider shall document on the drug regimen form whether he/she agrees/disagrees with the recommendation and provide a brief clinical rationale if no change is made.

Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure injectable medication was maintained secured according to established standards of practice The findings include:Observation on 4/6/26 at 9:23 AM identified the medication cart was positioned in front of Resident #60's room with a box labeled Rebif (injectable medication used to treat Multiple Sclorisis) on top. On top of the box was a grey injector pen in its package. Nursing staff were not observed at or within reach of the cart. Continued observation identified RN #1 and APRN #1 in Resident #60's room, speaking to the resident. RN #1 and APRN #1 were observed with their backs to the doorway and the medication cart during this interaction. At 9:27 AM, RN #1 was observed exiting the room and at the medication cart. Interview with RN #1 immediately following this observation identified that the medication was for Resident #60, and that she had pulled the medication box from the refrigerator due to the box having Resident #60's identifier information, which the individual autoinjector pens did not have. RN #1 identified that she had been observed for medication administration earlier in the morning by another surveyor and anticipated that she would be observed by this surveyor as well. RN #1 identified that the Rebif pens did not have individual labels that identified they were for Resident #60, so she pulled the entire box to ensure that she would be able to provide the label if questioned. RN #1 opened the box and 10 autoinjector pens were located within the box, along with the autoinjector pen on top, for a total of 11 autoinjector pens. RN #1 identified she should not have left the pens unsecured but wanted to speak with APRN #1 about Resident #60's medications and subsequently entered the resident's room with her back to the cart for several minutes. Interview with the DNS on 4/7/26 at 9:30 AM identified all medications for residents were to be locked and secured per facility policy,The facility policy for medication storage directed that medications must be secured and locked storage areas in compliance with state and federal requirements and accepted professional standards of practice. The policy further identified that access to medications was limited to only authorized personnel and medication storage areas included but were not limited to drawers, cabinets, medication rooms, refrigerators, and carts. The policy also directed that the facility must ensure that only appropriately authorized staff had access to medication storage areas.The facility policy on medication administration and documentation directed that it was the responsibility of the licensed nurse to assure that medications were not left unattended and that medications were secured in a locked area or were within the licensed nurse's visible control at all times.

Based on review of facility documentation, facility assessment, and interviews for 3 of 5 nurse aides (NAs #6, 7, and 8) reviewed for sufficient and competent staffing, the facility failed to ensure nurse aides had no less than 12 hours of in-servicing and competencies, completed in 2025.Review of the Annual Mandatory In-Service for Nurse Aides 2025 Tracker identified the following mandatory nurse aide in-services: annual mandatory, cultural competency, behavioral health, resident abuse prevention, resident rights, infection control and environmental safety, fun- fun-fun, trauma informed care, communication, prevention of skin breakdown, Heimlich/choking, IV, pain 1 and 2, oral care, dementia 1 and 2, and sexual harassment. Review of the Annual Education Schedule identified the following education would be completed for nurse aides, as follows: annual quiz in January, oral care and cultural competency in February, IV and behavioral health in March, dementia 1 in April, pain 1 and resident abuse prevention in May, dementia 2 and resident rights in June, infection control and environmental safety in July, fun fair in August, trauma informed care in September, communication in October, pain 2 in November, and preventing skin break down in December.NA #6 was hired on 5/2/19, and the 2025 Tracker identified NA #6 had not completed the cultural competency, behavioral health, resident abuse prevention, resident rights, infection control and environmental safety, fun-fun-fun, trauma informed care, communication, prevention of skin breakdown, corporate compliance, Heimlich/choking, IV, pain 1 and 2, oral care, Dementia 1 and 2, and sexual harassment education. NA #7 was hired on 7/6/1999, and the 2025 Tracker identified NA #7 had not completed the cultural competency, behavioral health, resident abuse prevention, resident rights, infection control and environmental safety, fun- fun-fun, trauma informed care, communication, Heimlich/choking, and sexual harassment education. NA #8 was hired on 5/11/25, and the 2025 Tracker identified NA #6 had not completed the cultural competency, Behavioral health, resident abuse prevention, resident rights, infection control and environmental safety, fun- fun-fun, trauma informed care, communication, prevention of skin breakdown, Heimlich/choking, IV, pain 1 and 2, oral care, Dementia 1 and 2, and sexual harassment education. Review of the 2025 untitled nurse aide total hours tracker identified NA #6 had 4 hours of education, NA #7 had 1.25 hours of education, and NA #8 had 0.5 hours.Interview with the VP of Clinical Services on 4/8/26 at 9:00 AM identified that she was unable to find documentation that supported that all nurse aides had completed at least 12 hours of in-servicing and competencies, in 2025. Interview with the Staff Development Nurse (LPN #1) on 4/8/26 at 9:15 AM identified that she began working at the facility in October 2025 and could not speak to the staff development process prior to October. LPN #1 indicated that all nursing staff receive an annual mandatory educational packet, which was an estimated 8 hours of education, in January from the receptionist, with the expectation that the employee would return the completed quiz to the receptionist by the month of their hire date and the topics in the packet include: Heimlich, choking, IV, oral care, pain, dementia, fall risk, resident centered care, resident rights, abuse, and fire safety. LPN #1 indicated that additional educational topics were distributed monthly to all nursing staff for as needed education and based off the Annual Education Schedule; the process would be the same, that the receptionist would distribute the education, and the staff member would attest to completing the education via signature or complete a quiz. The receptionist would then log the completed education onto the tracker. LPN #1 indicated that prior to today, she did not have access to the tracker, but the receptionist would provide her with a copy so she could follow up on outstanding education and provide re-education, as needed. LPN #1 was unable to identify why some staff education was incomplete on the 2025 Tracker and why some nurse aides had under 12 hours of education on the 2025 untitled total hours tracker.Interview with the DNS on 4/08/26 at 1:04 PM identified that she began working at the facility in September 2025, and the staff development position had been vacant for a while prior to LPN #1's hire in October 2025, which would have contributed to the incomplete tracking of nurse aide in-servicing and competency evaluation hours. The DNS indicated that it would be her expectation that 12 hours of nurse aide in-servicing would be met and tracked for all full-time, part-time, and per diem nurse aides. The DNS further indicated that the IDT was actively rebuilding the staff development position and making improvements to the processes.The facility assessment identified that nurse aide in-service training must be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #1) reviewed for quality of care, the facility failed to ensure use of a bed and chair alarm was assessed timely to ensure it was not a restraint and failed to ensure the care plan was based on a resident-specific assessment to support the use of the bed and chair alarms. The findings include: Resident #1's diagnoses included dementia, atrial fibrillation, osteoporosis, multiple rib fractures, depression, and history of falls. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of seven out of fifteen (7/15), indicative of being severely cognitively impaired, required partial to moderate assistance with ambulation and transfers and had no bed or chair alarms in use. The Resident Care Plan dated 10/29/25 identified Resident #1 was forgetful with poor safety awareness, and was at risk for falls related to deconditioned state, unsteady gait, and impaired mobility related to recent fall resulting in multiple rib fractures. Interventions directed use of a bed and chair alarm for safety per family's request, bed in the lowest position, call bell in reach and encourage use, adequate lighting, encourage common areas when out of bed, and offer toileting after resident's visitors end their visit. Physician order dated 12/27/25 directed bed and chair alarms to be used every shift. Observation of Resident #1 in his/her room on 1/14/26 at 10:20 AM identified Resident #1 was sitting on his/her bed with an active bed alarm in place. Additional observation identified a chair alarm in place on Resident #1's recliner chair. Record review failed to identify a comprehensive assessment and fall risk documentation addressing the clinical need, effectiveness, or individualized parameters for the use of bed and/or chair alarms. Further review failed to identify documentation explaining the use of alarms, any alternatives (or less restrictive interventions) to use of the alarms, and if the alarm use was assessed for a potential restraint. Interview and record review with the DON on 1/14/26 at 1:05 PM identified Resident #1 used bed and chair alarms at all times (every shift) for a high fall risk, and the care plan included the alarm use. The DNS stated Resident #1 does not utilize the call bell and will get out of bed alone. The DNS stated an assessment for use of the alarms was not completed, and stated routine nursing supervision was insufficient due to multiple attempts to get up independently and staff use the alarms to alert then when Resident #1 is moving. The DON was unable to provide documentation that less restrictive measures were trialed or that the use of the alarms was assessed to ensure they were not a restraint. Interview failed to identify why an assessment was not completed prior to use of the alarms. Review of the Chair/Bed Alarm Policy dated 7/2025 identified a chair alarm may be placed on a chair or wheelchair of a resident for his/her safety. The alarm will be used as an alternative to a restraint to alert staff that the resident is attempting to stand up alone. The alarm may also help to remind the resident to ask for assistance to get up. A bed alarm may be placed on a bed for a resident for safety. The alarm can be used as an alternative to a restraint for residents who attempt to get out of bed alone but are not safe in doing so.

Based on interviews, review of the clinical record, and facility policy for 1 of 4 residents (Resident #47) reviewed for nutrition, the facility failed to document the percentage of supplements consumed in regard to significant weight loss. The findings include: Resident #47's diagnoses included left sided hemiplegia and hemiparesis (muscle weakness) following a cerebral infarction, dysphagia, and dementia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #47 was severely cognitively impaired and required supervision or touch assistance with eating, partial/moderate assistance with oral hygiene, and was dependent with personal hygiene. Additionally, Resident #47's MDS identified no significant weight loss at that time. The Resident Care Plan dated 12/8/23 identified a nutritional concern due to a cerebral vascular accident, hemiplegia and hemiparesis, dysphagia, and dementia. Interventions included to provide a one person assist with meals, give large portions, juice supplement as ordered, and to monitor appetite daily. A review of Resident #47's weights identified that Resident #47 weighed 129.3 pounds (lbs) on 1/1/24. A Dietitian's note dated 2/2/24 identified Resident #47 weighed 119 lbs (Resident #47 had a 10.3 lb/7.9% weight loss in one month) and that there was a significant decrease in weight. The Dietitian recommended that the house juice supplement be increased from twice daily to three times daily. A physician's order dated 2/2/24 directed to give a house juice supplement of 177 milliliters (ml) three times a day. Resident #47's weights were 121 lbs on 3/1/24, 115 lbs on 4/1/24, 114.2 lbs on 5/3/24, and 109 lb on 6/5/24 (a 12 lb/9.9% weight loss in 3 months). A Dietitian's note dated 6/19/24 identified Resident #47 was seen by the physician due to progressive weight loss. The Dietitian recommended that the house juice supplement be increased from three to four times daily. A physician's order dated 6/19/24 directed to give a house juice supplement four times a day. A review of Resident #47's weights identified that Resident #47 weighed 107 lbs. on 6/21/24 (which indicated a 22.3 lbs/17.2% weight loss in less than 6 months). Interview and clinical record review with the Dietitian on 8/6/24 at 12:12 PM identified that tracking consumption of the house supplement was not documented since the supplement was ordered on 2/2/24 and would be documented on the Electronic Medication Administration Record (EMAR). Additionally, the house supplement was not transcribed into the EMAR to include the ml amount consumed. Although the nurse aides document total daily fluid intake on the intake record, it does not delineate the amount of nutritional supplement consumed. Interview and clinical record review with LPN #1 on 8/6/24 at 1:42 PM identified that nurses provide residents nutritional supplements and document it was given on the EMAR. Additionally, LPN #1 identified that the consumption amount of the house supplement was not being documented on the EMAR for Resident #47. LPN #1 further indicated that Resident #47 would typically only drink about half or a quarter of the house supplement, and not drink the whole supplement at a time. Interview with the Dietitian on 8/6/24 at 1:46 PM identified that with tracking of the house supplement consumption, along with checking labs and completing closer weight monitoring, she would be able to further evaluate Resident #47's diet needs. Additionally, the Dietitian indicated that there was a high calorie gelatin that could be added to Resident #47's diet order. Subsequent to surveyor inquiry, the order for the house juice supplement was changed by the Dietitian on 8/6/24 to consume 90 ml four times a day and to document the ml actually consumed on the EMAR. Additionally, the Dietitian collaborated with the Advanced Practice Registered Nurse to have lab work ordered and recommended weight monitoring weekly for 6 weeks, then monthly. Review of the Use of Nutritional Supplements policy dated 4/23 directed, in part, that supplement orders are transcribed on the EMAR. The ml of the supplement consumed by the resident is charted on the EMAR. The Dietitian should complete periodic reassessments of the need for continuation of supplemental feeding. 50250

Based on observations, interviews and record review for 1 of 1 sampled residents (Resident #566) reviewed for an indwelling urinary catheter, the facility failed to provide a privacy covering on a urinary collection bag. The findings include: Resident #566's diagnoses include retention of urine, benign prostatic hyperplasia, and Parkinson's disease. The Resident Care Plan dated 7/31/24 identified Resident #566 utilized an indwelling foley catheter. Interventions included enhanced barrier precautions, foley to remain patent, to maintain the foley as ordered in the treatment administration record and to provide education on catheter use. The Admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #566 was severely cognitively impaired, required substantial/moderate assistance for transfers and was dependent for toileting hygiene, bathing, and lower body dressing. Additionally, the MDS identified Resident #566 utilized an indwelling urinary catheter. Observations on 8/1/24 at 10:35 AM identified Resident #566 was in bed with an indwelling urinary catheter, the urinary collection bag was resting on the floor with urine visible in the collection bag, without the benefit of a privacy bag covering the collection bag. Observation on 8/5/24 at 6:26 AM identified Resident #566 was in bed with an indwelling urinary catheter (visible from the hallway), the urinary collection bag was resting on the floor with urine visible in the collection bag, without the benefit of a privacy bag covering the collection bag. Interview and observation with Registered Nurse (RN) #1 on 8/5/24 at 7:40 AM identified that per facility policy the drainage bag should be up off the floor and in a privacy bag. Subsequent to surveyor inquiry, Registered Nurse (RN) #1 placed a privacy covering on Resident #566's urinary collection bag and raised the collection bag off the floor. Interview with the Infection Control Nurse (LPN #5) on 8/7/24 at 10:16 AM identified collection bags should be stored on the bed rail or under wheelchair and in a privacy bag. Although requested, a facility policy for privacy coverings for urinary collection bags was not provided.

Based on interviews, review of the clinical record, and facility documentation for 1 of 5 sampled residents (Resident #47) reviewed for unnecessary medication, the facility failed to accurately transcribe an Advanced Practice Registered Nurse (APRN) medication order. The findings include: Resident #47 diagnosis included vascular dementia with behavioral disturbance, unspecified psychosis, and Alzheimer's disease. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #47 was severely cognitively impaired and required supervision with eating, partial assistance with oral hygiene, and was dependent with toileting, upper/lower body dressing, and personal hygiene. Additionally, the MDS identified Resident #47 received antidepressant medication. The Resident Care Plan dated 2/21/24 identified behavioral symptoms. Interventions included providing medications as ordered with physician discussion regarding dose revision and effect as needed. A Psychiatric progress note dated 4/17/24 written by APRN #1, identified that she was asked to evaluate Resident #47 for behavioral disturbances, restlessness, eating poorly, and trying to climb out of bed at night when his behaviors become acute. An order from APRN #1 dated 4/17/24 directed to discontinue Trazodone (a medication to treat depression) 50 milligrams (mg) at bedtime and start Trazodone 75 mg at bedtime. APRN #2 (medical APRN) entered an order in the electronic chart for Trazodone 25 mg at bedtime to start 4/17/24 (despite APRN #1 writing order for 75 mg). A nurse's note written by LPN #4 dated 4/17/24 at 8:48 PM identified an order written by APRN #1 that Trazodone was decreased to 25 mg at bedtime, despite APRN #1 writing an order for Trazodone for 75 mg (APRN #1's handwritten order was misinterpreted by LPN #4 to read 25 mg instead of 75 mg). Nursing notes dated 4/23/24 at 6:57 AM, identified extreme restlessness on the night shift; with Resident #47 removing his/her dry brief and soaker pad from the bed and urinating on the bed and clothes four times during the night. Additionally, the nursing notes identified Resident #47 had both legs over the side of the bed. Resident #47 wanted to check the roster, and staff unable to redirect the resident with offers of food or conversation, the resident did not sleep all shift. Nursing notes dated 4/24/24 at 7:17 AM, identified Resident #47 was restless all shift, again removing his/her brief and urinating on the linens on the floor three times during the night. Resident #47 had his/her legs over the positioning pillow and wanted to go to the theatre. Offers of food and fluids did not decrease restlessness. On 4/25/24 a progress note written by APRN #2 identified that Resident #47 had a recent reduction in two of his/her medications and that his/her restlessness had increased at night. APRN #2 recommendation at that time was to increase the Trazodone to 50 mg from 25 mg (despite the psychiatric APRN #1 originally writing order for Trazodone 75 mg on 4/17/24). Interview with LPN #5 on 8/6/24 at 2:00 PM identified that Psychiatric APRN #1 did not enter orders in the electronic chart but wrote her orders on paper. LPN #5 stated that LPN #4 (who no longer works at the facility) transcribed the orders incorrectly into the electronic chart. Interview with APRN #1 on 8/6/24 at 2:20 PM identified that she was unable to write orders in the electronic chart, but she communicated with nursing staff regarding the medication changes and the reason for the increase in dosage from 50 mg to 75 mg.

Based on interviews, review of the clinical record, and facility policy, for 1 of 2 residents (Resident #36) reviewed for pressure ulcers, the facility failed to ensure an alternating pressure mattress (APM) was set at the appropriate setting according to the physician's orders. The findings include: Resident #36's diagnoses included congestive heart failure, hypertension, unspecified protein calorie malnutrition and muscle weakness. The Admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #36 was moderately cognitively impaired, and was dependent on staff with bed mobility, transfers, and ambulation. In addition, Resident #36 was frequently incontinent of urine and bowel and was at risk of developing pressure ulcers. Physician's order dated 7/24/24 directed an alternating pressure mattress (APM) with air loss at a weight setting of 165 pounds and to check placement and inflation each shift. The Resident Care Plan dated 8/1/24 identified Resident #36 was at risk for skin breakdown due to decreased mobility, and incontinence. Interventions included an alternating pressure air mattress, following skin care protocol using preventive measures when indicated, offloading heels while in bed, and providing treatments as ordered. A physician progress note dated 8/2/24 identified Resident #36 with a 1.5 centimeter (cm) by 1.0 cm dark purple area with a small superficial opening on the coccyx. The physician identified the area as a new deep tissue injury possibly developed when Resident #36's APM deflated accidentally as reported by the nursing staff. Observation on 8/6/24 at 10:00 AM and 8/7/24 at 9:00 AM identified that Resident #36's APM was set at 200 pounds. Review of Resident #36's clinical record identified that staff was signing off the APM setting of 165 pounds. Observation and interview with the Wound Advanced Practice Nurse (APRN #3) and wound Nurse (RN #3) on 8/7/24 at 9:10 AM identified that the APM was set at 200 pounds instead of 165 pounds (per the physician's order). The Wound APRN further stated that an APM setting of 200 pounds could negatively affect the healing of the wound for Resident #36. In addition, APRN #3 stated that the physician order should have been followed for a setting at 165 pounds. Subsequent to surveyor inquiry, the APM setting was adjusted by APRN #3 to reflect Resident #36's weight of 165 pounds. Interview with the RN #4 on 8/7/24 at 9:20 AM identified that the Charge Nurse on the unit was responsible for checking the placement and inflation of the APM each shift and as needed. RN #4 stated that she had not yet made her rounds for the day shift and could not explain the reason the APM was not set at the correct setting. Review of facilities Pressure Reducing Mattress policy identified, in part, that residents with an identified pressure area will be provided with an alternating pressure air mattress when appropriate and the APM will be checked for placement and inflation each shift and as needed.

Based on observations, interviews, review of the clinical record, and facility policy for 1 of 1 sampled resident (Resident #11) reviewed for range of motion (ROM), the facility failed ensure a device was applied for hand contractures. The findings include: Resident #11's diagnoses included Alzheimer's disease, poly osteoarthritis abnormal posture, and contractures of right/left hands. A Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #11 had a short/long term memory problem and upper/lower extremity limited ROM/impaired on both sides. Additionally, the MDS identified Resident #11 required maximal assistance with eating and was dependent with oral hygiene, toilet use, shower/bathing and upper/lower body dressing. An Occupational Therapy (OT) evaluation and plan of treatment dated 1/17/24 indicated Resident #11 had impaired ROM to the right upper extremity (elbow, wrist, hand, thumb, index finger, middle finger, ring finger and little finger), additionally, impaired ROM to the left upper extremity (wrist, hand, thumb, index finger, middle finger, ring finger, and little finger). There was functional limitation present due to contracture and Resident #11's ability to express ideas, wants and ability to understand others was rarely or never understood. A physician's order dated 5/15/24 directed Resident #11 to have a [NAME] guard applied to the right hand daily for contracture management, remove for hand hygiene to be completed as needed every shift. Additionally, Resident #11 was to wear a rolled cloth to left hand daily, to remove for hand hygiene as needed every shift, ROM with morning and evening care every day and evening shift. The Resident Care Plan dated 7/10/24 identified functional deficits related to comorbidities and health conditions resulting in potential of low endurance and deconditioned state. Interventions included applying a rolled cloth to left hand as tolerated, transfer with assist of 2 with Hoyer lift and no ambulation at this time. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 was cognitively impaired with both short- and long-term memory problem, required total assistance with all activities of daily living (ADLS) and functional limitation in range of motion on both sides to both upper and lower extremities. An OT note dated 7/31/24 identified Resident #11 initially made facial expressions of pain when the therapist touched his/her right-hand and was initially guarded but tolerated ROM and minimal touching of his/her right hand, additionally he/she tolerated rolled up gauze in both hands. Nursing made aware. Observations on 8/1/24 at 10:33 AM, identified Resident #11 sleeping with hands in fists, without the benefit of cloth rolls in the hands. At 11:55 AM Resident #11 was up in the wheelchair sleeping with his/her neck leaning to right side and was moved into dining room by staff without the benefit of repositioning. Observations on 8/2/24 at 11:22 AM identified Resident #11 was up in the wheelchair without the benefit of a rolled cloth to the left hand. Interview with OT #1 identified that Resident #11 does not tolerate [NAME] guard in his/her right hand and should have a soft cloth hand rolls in his/her hands. An OT note date 8/2/24 identified Resident #11 gentle stretching to bilateral hands to decrease contractures to open hands for good hygiene care. Discussed with nursing that resident is unable to tolerate [NAME] guards and to continue to use soft cloth at this time. Observation on 8/5/24 at 10:33 AM identified Resident #11 sleeping with hands in fists without the benefits of cloth hand rolls. Observation on 8/6/24 at 11:55 AM identified Resident #11 was up in the wheelchair with his/her hands in a fist, without the benefits of cloth hand rolls or a palm guard. Observation on 8/6/24 at 12:16 PM identified Resident #11 in the dining room, handwashing was being provided for lunch, Resident #11 grimacing and crying out, pulling hand away. LPN #2 observed the resident's behavior, administered scheduled Tylenol and placed a call to APRN #4 for as needed medication for pain. Observation 8/6/24 at 1:50 PM identified Resident #11 in the room sleeping in a wheelchair without the benefit of a cloth hand roll in his/her hands, or palm guard. Observation on 8/7/24 at 9:27 AM identified Resident #11 lying in bed without the benefit of cloth handrolls in his/her hands. Observation on 8/7/24 at 10:01 AM with the DNS identified that cloth hand rolls were not in Resident #11's hands. In an interview, clinical record review and review of the Treatment Administration Record with the DNS on 8/7/24 at 10:01 AM failed to reflect documentation identifying resident refusals for the cloth hand rolls, except on 8/3/24. Subsequent to surveyor observations, a physician order was obtained to discontinue the palm guard on 8/6/24.

Based on observations, interviews and record review for 1 of 3 residents (Resident #566) reviewed for infection control, the facility failed to ensure the urinary collection bag was maintained off the floor. Resident #566's diagnoses include retention of urine, benign prostatic hyperplasia, and Parkinson's disease. The Resident Care Plan dated 7/31/24 identified Resident #566 utilized an indwelling foley catheter. Interventions included enhanced barrier precautions, foley to remain patent, to maintain the foley as ordered in the treatment administration record and to provide education on catheter use. The Admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #566 was severely cognitively impaired, required substantial/moderate assistance for transfers and was dependent for toileting hygiene, bathing, and lower body dressing. Additionally, the MDS identified Resident #566 utilized an indwelling urinary catheter. Observations on 8/1/24 at 10:35 AM and 8/5/24 at 6:26 AM identified Resident #566 was lying in bed with the urinary drainage collection bag resting on the floor with urine visible in the collection bag. Interview and observation of Resident #566 with Registered Nurse (RN) #1 on 8/5/24 at 7:40 AM identified that per facility policy the drainage bag should not be resting on the floor. Subsequent to surveyor inquiry, Registered Nurse (RN) #1 raised the collection bag so it was not resting on the floor. Observation of Resident #566 on 8/6/24 at 11:55 AM identified he/she was sitting in a wheelchair in the hallway with the urinary collection bag in a privacy bag located under the wheelchair and resting on the floor. Further observation at that time identified Nurse Aide (NA #1) pushing Resident #566 in the wheelchair in the hallway with the urinary drainage bag dragging on floor. Interview and observation with NA #2 in the presence of NA #1 on 8/6/24 at 11:55 AM identified that the drainage bag was dragging on the floor because there was no other place to secure the bag without it touching the floor. Subsequent to surveyor inquiry, NA #2 reported to the surveyor that the drainage bag was raised off the floor. Interview with the Infection Control Nurse (LPN #5) on 8/7/24 at 10:16 AM identified that collection bags should be kept off the floor, by being stored on the bed rail or under the wheelchair in a privacy bag. However, if the collection bag was in a privacy bag, then it was alright because the privacy bag acted as a barrier. Review of the Urinary Catheter Policy dated March 2024 directed to keep the collection bag below the level of the bladder and not place the urinary collection bag on the floor.

Based on review of the clinical record, facility policy and procedures and interviews for a one of three residents reviewed for weight loss (Resident #36) and/or for one of three residents reviewed for pressure sores (Resident #75), the facility failed to develop a comprehensive care plan that addressed the resident's dental concerns, significant weight loss, and/or assistance needed with ADL's, and/or failed to address the resident's dental/oral hygiene needs and/or failed to develop a comprehensive care plan to prevent a heel pressure sore from developing in a resident with a [MEDICAL CONDITION]. The findings include: 1a. Resident # 36 ' s [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] identified that the resident had broken and/or missing teeth and weighed 113 pounds. An admission MDS assessment dated [DATE] identified that the resident was severely cognitively impaired, required extensive assistance with all activities of daily living, including eating, and was non-ambulatory with a non-weight bearing status. Additionally, the resident had " obvious or likely cavity or broken natural teeth " and a weight of 98 pounds. Interview and review of R#36's care plan and clinical record with the RCP coordinator on 3/28/12 at 10:45 A.M. failed to provide documentation that the residents dental and/or oral hygiene needs/assistance required had been addressed in the care plan. b. R#36's dietitian's assessment on 12/11/11 documented a weight of 106 pounds. Dietary supplements were immediately started per dietician recommendations. On 12/27/11, the dietitan reassessed the resident and noted a weight of 92 pounds. The dietitian recommended increasing the 2 cal supplement from twice a day to three times a day. The care plan dated 12/20/11 identified "nutrition" as a problem. The only interventions noted were to encourage intake, monitor intake and weight, and to accomodate preferences as able. Interview and review of the clinical record on 3/28/12 at 10:45 AM with the care plan coordinator failed to provide documentation that the care plan reflected the resident's significant weight loss of 22 pounds throughout his/her stay and/or failed to reflect the assistance needed with ADL's due to his/her arm and [MEDICAL CONDITION]. The care plan failed to identify the presence of the fractures and/or the resident's level of assistance needed with all ADL's except for mobility. 2. Resident #75 was admitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. The hospital discharge summary dated 11/4/11 indicated that the resident's skin was without pressure sores. The admission MDS dated [DATE] identified that the resident was severely cognitively impaired, totally dependent on staff for all mobility and the "unhealed pressure ulcers" section of the assessment was originally coded as "0" indicating no pressure ulcers were present upon admission and later changed to "1" with a date of 1/11/2012 handwritten on the computerized form. The initial care plan dated 11/4/2011 identified the risk for skin breakdown, but did not identify the presence of a pressure sore or any interventions to prevent heel breakdown. physician progress notes [REDACTED]. The dietitian's assessment dated [DATE] indicated that the resident was without pressure sores/breakdown. Physical therapy notes dated 11/16/11 indicated that the resident was complaining of pain in the heels and a blister was discovered on the right heel. The wound was reported to the charge nurse. Nurse's notes and a pressure sore assessment dated [DATE] noted the onset of an unstageable pressure sore of the right heel. Physician orders [REDACTED]. The date of the initial discovery of the pressure sore (on the form) was crossed out and "11/4/11" was written in next to the original date without the benefit of initialing or a reason. A "separate pressure sore assessment form" dated 11/4/11 and 11/11/11 indicated that the resident had a 5 x 5 cm purulent, foul, sloughed blister on the right heel. Physician orders [REDACTED]. No prior documentation of heel lift boots or other off loading of the resident's heels was noted in the clinical record including nurse's notes, treatment records or nurse aide flow sheets from 11/4/11 on admission until 11/19/11. Interview with RN #1 on 3/28/2012 at 9:30 AM indicated that the initial identification of the pressure ulcer was on 11/16/2011. She was unable to explain why the Pressure Sore Assessment record she started at that time had the date crossed out and "11/4/11" written in as the origin date of the pressure sore. RN#1 indicated that the physical therapist notified her of the resident's complaint of heel pain and presence of a blister. She then called the physician, family and dietitian, assessed the wound and began treatment. She indicated that there was no wound and/or treatment prior to that date (11/16/11). Interview with the ADON, who completed the initial nursing assessment and signed the "separate pressure sore assessment form" that was dated 11/4/11, on 3/28/2012 at 10:30 AM failed to provide an explanation and/or documentation of any treatment orders to the questionable pressure sore of the heel on admission and/or any interventions to alleviate pressure to the area. She was unable to explain why the record failed to reflect a pressure sore anywhere except for her assessment, from 11/4/11 through 11/16/11. Although the ADON indicated that the physician and the dietician were notified of the heel blister on admission, Admission Physician order [REDACTED]. She was unable to provide a reason for the documented discrepancies, and/or explain if the resident was admitted with the pressure sore that wasn't treated for [REDACTED].

Based on observation, review of the clinical record, facility policies and procedures and interviews for three of four residents reviewed for a pressure sore (R #75, 25 and 47), the facility failed to promote the healing and/or prevention of the development of a pressure sore. The findings included: 1. Resident #75 was admitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. The hospital discharge summary dated 11/4/11 indicated that the resident's skin was without pressure sores. The admission MDS dated [DATE] identified that the resident was severely cognitively impaired, totally dependent on staff for all mobility and the "unhealed pressure ulcers" section of the assessment was originally coded as "0" indicating no pressure ulcers were present upon admission and later changed to "1" with a date of 1/11/2012 handwritten on the computerized form. The initial care plan dated 11/4/2011 identified the risk for skin breakdown, but did not identify the presence of a pressure sore or any interventions to prevent heel breakdown. The resident was noted to have a surgical incision to the right [MEDICAL CONDITION] site. The dietitian's assessment dated [DATE] indicated that the resident was without pressure sores/breakdown. physician progress notes [REDACTED]. Physical therapy notes dated 11/16/11 indicated that the resident was complaining of pain in the heels and a blister was discovered on the right heel. The wound was reported to the charge nurse. Nurse's notes and a pressure sore assessment dated [DATE] noted the onset of an unstageable pressure sore of the right heel. Physician orders [REDACTED]. The date of the initial discovery of the pressure sore (on the form) was crossed out and "11/4/11" was written in next to the original date without the benefit of initialing or a reason. A "separate pressure sore assessment form" dated 11/4/11 and 11/11/11 indicated that the resident had a 5 x 5 cm purulent, foul, sloughed blister on the right heel. Physician orders [REDACTED]. No prior documentation of heel lift boots or other off loading of the resident's heels was noted in the clinical record including nurse's notes, treatment records or nurse aide flow sheets from 11/4/11 on admission until 11/19/11. Interview with RN #1 on 3/28/2012 at 9:30 AM indicated that the initial identification of the pressure ulcer was on 11/16/2011. She was unable to explain why the Pressure Sore Assessment record she started at that time had the date crossed out and "11/4/11" written in as the origin date of the pressure sore. RN#1 indicated that the physical therapist notified her of the resident's complaint of heel pain and presence of a blister. She then called the physician, family and dietitian, assessed the wound and began treatment. She indicated that there was no wound and/or treatment prior to that date (11/16/11). Interview with the ADON, who completed the initial nursing assessment and signed the "separate pressure sore assessment form" that was dated 11/4/11, on 3/28/2012 at 10:30 AM failed to provide an explanation and/or documentation of any treatment orders to the questionable pressure sore of the heel on admission and/or any interventions to alleviate pressure to the area. She was unable to explain why the record failed to reflect a pressure sore anywhere except for her assessment from 11/4/11 through 11/16/11. Although the ADON indicated that the physician and the dietician were notified of the heel blister on admission, Admission Physician order [REDACTED]. She was unable to provide a reason for the documented discrepancies, and/or explain if the resident was admitted with the pressure sore that wasn't treated for [REDACTED]. 2. R#25's [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] identified the resident as independent for decision-making skills, requiring extensive assistance from staff for most activities of daily living to include bed mobility, transfers and personal hygiene, utilizes an indwelling catheter and always incontinent of stool for bowel status. The resident care plan updated on 3/13/12 identified a problem noting a risk for skin breakdown due to decreased mobility and history of fragile and dry skin. Interventions included observing and applying lotion to the skin with care, turning and repositioning as indicated, pressure relieving devices (i.e. air mattress and seat cushion), changing position when out of bed for comfort and ensure the seat cushion is facing the correct way. Intermittent observations of R#25 on 3/29/12 at 9:30 A.M. identified the resident seated in bed, asleep with the breakfast tray in front of the resident. On 3/29/12 at 10:25 A.M. during a dressing change with RN #3, the resident was observed as having a superficial open area to the coccyx without presence of exudate, and measuring 0.8 cm (centimeters) x 0.7 cm. beneath a [MEDICATION NAME] dressing. On 3/29/12 at 10:42 A.M. during intermittent observations of R #25 with RN #3, the resident was identified lying on his/her buttocks with 2 cloth chucks placed underneath the buttocks and extending to the upper back. On 3/29/12 around 11:00 A.M., R#25 was observed seated in his/her wheelchair in the hallway and at 12:10 P.M. the resident was observed in the same position seated in his/her wheelchair in the hallway by the DON. An interview with the DON at the time indicated that although the resident had been on his/her back since the initial observation, pressure reduction was being carried out by tilting the chair at various degrees while the resident continued to remain seated position for 2 hours and 40 minutes, was without the benefit of pressure relief on his/her coccyx. A Braden scale assessment completed on 3/1/12 identified a total score of 14 indicating the resident was at a high risk for developing a pressure ulcer. On 3/29/12 at 10:55 A.M. following the observation of R#25's pressure sore to the coccyx area, an interview and review of the weekly skin condition report with RN #3 indicated that on 3/8/12 she initially noted that the resident had an immeasurable area that looked excoriated and more diffused throughout the right buttock. RN #3 further indicated that dressing changes to the resident's coccyx area are normally done during the 3 P.M. to the 11 P.M. shift; she had not seen and/or assessed the wound until today during the treatment and was unaware that the resident wound was now a stage II pressure ulcer. Upon further review of the weekly skin condition report it was identified that on 3/13/12 a more defined area was noted and was measured at 1.2 cm x 0.8 cm without exudate. On 3/29/12 at 12:10 P.M. interviews and review of the clinical record with the DON and the ADON indicated that weekly assessments of residents with pressure ulcers are assessed by the DON however since R#25's area was noted as excoriations, the assessments had not been done. The DON further indicated her lack of awareness of R#25's pressure ulcer. 3. Resident #47's [DIAGNOSES REDACTED]. An admission MDS dated [DATE] identified the resident as severely impaired for decision-making skills, requiring extensive assistance from staff with bed mobility, transfers, and toilet use, was at risk for developing pressure ulcers, and had intact skin. An interim care plan dated 11/28/11 identified a potential problem with pressure ulcer and/or skin care. Interventions included following the facility skin care protocol and/or preventative measures, and immediately reporting to the nurse any redness and/or skin breakdown. No interventions were included to address a turning and repositioning schedule, and/or off loading of bilateral heels were identified. However, physicians orders dated 11/28/11 directed the staff to utilize a left leg immobilizer at all times with abduction pillow, and an activity order of non weight bearing of the left lower extremity. Review of pressure ulcer risk worksheet dated 11/28/11 lacked documentation to reflect that a turning schedule and or heel pressure reduction was initiated on admission. A Braden Scale dated 11/29/11 identified a score of 16 indicating a risk for skin breakdown. A comprehensive care plan initiated on 12/14/11 identified a risk for skin breakdown due to left [MEDICAL CONDITION], and limited mobility and although interventions included pressure reducing mattress on bed and pressure reducing cushion in wheelchair; documentation was lacking to reflect that interventions were put in place to address a turning and repositioning schedule and/or the off loading of the resident's heels. Upon further review an updated careplan dated 12/17/12 identified a problem of a left heel dried blood blister. Interventions included a foam podus boots (to heels) at all times. A review of the physician progress notes [REDACTED]. A review of the resident care flow sheet for bed mobility during the period of 11/28/11 to 12/17/11 and nursing notes during the period of 11/28/11 to 12/17/11 lacked documentation to reflect that the resident was provided turning and/or repositioning and/or off loading of heels and/or provided with a pressure relief device in spite of the resident risk for developing a pressure sore and poor nutritional status during the aforementioned period. On 3/29/12 at 11:00 A.M. interview and review of the clinical record with the DON indicated that although the residents at risk for skin breakdown were expected to have had a turning and repositioning schedule, and/or provision of pressure relief via off-loading the residents' heels, documentation was lacking to reflect that the aforementioned treatment and/or modalities were in place. On 3/30/12 at 7:35 A.M. and 7:55 A.M. interviews with staff who frequently work the night shift (NA #5 and LPN #1) indicated when performing their rounds a resident is usually turned and/or repositioned twice during their shift. A review of the facility skin protocol identified in part, that any resident who scores 18 or below on the Braden Scale is identified at risk for developing pressure ulcers and staff should proceed to the Pressure Ulcer Prevention Worksheet to develop an individualized resident skin care program. Residents identified as dependent on staff for repositioing should be repositioned at least every two hours per a turning schedule, and particular attention given to reducing the pressure on the heels of residents identified at risk.