Every finding on record at Heritage Nursing Center - Skilled Nursing by Ameri

Based on observation, interview, and record review, the facility failed to ensure all components of the call light system was functioning correctly. The facility also failed to ensure call lights were placed within reach to meet resident needs. This deficient practice had the potential to affect all the residents in the facility. The facility census was 48.Review of the facility's policy titled, Call Lights: Accessibility and Timely Response, revised 2025, showed:- The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response;- All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light;- All residents will be educated on how to call for help by using the resident call system;- Staff will ensure the call light is within reach of resident and secured, as needed;- The call light system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room;- The call system must be accessible to the resident at each toilet and bath and shower facility. The call system should be accessible to a resident lying on the floor;- Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied;- Ensure the call system alerts staff members directly or goes to a centralized staff work area;- All staff who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be identified. Review of Resident Council Meeting minutes showed:- [DATE], unanswered call light complaints addressed for one hour or more with a resolution to notify the Director of Nursing (DON) of a concern;- [DATE], staff taking too long to get residents to the restroom complaints with a resolution to notify the DON of a concern;- [DATE], call lights being on too long complaints with no documentation of a resolution. Observation on [DATE] showed:- At 2:48 P.M., Resident #29 lay in bed with the call light out of reach of the resident where it lay on the floor; - At 2:49 P.M., Resident #7 lay in bed with the call light out of reach of the resident where it lay on the floor;- At 2:50 P.M., Resident #24 lay in bed with the call light out of reach of the resident where it lay on the floor;- At 2:51 P.M., Resident #30 lay in bed with the call light out of reach of the resident where it lay on the floor;- At 2:52 P.M., Resident #4 lay in bed with the call light out of reach of the resident where it lay on the floor;- At 2:53 P.M., Resident #43 lay in bed with the call light out of reach of the resident where it lay on the floor; - At 2:54 P.M., Resident #35 lay in bed with the call light out of reach of the resident where it lay on the floor; - 2:55 P.M., showed Resident #39 lay in bed with the call light out of reach of the resident where it lay on the floor. Observations on [DATE] at 2:55 P.M. of the Call Light Indicator panel, located on the wall at the main nurses' station on the North Hall, showed each call light in each room on the North Hall had a corresponding light on the panel. When a call light was activated in a room, the indicator light on the panel would turn red and light up. During this observation, red lights activated for rooms N#3 and N#4. No audible sound came from the indicator panel. Observations on [DATE] at 2:57 P.M., showed no light indicated an activated call light above any of the resident doorways on the North Hall. No audible sound indicated a call light was on. During an interview on [DATE] at 2:59 P.M., Certified Nurse Assistant (CNA) A said he/she monitored the call light indicator panel to see if there were any rooms with red lights to show a call light was activated. The call light panel did not always make a sound, and if it did, the sound was very faint because there wasn't much volume to it. The facility was aware of the concern. Observations on [DATE], of the Call Light Indicator panel on the Homeward Bound Hall, showed:- At 8:26 A.M., room [ROOM NUMBER] with a red light activated on the call light system panel and no audible sound;- At 8:44 A.M., room [ROOM NUMBER] with a red light activated on the call light system panel and no audible sound;- At 8:46 A.M., room [ROOM NUMBER] with a red light activated on the call light system panel and no audible sound;- At 8:48 A.M., room [ROOM NUMBER] with a red light activated on the call light system panel and no audible sound;- From 8:26 A.M. - 8:50 A.M., CNA C walked by the call light system panel as he/she picked up the breakfast meal trays and exited the unit with the breakfast meal cart;- From 8:26 A.M. - 8:50 A.M., Registered Nurse (RN) A sat at the nurse's station with his/her back to the call light system panel. Observations on [DATE] at 8:51 A.M., showed no light indicated an activated call light above any of the resident doorways on the Homeward Bound Hall. No audible sound indicated a light was on. During an interview on [DATE] at 8:53 A.M., CNA C said he/she had a concern with the call light system not making an audible sound. He/She had been employed at the facility for some time and the call light system never made an audible sound. The facility was aware of the concern. During an interview on [DATE] at 8:58 A.M., RN A said the call light panel had never made an audible sound for the rooms on the Homeward Bound Hall since he/she had been employed. Facility administration was aware of the concern that there was no audible alert for a call light. During the Resident Council Meeting on [DATE] at 9:37 A.M., Residents #8, #9, and #43 said they had concerns related to the call lights not being answered in a timely manner. The three residents did not know if the reason for the delay was staffing, or the call lights themselves not operating correctly. The three residents said call lights and the delay in answering them had been a topic at the last few Resident Council meetings. Observations on [DATE] at 4:06 P.M., of the Homeward Bound Hall, showed:- room [ROOM NUMBER]'s bathroom emergency call light pushed by the Administrator to activate the light; - room [ROOM NUMBER] call light with a red light activated on the unit's call light system panel and no audible sound. During an interview on [DATE] at 3:02 P.M., the Administrator said there was no way to turn the call light volume up or down. It did not make a noise for homelike environment purposes. There was no report to check call light times to see how long lights had been activated. Staff used the call light board at the main nurse's wing to see when call lights were on, but usually the residents just told them or yelled out when they needed something. The call light system didn't have any type of visual lights near the resident rooms to alert staff a call light was activated. She would expect call lights to be within reach at all times of the residents. During an interview on [DATE] at 4:14 P.M., the Administrator said she was not aware the call lights in Room N3 and Room N5 did not make an audible sound at times and no reports from staff had been made regarding the issue. She was aware of staff requests for lights to be placed on the outside of resident rooms for visual monitoring. She was not aware the call light system on the unit did not have an audible sound for staff to hear. Staff had not made her aware of the unit concern and no reports had been brought to her attention on the issue.

Based on observation, interview, and record review, the facility failed to reconcile the overflow (extra, not currently in use) narcotics (a process to count and document the exact narcotic inventory on hand) for one out of two observed medication carts. This practice affected one resident (Resident #16) and could potentially affect all residents. The facility census was 48.Review of the facility's policy titled, Controlled Substance Administration and Accountability, not dated, showed:- Two licensed nurses or a licensed nurse and Certified Medication Technician (CMT) account for all controlled substances and access keys at the end of each shift. Observation on 02/16/26 at 3:15 P.M., of the Northwest Hall medication cart showed: - One card of hydrocodone/acetaminophen (a narcotic medication used for pain control) 10/325 milligram (mg) with 30 tablets for Resident #16's;- One card of gabapentin (a controlled nerve pain medication) 100 mg with 16 tablets for Resident #16's. Review of the Northwest Hall Overflow (extra, not currently in use) Narcotic Count Log on 02/16/26 at 3:16 P.M., showed:- No documentation for 30 tablets of hydrocodone/acetaminophen 10/325 mg for Resident #16;- No documentation for 16 tablets of gabapentin 100 mg for Resident #16. During an interview on 02/16/26 at 4:17 P.M., Licensed Practical Nurse (LPN) I said they did not reconcile the overflow narcotic medications at the change of every shift like they should. During an interview on 02/16/26 at 4:20 P.M., CMT L said that he/she did not reconcile the overflow narcotic medications every shift change. During an interview on 02/16/26, at 4:26 P.M., the Director of Nursing (DON) said he expected staff to reconcile the narcotic medications and the overflow narcotic medications at each shift change. During an interview on 02/18/26, at 3:26 P.M., the Administrator said she expected staff to reconcile all narcotic medications on the medication cart which included the overflow narcotic medications every shift change.

Based on observation, interview, and record review, the facility failed to follow physician's orders for one resident (Resident #37) out of one sampled resident with a PureWick (a type of external catheter). The facility census was 48. Review of the facility's policy titled, External Catheter for Urinary Incontinence Management, undated, showed:- The Interdisciplinary Team (IDT) will review and determine along with the practitioner which resident(s) would be appropriate for the use of an external catheter to manage urinary incontinence;- The nurse will obtain and verify the physician's order for use of the external catheter. 1. Review of Resident #37's medical record showed:- A diagnosis for overactive bladder, dated 04/17/25;- An order for a PureWick external catheter at bedtime, place in the evening, 04/18/25;- An order for a PureWick external catheter at bedtime, remove in the morning, 04/18/25. Observations on 02/15/26 at 11:38 A.M., 02/15/26 at 1:17 P.M., 02/17/26 at 10:28 A.M., and 3:36 P.M., and 02/18/26 at 12:49 P.M., showed the resident sat in a recliner in his/her room with the PureWick catheter in place. Observation on 02/16/26 at 2:38 P.M., showed the resident lay in bed with the PureWick in place. Observation on 02/18/26 at 9:28 A.M., showed:- The resident sat in a recliner;- Certified Nurse Aide (CNA) F put on gloves and placed the PureWick for the resident. During an interview on 02/18/26 at 9:28 A.M., CNA F said he/she placed the PureWick external catheter every morning because that's what the resident wanted. During an interview on 02/15/26 at 11:38 A.M., Resident #37 said he/she wore the PureWick anytime he/she was in the recliner or in the bed because that was what when he/she wanted to wear it. During an interview on 02/18/26 at 1:39 P.M., the Director of Nursing (DON) said the PureWick was only ordered for the resident at nighttime, but the family and the resident insisted the PureWick was in place at all times. The staff hadn't notified the physician the resident wore it more often that what was ordered because it was the resident's decision to do so. During an interview on 02/18/26 at 1:44 P.M., CNA A said the PureWick was on the resident during the day because the resident asked for it to be put in place. During an interview on 02/18/26 at 2:27 P.M., CNA E said he/she put the PureWick in place because the resident always asked for it to be applied. During an interview on 02/18/26 at 3:25 P.M., the Administrator said the PureWick external catheter should be applied to the resident as ordered by the physician.

Based on interview and record review, the facility failed to provide resident care for activities of daily living (ADLs) when the residents did not receive scheduled showers for six residents (Residents #1, #2, #4, #8, #37 and #43) out of 12 sampled residents. The facility census was 48.Review of the facility's policy titled, Resident Showers, not dated, showed:- It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice;- Resident will be provided showers as per request, or as per facility schedule and based upon resident safety;- Partial baths may be given between regular shower schedules;- Did not address residents receiving shower/baths given by hospice staff. 1. Review of Resident #1's medical record showed:- admitted on [DATE];- Diagnosis of cerebrovascular (stroke) event with hemiplegia (total paralysis on one side of the body) and hemiparesis (weakness or partial paralysis on one side of the body);- Dependent upon staff for bathing. Review of the resident's Shower Schedule, dated 01/01/26 - 02/18/26, showed:- The resident scheduled bed baths/showers from the hospice staff on Tuesday and Thursday. Review of the resident's Hospice Shower Sheets, dated 01/01/26 - 02/18/26, showed:- The resident did not receive a shower/bed bath on 01/01/26, 01/22/26, 01/26/26, 01/29/26, and 02/17/26;- Five missed out of 13 opportunities. During an interview on 02/18/26 at 1:40 P.M., Certified Nurse Aide (CNA) D said when the facility had a shower aide, then the shower aide did the resident's showers. However, when the facility did not have a shower aide, then the assigned aide on the hall gave the showers when scheduled. CNA D said he/she had never given Resident #1 a shower or bath. Hospice did his/her showers. 2. Review of Resident #2's medical record showed:- admitted on [DATE];- Diagnoses of right femur (thigh bone) fracture, history of falls, depression (a serious medical illness that negatively affects how you feel, the way you think and how you act)and anxiety (persistent worry and fear about everyday situations);- Substantial/maximal assistance with bathing and showers. Review of the resident's Shower Schedule, undated, showed:- The resident scheduled for showers on Tuesday and Friday. Review of the resident's Shower Sheets, dated 01/01/26 - 02/18/26, showed:- The resident did not receive a shower on 01/02/26, 01/13/26, 01/16/26, 01/20/26, 01/23/26, 01/27/26, 01/30/26, 02/03/26, 02/06/26, 02/10/26, 02/13/26, and 02/17/26;- 12 missed out of 13 opportunities for scheduled showers. During an interview on 02/18/26 at 10:38 A.M., Resident #2 said staff sometimes assisted him/her with bathing while in bed or at the table beside his/her bed. 3. Review of Resident #4's medical record showed:- admitted on [DATE];- Diagnoses of chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), depression, anxiety, Alzheimer's disease (progressive mental deterioration), dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), schizophrenia (a condition characterized by abnormal thought processes and deregulated emotions), and urinary tract infection (UTI - a kidney or bladder infection);- Substantial/maximal assistance with bathing and showers;- Severely impaired vision. Review of the resident's Shower Schedule, undated, showed:- The resident scheduled for showers on Monday and Thursday. Review of the resident's Shower Sheets, dated 01/01/26 - 02/18/26, showed:- The resident did not receive a shower on 01/01/26, 01/05/26, 01/08/26, 01/12/26, 01/19/26, 01/29/26, 02/02/26, 02/05/26, 02/09/26, 02/12/26, and 02/16/26; - 11 missed out of 14 opportunities for scheduled showers. 4. Review of Resident #8's medical record showed:- admitted on [DATE];- Diagnosis of cerebrovascular event with hemiplegia and hemiparesis;- Substantial/maximal assistance with bathing and showers. Review of the resident's Shower Schedule, undated, showed:- The resident scheduled for showers on Tuesday and Friday. Review of the resident's Shower Sheets, dated 01/01/26 - 02/18/26, showed:- The resident did not receive a shower/bed bath on 01/02/26, 01/06/26, 01/09/26, 01/13/26, 01/16/26, 01/20/26, 01/23/26, 01/30/26, 02/06/26, 02/10/26, 02/13/26, and 02/17/26;- 12 missed out of 14 opportunities for scheduled showers. During an interview on 02/18/26 at 9:34 A.M., Resident #8 said he/she did not get showers twice a week. 5. Review of Resident #37's medical record showed:- admitted on [DATE];- Diagnoses of heart failure, muscle wasting, and stroke with hemiplegia and hemiparesis;- Partial to moderate assistance with bathing and showers. Review of the resident's Shower Schedule, undated, showed:- The resident scheduled for showers on Monday and Thursday during the morning. Review of the Resident's Shower Sheets, dated 01/01/26 - 02/18/26, showed:- The resident did not receive a shower on 01/01/26, 01/05/26, 01/08/26, 01/12/26, 01/15/26, 01/19/26, 01/22/26, 01/26/26, 01/29/26, 02/02/26, 02/05/26, 02/09/26, 02/12/26, and 02/16/26;- 14 missed out of 14 opportunities for scheduled showers. During an interview on 02/15/26 at 11:38 A.M., Resident #37 said he/she thought his/her assigned shower day was Friday and couldn't remember the last time he/she had a shower or bed bath. 6. Review of Resident #43's medical record showed:- admitted on [DATE];- Diagnosis of cerebrovascular event with hemiplegia and hemiparesis;- Substantial/maximal assistance with bathing and showers. Review of the resident's Shower Schedule, undated, showed:- The resident scheduled for showers on Tuesday and Friday. Review of the resident's shower sheets, dated 01/01/26 - 02/18/26, showed:- The resident did not receive a shower/bed bath on 01/02/26, 01/09/26, 01/13/26, 01/16/26, 01/23/26, 01/27/26, 01/30/26, 02/06/26, 02/13/26, and 02/17/26;- 10 missed out of 14 opportunities for scheduled showers. During an interview on 02/18/26 at 9:35 A.M., Resident #43 said he/she did not get a shower twice a week and was lucky to get one a week because staff always told him/her it wasn't his/her shower day. During an interview on 02/18/26 at 3:01 P.M., the Director of Nursing (DON) said he would expect residents to receive a shower at least twice a week. Staff did not give hospice residents showers on a regular basis, only if there was some kind of accident or need. He tried to check the shower sheets every three to four days to make sure staff were doing showers like they should. He said the facility didn't contact hospice on why showers/baths weren't given for a resident. If showers/baths weren't documented as given, it was probably because the resident refused it. During an interview on 02/18/26 at 3:27 P.M., the Administrator said she expected the residents to get at least two showers a week. She expected the DON and ADON to check the shower sheets regularly and if a resident had refused a shower, for it to be documented.

Based on interview and record review, the facility failed to follow per the facility policy to complete a criminal background check (CBC) for one employee of eight sampled employees prior to hire. The facility census was 48.Review of the facility policy titled, Criminal Background Checks, not dated, showed:- The facility representative shall be responsible for processing a criminal background check on each employee, prior to the employee starting the job, in which they have been hired;- The purpose is to comply with Criminal Records Review Law (House [NAME] 1362) requiring criminal background checks be done on all applicants through a qualified agency;- Once the information on the applicant is received by the facility, and no pertinent criminal history is indicated, the applicant may begin work. 1.Review of Employee C's personnel file showed:- A hire date of 11/06/25;- No documentation the CBC was completed before the employee's hire date. During an interview on 02/18/26 at 1:45 P.M., the Director of Nursing (DON) said she was responsible for doing the CBCs on employees and did not know how this one was missed. During an interview on 02/18/26 at 1:50 P.M., the Administrator said the CBC should be checked on all new hires before they began work in the facility. The DON was responsible for doing the pre-hire paperwork and the Administrator was responsible for making sure everything was completed, but the paperwork did not get to her. She did not know what happened in this case.

Based on observation, interview, and record review, the facility failed to provide a clean and homelike environment by not finding the source of a persistent, lingering, foul odor inside the building. This deficient practice had the potential to affect all residents. The facility census was 48.Review of the facility's policy titled, Safe and Homelike Environment, not dated, showed:- In accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment;- Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Observations showed:- On 02/15/26 at 9:00 A.M., and 2:00 P.M., the facility with strong foul odors near the front entrance, commons area, south and northwest halls;- On 02/16/26 at 8:30 A.M., and 1:00 P.M., the facility with strong foul odors in the commons area, south and northwest halls;- On 02/17/26 at 8:20 A.M., the facility with strong foul odors near the front entrance, south and northwest halls;- On 02/17/26 at 9:45 A.M., the Administrator cleaned the carpet with a towel and spray bottle on the south hall;- On 02/18/26 at 8:30 A.M., and 2:20 P.M., the facility with a strong foul odor at the front entrance. During an interview on 02/18/26 at 1:30 P.M., Certified Nurse Aide (CNA) D said there were odors that linger at times in the facility and were really strong at times. During an interview on 02/18/26 at 2:20 P.M., CNA E said there were odors in the facility at times and for the most part was just a stale smell of some kind. He/She never reported it to anyone due to thinking all staff could smell the odors. During an interview on 02/18/26 at 2:55 P.M., the Administrator said she had someone report to her today the facility had strong odors. She knew the northwest hall smelled because some of the male residents urinated on the floors when using the bathroom. Complaint #2743167

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 28 opportunities with five errors made, resulting in an error rate of 17.86% for five residents (Residents #7, #8, #19, #22 and #28) out of eleven sampled residents. The facility's census was 48. Review of the facility's policy titled, Insulin Pen, dated 2024, showed: - Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir; - Procedure to prime the insulin pen: dial two units by turning the dose selector clockwise; with the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. Review of the Humalog/lispro (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) Kwik Pen (insulin in a pen-type device) instructions, revised July 2023, showed: - Prime the pen by turning the dose knob to two units; - Hold the pen with the needle pointing up; - Tap the cartridge holder gently to collect air bubbles at the top; - Push the dose knob in until it stops, and zero is seen in the dose window, count to five slowly, insulin will be visible at the tip of the needle. Review of the Novolog/Fiasp/aspart (fast-acting insulin injected just below the skin that helps lower mealtime blood sugar spikes) Flex Pen administration instructions, dated September 2021, showed: - Prime the pen by turning the dose selector to two units; - Keep the needle upwards and press the push-button until the dose selector reads zero. 1. Review of Resident #7's Physician Order Sheet (POS), dated November 2024, showed an order for Novolog insulin pen 100 units per milliliter (ml) subcutaneous (an injection under the skin) with meals per a sliding scale of blood sugar of 81-150=0 units, 151-250=3 units, 251-350=6 units, 351-400=9 units, dated 06/26/24. Observation of Resident #7's medication administration on 11/20/24 at 11:33 A.M., showed: - Licensed Practical Nurse (LPN) C administered the Novolog insulin as ordered; - LPN C failed to prime the Novolog Kwik Pen per the manufacturer's instructions prior to the administration of the insulin 2. Review of Resident #8's POS, dated November 2024, showed an order for Humalog insulin pen 100 units per ml subcutaneous with meals per a sliding scale of blood sugar of of 0-149=0 units, 150-200=2 units, 201-250=6 units, 251-300=8 units, 301-350=10 units, 351-400=12 units, 12 units greater than 400 call MD, dated 11/07/24. Observation of Resident #8's medication administration on 11/20/24 at 11:55 A.M., showed: - LPN D administered the Humalog insulin as ordered; - LPN D failed to prime the Humalog Flex Pen per the manufacturer's instructions prior to the administration of the insulin. 3. Review of Resident #19's POS, dated November 2024, showed an order for Fiasp insulin pen 100 units per ml subcutaneous with meals per a sliding scale of blood sugar of 0-100=0 units, 101-200=4 units, 201-300=6 units, 301-400=8 units, dated 07/12/24. Observation of Resident #19's medication administration on 11/20/24 at 10:46 A.M., showed: - LPN C administered the Fiasp insulin as ordered; - LPN C failed to prime the Fiasp Flex Pen per the manufacturer's instructions prior to the administration of the insulin. 4. Review of Resident #22's POS, dated November 2024, showed an order for lispro insulin pen 100 units per ml subcutaneous with meals per a sliding scale of blood sugar of 81-150=0 units, 151-250=3 units, 251-350=6 units, 351-400= 9 units, over 401 call MD, dated 08/21/24. Observation of Resident #22 medication administration on 11/20/24 at 11:45 A.M., showed: - LPN C administered the lispro insulin as ordered; - LPN C failed to prime the lispro Kwik Pen per the manufacturer's instructions prior to the administration of the insulin. 5. Review of Resident #28's POS, dated November 2024, showed an order for Novolog insulin pen 100 units per ml subcutaneous with meals per sliding scale of blood sugar of 0-80=0 units, 0 units-juice; 81-150=0 units, 151-250=3 units, 251-350= 6 units, [PHONE NUMBER]=9 units, call MD, dated 08/21/24. Observation of Resident #28 medication administration on 11/20/24 at 11:16 A.M., showed: - LPN C administered the Novolog insulin as ordered; - LPN C failed to prime the Novolog Kwik Pen per the manufacturer's instructions prior to the administration of the insulin. During an interview on 11/20/24 at 11:50 A.M., LPN C said he/she heard that once an insulin pen was primed with the first use, it was not necessary to prime the insulin pen with each use. During an interview on 11/21/24 at 12:10 P.M., Registered Nurse (RN) E said that before administering insulin, the insulin pen must be primed with two units of insulin before administering the insulin to the resident. During an interview on 11/21/24 at 12:10 P.M., the Director of Nursing (DON) said staff should prime insulin pens with two units with every insulin administration.

Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) and proper infection control practices during wound care and when staff were accessing and administering medications through a central venous access device (CVAD - a thin, soft, flexible tube that is placed in a vein that leads to the heart) for one resident (Resident #1) out of one sampled resident. The facility also failed to use proper hand hygiene during wound care for one resident (Resident #1) out of four sampled residents. This deficient practice had the potential to affect all residents in the facility. The facility census was 48. Review of the facility's policy, titled, Clean Dressing Change, dated 2023, showed: - Loosen the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution or use adhesive remover to remove tape; - Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle; - Wash hands and put on clean gloves; - Cleanse wound as ordered, pat dry with gauze; - Wash hands and put on clean gloves; - Apply topical ointments or creams and dress the wound as ordered. Protect the surrounding skin as indicated with skin protectant; - Secure dressing. [NAME] with initials and date; - Discard disposable items and gloves into appropriate trash receptacle and wash hands. Review of the facility's policy, titled, Enhanced Barrier Precautions, dated 2024, showed: - An order for EBP will be obtained for residents with any of the following: wounds (e.g. chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g. central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, peripherally inserted central catheter (PICC) lines, midline catheters) even if the resident is not known to be infected or colonized with multi-drug resistant organism (MDRO); - Make gowns and gloves available immediately near or outside of the resident's room; - Personal protective equipment (PPE) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room; - High-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing brief or assisting with toileting, device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters, wound care: any skin opening requiring a dressing. Review of the facility's policy, titled, Intravenous Therapy, dated 2024, showed: - Procedure for Intermittent Medication Infusion: disinfect needleless connector with appropriate antiseptic agent as per facility protocol; attach a 10 milliliter (ml) syringe, normal saline, and confirm patency of the vascular access device; disinfect the needless connector again with an appropriate antiseptic agent; if medication is set to the primary tubing, disconnect, disinfect the needless connector with an appropriate antiseptic solution and flush and/or lock with normal saline/locking solution as per protocol for a vascular device. Observation on 11/20/24 at 1:03 P.M., of Resident #1's medication administration showed: - Signage posted outside of the resident's room that instructed staff to wear gown and gloves for resident care; - Licensed Practical Nurse (LPN) C entered the resident's room to administer a medication; - Resident #1 had a CVAD; - LPN C performed hand hygiene and applied clean gloves; - LPN C failed to put on a gown prior to accessing the CVAD line. Observation on 11/20/24 at 1:45 P.M., Resident #1's CVAD access care showed: - LPN C did not put on a gown; - LPN C disconnected the tubing from the CVAD access; - The male end of the PICC line hub rested on the resident's arm; - LPN C reached for the normal saline syringe and attached the syringe to the hub without using an antiseptic agent before placing the lock cap. Observation on 11/20/24 2:03 P.M., of Resident #1's wound care showed: - LPN C prepared the wound dressings without gloves and without having performed hand hygiene; - LPN C performed wound care without a gown; - LPN C removed the saturated dressing from the right lower extremity; - LPN C changed gloves and did not perform hand hygiene; - LPN C used wound cleanser and gauze to clean the wound and patted dry with clean gauze; - LPN C applied collagen (a wound dressing that stimulates new tissue growth), calcium alginate with silver (a wound dressing that help to prevent infection and promote healing), absorbent pad, border dressing, and a compression sock to the right lower extremity; - LPN C performed hand hygiene and applied clean gloves; - LPN C removed the compression sock and the soiled dressing from the left lower extremity; - LPN C changed gloves and did not perform hand hygiene; - LPN C used wound cleanser to loosen the soiled dressing from the wound; - LPN C changed gloves and did not perform hand hygiene; - LPN C applied collagen, calcium alginate, absorbent pad, border dressing and a compression sock to the left lower extremity; - LPN C removed the gloves and performed hand hygiene. During an interview on 11/21/24 at 12:10 P.M., the Director of Nursing (DON) said gown and gloves should always be put on before providing care to a resident with EBP in place. When a PICC line was accessed, staff should the scrub the hub of the PICC line every time. During an interview on 11/21/24 at 12:20 P.M., Registered Nurse (RN) E said when doing wound care, he/she would change gloves and do hand hygiene after removing the soiled dressing. If a resident was on EBP, he/she would put on PPE of at least a gown and gloves. When accessing a PICC line, he/she would remove the green cap and scrub the hub before connecting anything to the PICC line. When disconnecting the tubing from the PICC line, he/she would scrub the hub for 2 two minutes and place an alcohol cap onto the PICC line.

Based on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS - a federal mandated assessment to be filled out by the facility staff) on or within 14 days of a resident's admission to hospice (healthcare focused on the quality of life of a terminally ill person) for one resident (Resident #4) out of three sampled residents. The facility census was 48. Review of the facility's policy titled, Care Plan Policy, revised May 2024, showed: - The purpose of the policy is to set out the values and framework within which the individuals care is completed and updated; - Care planning is critical to the quality of service in any care home; - Care plans will be updated with quarterly, annual and significant change MDS's according to the the resident assessment instrument (RAI - an assessment tool used to gather important care area information on a resident's strengths and weaknesses) manual. Care plans will also be updated with any changes in direct care of the individual and reviewed upon any readmission into the facility by the interdisciplinary team (IDT - a group of healthcare professionals from diverse fields who work in a coordinated effort toward a common goal for a resident); - The policy did not address completing a significant change MDS on or within 14 days of a resident's change in a health condition. 1. Review of Resident #4's medical record showed: - admitted to facility on 06/06/24; - admitted to hospice on 10/11/24. Review of the resident's MDS assessments showed: - No significant change on or after of the resident's admission to hospice on 10/11/24; - The facility failed to submit a significant change MDS assessment on or within 14 days after the resident admitted to hospice. During an interview on 11/20/24 at 3:35 P.M., the offsite MDS Coordinator said he/she would expect a significant change MDS to be completed on or within 14 days after a resident had been admitted to hospice services. During an interview on 11/20/24 at 4:48 P.M., the Director of Nursing (DON) said she would expect a significant change MDS to be completed within 14 days after a resident had been admitted to hospice. During an interview on 11/20/24 at 4:52 P.M., the Administrator said she would would expect a significant change MDS to be completed on or within 14 days after a resident had been admitted to hospice.

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment. This deficient practice had the potential to affect all residents at the facility. The facility census was 48. Review of the facility's policy titled, Safe and Homelike Environment, revised August 2024, showed: - In accordance with residents' rights, the facility will provide a safe, clean comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services and that the physical layout of the facility maximizes resident independence and does not pose a safety risk; - Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas; - Orderly is defined as an uncluttered physical environment that is neat and well-kept. 1. Observations on 11/18/24 at 9:06 A.M., 11/19/24 at 10:05 A.M., 11/20/24 at 11:01 A.M., and 11/21/24 at 8:01 A.M., of the facility's outside front entrance showed: - A buildup of spider webs and dirt on the vinyl ceiling and sides located under the awning; - A buildup of dirt and debris inside nine light covers on the vinyl ceiling located under the awning. 2. Observations on 11/18/24 at 9:17 A.M., 11/19/24 at 10:15 A.M., 11/20/24 at 11:11 A.M., and 11/21/24 at 8:11 A.M., of the outside exit door near the therapy room showed: - A buildup of spider webs and dirt located on the outside vinyl ceiling and sides; - A buildup of spider webs and dirt on two sprinkler heads located on the vinyl ceiling. 3. Observations on 11/18/24 at 9:44 A.M., 11/19/24 at 10:24 A.M., 11/20/24 at 11:35 A.M., and 11/21/24 at 8:23 A.M., of the outside exit door near the laundry room showed: - A buildup of spider webs and dirt located on the vinyl ceiling and sides; - A buildup of spider webs and dirt on a sprinkler head located on the vinyl ceiling. 4. Observations on 11/18/24 at 9:59 A.M., 11/19/24 at 10:34 A.M., 11/20/24 at 11:51 A.M., and 11/21/24 at 8:47 A.M., showed a buildup of spider webs and dirt located on the outside vinyl ceiling of the exit door located near room [ROOM NUMBER] and room [ROOM NUMBER]. 5. Observations on 11/18/24 at 10:06 A.M., 11/19/24 at 2:15 P.M., and 11/20/24 01:08 P.M., of the North (N) Hall showed several areas of deep-scraped exposed sheetrock and peeled paint on the bottom part of the right-side wall near the window in Room N3. 6. Observations on 11/20/24 at 8:05 A.M., showed: - Several areas of exposed wood and black marks on the baseboards located at the front main entrance; - Several straight-lined dark scrapes by the restroom doors located near the front entrance; - Several dark scuff marks, scratches, and deep scrapes on two large decorative columns located between the main commons area and the TV sitting area at the front entrance; - A large piece of loosened wallpaper above the bird aviary (cage) located in the TV sitting area. 7. Observation on 11/20/24 at 8:10 A.M., of the South (S) Hall showed several areas of exposed sheetrock near the door in Room S4. 8. Observation on 11/20/24 at 8:15 A.M., of the Northwest (NW) Hall showed: - Several deep straight-lined scrapes on the entrance door located in Room NW2; - A large water stain on the ceiling located between Room NW1 and Room NW3. 9. Observation on 11/20/24 at 12:45 P.M., of the assisted bathing room near Suite 114 showed: - A broken/chipped ceramic tile located on the bottom of a divider wall between the toilet area and the handwashing sink; - Several loose, broken/chipped ceramic tiles located on the bottom left-side area of the shower stall; - A buildup of dirt and debris inside four light fixture covers located on the ceiling; - A light fixture with no illumination (lighting) located on the ceiling near a wall cabinet on the left-side. 10. Observation on 11/20/24 at 12:52 P.M., of the assisted bathing room near Suite 113 showed: - A buildup of hair and debris on a floor drain located in the shower stall; - A broken/chipped ceramic tile located on the bottom of a divider wall between the toilet area and handwashing sink; - A buildup of dirt and debris inside four light fixture covers located on the ceiling; - A light fixture with no illumination located on the ceiling between the divider curtains upon entrance. Review of the maintenance request forms, dated September 2024 through November 2024, showed no documentation of areas of concerns addressed. During an interview on 11/20/24 at 10:20 A.M., Housekeeper A said he/she did not clean the sprinkler heads or the outside of the exit doors. Maintenance was responsible for the sprinkler heads and outside work. If there were any environmental issues, he/she verbally told the Maintenance Supervisor (MS). During an interview on 11/20/24 at 10:24 A.M., Housekeeper B said he/she was still new to the job in housekeeping and did not know who cleaned the sprinkler heads inside the building or the outside areas. It probably would be more of a maintenance department responsibility. If there was a repair needed, he/she verbally told the housekeeping supervisor and was not aware of a maintenance request form to be filled out. During an interview on 11/21/24 at 10:01 A.M., the MS said staff usually told him/her when something needed to be addressed. It would be more effective if staff would write down environmental concerns on a maintenance request form. The sprinkler heads and outside areas of the facility was the maintenance department's responsibility. During an interview on 11/21/24 at 11:02 A.M., the Administrator said she would expect staff to write down any environmental concerns so they could be addressed in a timely manner on a maintenance request form instead of verbally telling the MS. The sprinkler heads and outside areas of the facility was the responsibility of the maintenance department.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This has the potential to affect all residents. The facility census was 42. Review of the facility's policy titled, Food Safety Requirements, revised February 2023, showed: - It is the policy of the facility to procure food from sources approved or considered satisfactory by federal, state and local authorities; - Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety; - Food safety practices shall be followed throughout the facility's entire food handling process; - This process begins when food is received from the vendor and ends with delivery of the food to the resident; - Elements of the process include the following; storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms, (a microscopic organism, especially a bacterium, virus, or fungus); preparation of food, including thawing, cooking, cooling, holding, and reheating; distribution and service of food to the resident, including transportation, set up, and assistance; - Equipment used in the handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food; employee hygienic practices; dry food storage, keep foods/beverages in a clean, dry area off the floor and clear of ceiling sprinklers, sewer/waste disposal pipes, and vents; refrigerated storage, foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable; practices to maintain safe refrigerated storage include monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals during all hours of operation; labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; keeping foods covered or in tight containers; when preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards; thawing, approved methods for thawing frozen foods include thawing in the refrigerator, submerging under cold water, thawing in a microwave oven, or as part of a continuous cooking process; and thawing at room temperature is not acceptable. 1. Observation on 09/12/23 at 9:24 A.M., of the dry food storage room showed: - One 35 pound (lb.) cooking oil container sat on the floor; - Scattered debris below the food storage shelves; - One unsealed, undated 29 lb. cardboard container with biscuit dough inside the reach-in freezer unit. 2. Observation on 09/12/23 at 9:35 A.M., of the kitchen showed: - One uncovered container with hash brown potatoes thawed on a food cart; - Food debris and oily film build-up on the floor beneath the range; - The commercial dishwasher with white grime build up on the exterior surfaces. 3. Observation on 09/13/23 at 11:15 A.M., of the kitchen showed: - Four 16 inch (in.) x 24 in. x 1 in. deep baking pans with a sticky film, black grime build-up in the inside corners, on the cooking surface and outer surfaces; - The commercial dishwasher with white grime build up on the exterior and interior surfaces; - Eleven ceiling diffusers (one of the few visible parts of an air conditioning system) with a brown substance on the front exterior surfaces and between the ventilation louvers; - One 48 in. x 16 in. plastic ceiling diffuser with dust build up ventilation louvers; - Scattered debris below the commercial range, refrigeration equipment and food preparation counter. 4. Observation on 09/15/23 at 8:49 A.M., of the dry food storage room showed: - One 35 lb. cooking oil container sat on the floor; - Scattered debris below the food storage shelves; - One unsealed, undated 29 lb. cardboard container with biscuit dough inside the reach-in freezer unit; - Scattered debris and six 1 in. ice formations inside the reach-in freezer unit; - Two large undated clear plastic bins with dry white beans and rice without a label; - One large uncovered, undated clear bin partially filled with raw onions without a label; - One large uncovered, undated bin filled with raw sweet potatoes without a label; - Two unsealed, undated bags partially filled with corn chips sat on the food shelf near the reach-in freezer unit; - One unsealed, undated bag partially filled with potato chips sat on the food shelf near the reach-in freezer unit; - One unsealed, undated bag partially filled with tortilla chips sat on the food shelf near the doorway. 5. Observation on 09/15/23 at 9:00 A.M., of the kitchen showed: - Scattered debris below the commercial range, refrigeration equipment and food preparation counter; - One partially filled plastic dispenser with alcohol based hand sanitizer, wall mounted on the right side of the handwashing sink; - No trash can beside the handwashing sink. During an interview on 09/15/23 at 8:50 A.M., the Dietary Aide A said usually the hand sanitizer near the handwashing sink in the kitchen was used at least twice daily. The floors should be cleaned daily in the kitchen. Dietary workers were expected to clean routinely in the kitchen. During an interview on 09/15/23 at 9:20 A.M., the Dietary Manager said the Maintenance Director takes care of the vents in the ceiling. Kitchen deep cleaning was done over the weekend and staff should be sweeping under the appliances, shelves and cleaning the refrigerators. The cleaning logs should be signed but were not updated. It was more of a list than a log. The dishwasher was serviced by an outside company, the ceiling vents should not have had a brown substance on them and were normally cleaned and repainted annually by the maintenance department. The food boxes in the freezer should be closed and dated before they were returned to the freezer. There should not be ice formations or debris in the freezer. The facility did not have a water softener so lime scale build-up was an issue with the dishwasher. The chips should not be left open on the shelves in the dry storage and should have been dated when they were opened. Bins with vegetables should be dated and covered in the dry food storage but were not. The freezers should defrost automatically and should not have had frost build up. Sanitizing hand gel was carried and used daily. It was available in a dispenser by the handwashing sink. During an interview on 09/15/23 at 9:30 A.M., the Administrator said that the ceiling vents should not have had a brown substance on them or dust build up and were normally cleaned and repainted annually by the Maintenance Director. The food boxes in the freezer should be closed and dated. There should not be ice formation or debris in the freezer. The floors and walls below the food shelves and refrigeration equipment should be clean. The deep cleaning should be done on the weekends and cleaning logs should be signed. The facility did not have a water softener so lime scale was an issue in the dishwasher. Potato and corn chip bags should not be left open on the shelves in the dry storage and should be dated. Bins with vegetables should be dated and covered in the dry food storage. The hand sanitizer dispenser should be removed from the handwashing sink area and a trash can should be available near the sink. The freezers should not have had an ice build-up and should be defrosted. Left over items in the freezer should be dated and containers should be closed. Frozen foods should be thawed safely and not at room temperature. The kitchen policy should be followed. During an interview on 09/15/23 at 11:37 A.M., the Maintenance Director said the air conditioning covers in the kitchen should have been cleaned already. They had to be taken to the car wash normally and sprayed clean. They were repainted after they had been cleaned. The large air return grill should not be covered in dust but it should have been cleaned a couple weeks ago.

Based on interview and record review, the facility failed to revise and update the comprehensive care plan for two residents (Resident #22 and #26) out of 12 sampled residents. The facility's census was 34. 1. Record review of the facility's policy titled, Care Plan Policy, dated [DATE], showed: - Care planning is critical to the quality of service in any care home. It is the means by which the values of the home are translated into specific objectives for each individual who lives there. This overview sets a framework for proper planning. Planned action should reflect personal choices identified through interviews with the individual, family, Interdisciplinary Team (IDT) and Minimum Data Set (MDS: a federally mandated assessment to be completed by the facility) assessment and Care Assessment Areas (CAAs). The care plan should be the means by which the identified needs and wishes of the individual are recorded. It ensures that care is offered consistently by well-informed staff, aware of the individual care needs; - Care plans will be updated with quarterly, annual, and significant change MDSs according to the RAI manual; - Care plans will also be updated with any changes in direct care of the individual and reviewed upon any readmission into the facility by the Interdisciplinary Team; - Care plans will be accessible to staff to reflect interventions for the resident's individualized plan of care; - The care plan is a guide for care with individualized goals and interventions to accomplish them. 2. Record review of Resident #22's medical record showed: - admitted on [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Weekly Skin Assessment, dated [DATE], contained documentation of a pressure ulcer to left heel measuring 0.2 centimeters (cm) by 0.2 cm by 0 cm; - Nurse Progress Note, dated [DATE], contained documentation for new orders for wound care: discontinue treatment to left heel, area is resolved; - The comprehensive care plan, dated [DATE], contained documentation of a pressure ulcer to left heel has reopened. This is a reoccurring area. During an interview on [DATE] at 9:34 A.M. with Certified Nurse Assistants (CNA) A and B both said the resident's heel wound has healed and is no longer open. Observation of the resident on [DATE] at 9:34 A.M. showed no open area on the left heel. 3. Record review of Resident #26's medical record showed: - admitted on [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - POS, dated [DATE], contained documentation of an order dated [DATE], to admit to hospice care (health care services for the terminally ill), an order, dated [DATE], for Do Not Resuscitate (DNR, instructs healthcare providers not to do cardiopulmonary resuscitation (CPR: life-saving measures) if a patient's breathing stops or if the patient's heart stops beating); - Nurse progress note, dated [DATE], contained documentation of the resident to be DNR status; - The comprehensive care plan did not contain the DNR status until [DATE]. 4. During an interview on [DATE] at 9:41 A.M., the MDS Coordinator, Director of Nursing (DON), and Administrator said they would expect the comprehensive care plan to be updated immediately with a change or as soon as possible.

Based on interview and record review, the facility failed to complete a comprehensive discharge summary including a recapitulation of stay and complete reconciliation of medications for one resident (Resident #36) out of two sampled closed records. The facility's census was 34. Record review of Resident #36's medical record showed: - admitted on [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Physician Discharge Summary, dated 9/13/21, contained documentation of the resident requested to go home this morning. Physician called. New order to go home received. Resident called family to come and take him/her home; - Nurse Progress Note, dated 9/13/21 at 11:00 A.M., contained documentation of the resident as alert and oriented, agitated and ready to leave, called family and told them he/she was leaving. Resident left facility as soon as his/her paperwork was finished. He/she was irritated to have been here in the first place. Went over paperwork, medications, belongings, and checked resident's vital signs before he/she left. Resident had no open skin, generalized bruising. Walked him/her to door and everyone is aware of his/her departure; - Instructions for Care of Resident after Discharge, dated 9/13/21, did not contain the quantity count of the medications sent with the resident for calcium 600 milligrams (mg) plus vitamin D3, [MEDICATION(S)] (a diuretic medication) 40 mg, aspirin 81 mg, potassium 10 milliequivalents (meq), tamsulosin 0.4 mg, [MEDICATION(S)] (a corticosteroid used to treat [CONDITION(S)] illnesses), [MEDICATION(S)] (an anticonvulsant medication) 250 mg three times daily, [MEDICATION(S)] (a [MEDICATION(S)] medication) 17 grams once daily, senna [MEDICATION(S)] (a [MEDICATION(S)] medication) 8.65-50 mg daily in the morning, [MEDICATION(S)] (an antidepressant medication) 100 mg at bedtime, and [MEDICATION(S)] (an inhaler) one puff daily. No dosage or frequency for [MEDICATION(S)] and no frequency of dosage for calcium, [MEDICATION(S)], aspirin, potassium, and tamsulosin. During an interview on 11/18/21 at 9:41 A.M., the Administrator said the facility does a medication reconciliation, they document what they are sending home with the resident, and the resident and/or family have to sign it. A medication reconciliation was completed for the resident, but a recapitulation was not. The facility staff felt that it wasn't necessary since the resident was in the facility for such a short time. The facility did not provide a policy for discharge summary or recapitulation of stay.

Based on interview and record review, the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for three residents (Resident #13, #20, and #24) out of 12 sampled residents. The facility's census was 34. 1. Record review of the facility's policy titled, Notice Requirements Before Transfer/Discharge Policy, dated December 2018, showed before the facility transfers or discharges a resident, the facility will send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. 2. Record review of Resident #13's nurse's notes showed the resident transferred to the hospital on 10/18/21 and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation of notification of the Office of the State Long-Term Care (LTC) Ombudsman. 3. Record review of Resident #20's nurse's notes showed the resident transferred to the hospital on 8/11/21 and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation of notification of the Office of the State Long-Term Care (LTC) Ombudsman. 4. Record review of Resident #24's nurse's notes showed the resident transferred to the hospital on 10/18/21 and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation of notification of the Office of the State Long-Term Care (LTC) Ombudsman. 5. During an interview on 11/17/21 at 3:47 P.M., the Social Services Director (SSD), Director of Nursing (DON), and Administrator said they would expect the Office of the State Long-Term Care (LTC) Ombudsman to be provided a list of hospitalization s monthly. The SSD said he/she failed to send them after July 2021. During an interview via email on 11/15/21 at 7:34 A.M., the Office of the State Long-Term Care Ombudsman Director said she had been receiving the facility's transfer notices up until July 2021, but hasn't received any since that time.

Based on interview and record review, the facility failed to issue a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notice (SNFABN: Medicare requires SNFs to issue the SNFABN to beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is not medically reasonable and necessary or considered custodial) Form for two residents (Resident #2 and #36) who remained in the facility when benefits were not exhausted out of three sampled residents. The facility's census was 34. 1. Record review of the facility's undated policy titled, Medicare Discharge Policy Forms , , , R-131 and showed when a resident is discharged from Medicare Part A services that the CMS guidelines and instructions will be followed. Record review of the facility's policy titled, Beneficiary Liability Protection Notice Scenarios for Surveyors, dated February 2017, showed a denial letter or ABN to be provided when a resident has skilled benefit days remaining and is being discharged from Part A services and will continue living in the facility. 2. Record review of Resident #2's medical record showed Medicare Part A Services began on 6/1/21, ended on 6/30/21 and the resident remained in the facility. The facility did not issue a CMS SNF ABN Form . 3. Record review of Resident #36's medical record showed Medicare Part A services began on 8/23/21, ended on 10/19/21, and the resident remained in the facility. The facility did not issue a CMS SNF ABN Form . 4. During an interview on 11/17/21 at 3:47 P.M., the Social Services Director and Administrator said they missed these forms and they should have been completed.

Based on interview and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS: a federally mandated assessment to be completed by the facility) for three residents (Residents #13, #26, and #86) out of 12 sampled residents. The facility's census was 34. 1. Record review of the facility's policy titled, Resident Assessment Instrument (RAI) Minimum Data Set (MDS) Policy, dated January 2019, showed: - The RAI assists skilled nursing facility staff to consistently and accurately gather information regarding resident needs and strengths, which provides the foundation for an individualized interdisciplinary plan of care; - The RAI process is coordinated by an RN and includes an Interdisciplinary Team (IDT) of nursing, social services, dietary, rehab/restorative, activities, pharmacy and medical staff; - The resident and family/legal guardian are included as integral members of the team and shall be included in the assessment and care planning process; - The RAI process includes accurate and timely completion of the following Omnibus Budget Reconciliation Act (OBRA: developed to improve the quality of care for nursing homes) required assessments: - Initial admission assessment within 14 days of admission; - Care assessment areas (CAAs) within 14 days of admission; - Plan of care with 21 days of admission or within seven days of completion of MDS and CAA's; - Quarterly assessments as guidelines in the RAI user's manual; - Annual assessment with CAA's as guidelines in the RAI user's manual; - Significant change in status/significant correction assessment with CAA's as identified appropriate by the IDT and according to guidelines in the RAI user's manual and revision to the care plan; - Entry, discharge return not anticipated, discharge return anticipated and death in the facility tracking forms as guidelines provided in the RAI user's manual; - PPS Assessment will be completed and transmitted according to the guidelines of the RAI 3.0 user's manual. 2. Record review of the facility's policy titled, Care Plan Policy, dated 5/2019, showed: - Care plans will be updated with quarterly, annual and significant change MDS's according to the RAI manual; - Care plans will also be updated with any changes in direct care of the individual and reviewed upon any readmission into the facility by the IDT. 3. Record review of Resident #13's medical record showed: - admitted on [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - The comprehensive care plan, dated 10/8/21, contained documentation as the resident to receive [CONDITION(S)] every Monday, Wednesday, and Friday started on 9/25/19; - Annual MDS, dated [DATE], section O100J did not contain documentation as the resident received [CONDITION(S)]. 4. Record review of Resident #26's medical record showed: - admitted on [DATE]; - diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - POS, dated 11/1/21, contained documentation of an order, dated 10/7/21, to admit to hospice care (health care services for the terminally ill); - Significant change MDS, dated [DATE], for admission to hospice showed section J1400 for prognosis that may result in life expectancy of less than six months documented as no, and section O100K for hospice care documented as yes. 5. Record review of Resident #86's medical record showed: - admitted on [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - POS, dated 11/8/21, showed an order, dated 10/22/21, to admit to hospice care; - Admission MDS, dated [DATE], showed section J1400 for prognosis that may result in life expectancy of less than six months documented as no, and section O100K for hospice care to documented as yes. 6. During an interview on 11/18/21 at 9:41 A.M., the MDS Coordinator, Director of Nursing (DON), and Administrator said they would expect the MDS to accurately reflect each care area and for J1400 to be marked yes for hospice residents.

Based on interview and record review, the facility failed to review, update, and sign the infection prevention and control program (IPCP) annually. This deficient practice had the potential to affect all residents in the facility. The facility census was 51. Record review of the facility's IPCP policy, showed: - A policy on how to clean/disinfect a resident's room, dated 8/2013; - A policy on how to clean environmental surfaces, dated 6/2009; - A departmental laundry/linen policy, dated 1/2014; - An infection control policy, undated; - No review date of the IPCP; - No signature by the Medical Director; - No signature by the Administrator. During an interview on 2/06/20 at 12:47 PM the Administrator said she did not know the IPCP policy needed to be reviewed and signed annually. He/she thought the Antibiotic Stewardship plan was the same as the IPCP. He/she did not realize the Antibiotic Stewardship plan was part of the IPCP and the IPCP also had to be reviewed annually.

Based on observation, interview, and record review, the facility failed to ensure the proper sanitation of the dishes for resident use, increasing the risk of cross-contamination and food-borne illness. These practices affected all residents. The facility census was 51. 1. Observation on 2/3/20 at 1:15 P.M., of the Homeward Bound unit, showed: - Staff loaded the residential type dishwasher with dirty plates, glasses, and silverware from the lunch meal for the Homeward Bound residents; - The dishwasher not a commercial grade dishwasher. Record review of (MONTH) 2020 and (MONTH) 2020 sanitation logs, showed: - No sanitation logs for (MONTH) or February; - Missed 36 times out of 36 opportunities. Record review of the dishwasher temperature log for (MONTH) 2020 and (MONTH) 2020, showed: - No record of dishwasher temperature recorded for (MONTH) or February; - Missed 36 opportunities out of 36 opportunities. During an interview on 2/5/20 at 11:00 [NAME]M., the Dietary Manager (DM) said the Homeward Bound unit staff washes all of their dishes and only send the serving dishes back to the kitchen. They use the dishwashing pods the kitchen provides for them. The DM thought the pods sanitized the dishes. The DM did not know if there were sanitation logs on Homeward Bound or not. The DM also said the dishwasher in the kitchen is a high temperature dishwasher and since it is above 180 Fahrenheit (F), sanitizer is not needed. The DM said he/she guessed the temperature logs for the dishwasher for (MONTH) had been taken out and thrown away and they hadn't recorded any temperatures for (MONTH) yet, but they should be recording the temperatures. During an interview on 2/5/20 at 2:00 P.M., the Administrator said the staff on Homeward Bound are supposed to put a half of cup of bleach in the bottom of the dishwasher every time it is run, but it isn't documented so they are unable to prove it is done. The kitchen staff should be recording the temperatures of the dishwasher everyday. Record review of the facility's Sanitization for High - Temperature Dishwashing Machines policy, dated 10/2008, showed: - Wash temperature of 150 F - 165 F for at least 45 seconds; - Rinse temperature of 163 F - 180 F for at least 12 seconds.

Based on interview and record review, the facility failed to implement care plans with specific interventions tailored to meet individual needs for three residents (Resident #2, #30, and #40) out of 13 sampled residents. The facility census was 51. 1. Record review of Resident #2's medical record showed: - Resident admitted to the hospital on [DATE] and 1/9/20 for blood [MEDICAL CONDITION] for the treatment of [REDACTED]. - A weight of 248.0 pounds (lbs) in 8/19; - A weight of 242.2 lbs in 9/19; - A weight of 234.0 lbs in 10/19; - A weight of 249.3 lbs in 11/19; - A weight of 220.0 lbs in 12/19; - A weight of 183.0 lbs in 1/20; - A weight loss of 26.21 percent (%) from 8/19 - 1/20. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 10/17/19, showed: - A [DIAGNOSES REDACTED].>- A weight loss of 5% or more in the last month or a loss of 10% or more in the last six months; - Not on a physician-prescribed weight-loss regimen. Record review of the resident's Physician order [REDACTED]. - an order for [REDACTED]. Record review of the resident's care plan, revised on 2/5/20, showed: - On a regular diet with regular texture thin liquid consistency; - No [MEDICAL CONDITION] with interventions addressed; - No weight loss addressed. 2. Record review of Resident #30's significant change MDS, dated [DATE], showed: - An admission date of [DATE]; - [DIAGNOSES REDACTED]. - Received antidepressant and antianxiety medications daily. Record review of the resident's POS, dated 2/2020, showed: - an order for [REDACTED].>- an order for [REDACTED].>- an order for [REDACTED]. Record review of the resident's care plan, revised on 1/20/20, showed: - A [DIAGNOSES REDACTED]. - A focus of received medication to manage his/her depression and anxiety with risks of side effects of these medications; - Resident recently admitted for an inpatient psychiatric hospital stay for behaviors; - No significant side effects of the antidepressant and antianxiety medications addressed; - No non-pharmacological interventions to help improve his/her mood and behaviors. 3. Record review of Resident #40's admission MDS, dated [DATE], showed: - An admission date of [DATE]; - [DIAGNOSES REDACTED]. - Received antipsychotic (a major tranquilizer) and antidepressant medications daily. Record review of the resident's POS, dated 2/2020, showed: - an order for [REDACTED].>- an order for [REDACTED]. Record review of the resident's care plan, revised on 2/5/20, showed: - [DIAGNOSES REDACTED]. - A focus of received medication to help manage his/her depression; - No significant side effects of the antipsychotic and antidepressant medications addressed; - No non-pharmacological interventions to help improve his/her mood. During an interview on 2/6/20 at 12:13 P.M., the MDS Coordinator said a resident's care plan should address significant side effects of any [MEDICAL CONDITION] (any medication capable of affecting the mind, emotions, and behavior) medications and any non-pharmalogical interventions used to help improve the resident's mood and/or behavior. [MEDICAL CONDITION] with interventions and weight loss should also be care planned for a resident. During an interview on 2/06/20 at 12:55 P.M., the Director of Nursing (DON) said she would expect the care plans to address the significant side effects of [MEDICAL CONDITION] medications and the non-pharmalogical interventions used to help improve a resident's mood and/or behavior. She would expect a resident's [MEDICAL CONDITION] with interventions and their weight loss to be care planned also. Record review of the facility's Resident Centered Care Plan Process policy, dated 12/01/16, showed: - The interdisciplinary team, the resident themselves, and the resident representative, will develop a comprehensive care plan for each elder that includes measurable objectives and timetables to meet each elder's clinical, nursing, and mental and psychosocial needs identified in the comprehensive assessment; - The interdisciplinary team will plan the resident's individualized care, treatment and services based on needs identified by the resident's assessment, including strengths and goals, reassessment and results of diagnostic testing; - The plan of care will include the care, treatment and services, with interventions to instruct staff to facilitate the resident to meet their goals; - The plan of care will be individualized, based on the diagnosis, comprehensive elder assessments and personal goals of the resident and his/her representative; - The plan of care will be individualized to the needs of the resident.

Based on interview and record review, the facility failed to ensure the baseline care plan (initial plan for delivery of care and services) included specific interventions for one resident (Resident #40) out of four sampled residents. The facility census was 51. 1. Record review of Resident #40's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/26/19, showed: - admitted to the facility on [DATE]; - A [DIAGNOSES REDACTED]. - Moderately impaired cognitive status. Record review of the resident's baseline care plan, dated 12/16/19, showed: - Did not address the resident's dementia with individualized interventions. During an interview on 2/6/20 at 12:02 P.M., Licensed Practical Nurse (LPN) A said the admitting nurse is responsible for completing the initial care plan and dementia should be addressed on it if the resident has that diagnosis. During an interview on 2/06/20 at 12:54 P.M., the Director of Nursing (DON) said she would expect dementia to be addressed on the initial plan of care if that's what the resident was admitted for . Record review of the facility's Resident Centered Care Plan Process policy, dated 12/01/16, showed: - An interim, temporary care plan will be developed by the clinical staff at the time of the admission based on the clinical assessment of the elder and information provided at the time of admission to include appropriate individualized interventions based on the assessed needs and condition of the elder prior to the development of the comprehensive, individualized plan of care; - A baseline care plan will be developed within 48 hours of a resident's admission that will include the minimum healthcare information necessary to properly care for the resident.