Every finding on record at Highland Ridge Rehab Center

Based on observations, staff interview, and facility document review, the facility staff failed to prepare, store, distribute, and serve food in accordance with professional standards for food service safety in the facility kitchen and in 4 of 4 unit pantries/nutrition rooms.The findings included:For the facility, the facility staff failed to discard out-of-date food items, failed to date and label perishable food items, failed to maintain clean dietary equipment, failed to store food under sanitary conditions, failed to utilize hair and beard restraints for dietary personnel, and failed to practice proper hand hygiene.An initial tour of the kitchen on 2/24/2026 at 10:51 AM was completed with the Registered Dietician (RD).Observation of the dry storage area revealed the following items:7 boxes of Quaker barley with a best by (BB) date of 8/30/251 large bag of Hershey's chocolate chips with a BB date of 9/3/25 that was open to air and not sealed1 bag of French-fried onions with a BB date of 12/16/241 large bag of graham cracker crumbs open to air and not sealed5 boxes of thickened sweet tea lemon flavor with a BB date of 1/28/266 boxes of thickened sweet tea lemon flavor with a BB date of 2/19/261 box of thickened apple juice with a BB date of 1/26/261 open container of Folgers coffee without an open date1 container of ground oregano with a BB date of 8/26/25 The RD was made aware of the items and removed them. On 2/24/26 at 11:20 AM, the walk-in refrigerator was observed.The following observations were made in the walk-in refrigerator:1 pan of prepared food in a deep tray was resting on a plastic crate on the floor without a label or date. A large silver tray was observed to have several dried brown liquid spots and multiple pieces of dried, loose, shredded cheese resting on the bottom of the tray. The tray contained the following items: 1 large ziplock bag of cubed ham without a label or date1 small ziplock bag of small dices of ham and 1 slice of ham without a label or date.2 chef salads in Styrofoam containers1 ziplock with a slab of ham1 ziploc bag of coleslaw1 bag of shredded mozzarella cheese3 containers of salad that were not labeled Continued observations of the walk-in refrigerator revealed: 4 meat and cheese sandwiches in ziploc bags without dates were noted on top of the second shelf on the right1 covered container of yellow cheese slices labeled Use by 2/16/26 was observed to have multiple brown crumbs on the cheese and in the bottom of the container2 large, uncovered trays of prepared crumbled cake-like white food with a red sauce were resting on a tray rack towards the back of the refrigerator45 uncovered plastic Jell-O cups without dates or lids18 covered cups of pudding without dates1 box on the bottom shelf on the left-side contained 2 large rounds of ground beef with use or freeze by dates 2/19/261 box containing (2) smoked turkey meat was noted to be sitting on a box fresh apples2 large trays of turkey sandwiches without a label The RD was made aware and removed the items.Other staff #2 was interviewed and reported that cooks are trained on first in - first out when stock comes in and that things have been getting missed for about 2 weeks since they lost most of their staff.On 2/25/26 at 12:00 PM, other staff #4 (OS#4), other staff #5 (OS#5), and other staff #6 (OS#6) entered the facility kitchen to begin their scheduled shift and proceeded to the hand-washing sink. None of the dietary employees wore a hair restraint. OS#6 had visible facial hair and a beard net was not visible.When asked about the protocol for hair restraints and beard nets, OS#4 stated there are no hair restraints outside of the kitchen door for them to use. OS#5 stated this is how they have been entering the kitchen. OS#6 stated he was never educated on hair nets or beard restraints and he had started in the kitchen in February 2026.On 2/25/26 at 12:06 PM, the regional director of dining services (RDDS) stated he was going to put in a work order to have a holder for hair and beard restraints to be provided outside of the facility kitchen entrance for the dietary employees to utilize prior to entering the facility kitchen. RDDS also stated he would provide education for the dietary staff, as they had not had a dietary manager for a few weeks.On 2/25/26 at 12:14 PM, other staff #2 (OS#2) who was the cook, was observed to put oven mitts over her gloves to remove a pan of egg noodles from the steamer to add to the serving station. OS#2 replaced the pan of egg noodles and then removed the oven mitts. The RDDS reminded OS#2 to change gloves. OS#2 was not observed to practice hand hygiene and put on new gloves.On 2/25/26 at 12:26 PM, OS#2 was observed to take a break for a drink of water. OS#2 changed gloves and did not practice hand hygiene. The RDDS asked OS#2 to wash hands and OS#2 washed her hands and put on new gloves.On 2/25/26 at 12:44 PM, OS#2 was observed to put oven mitts over her gloves to add more egg noodles to the serving station. OS#2 removed the oven mitts and changed gloves but did not practice hand hygiene.These concerns were discussed at the end of day meeting on 2/25/26 at 3:05 PM with the administrator, director of nursing, regional director of clinical services, unit manager #1, unit manager #2, unit manager #3, and assistant director of nursing.On 02/26/2026 at 8:30 AM, the D-Wing nutrition room was observed to contain the following items in the refrigerator:5 half meat and cheese sandwiches in individual baggies without dates or labels21 various food items in styrofoam bowls with lids without dates or labels5 various food items in styrofoam bowls with lids without dates or labels2 cups of covered puddings without datesCertified nursing assistant #6 made aware and disposed of items.On 02/26/2026 at 8:40 AM, the B-Wing nutrition room was observed to contain the following items:The sink was covered and out of order1 large tub of peanut butter with a BB date of 1/19/26 without an open date1 small tub of peanut butter without an open dateMultiple dried, red liquid splatters on the shelves and bottom of refrigerator were noted. Certified nursing assistant #7 made aware and disposed of items and stated that they would clean the refrigerator.On 02/26/2026 at 8:45 AM, the C-Wing nutrition room was observed to contain the following items in the refrigerator:15 food items in styrofoam bowls with lids without a date or label7 covered pudding bowls without a date1 box of thickened apple juice with a BB date of 1/27/264 half meat and cheese sandwiches in baggies were observed in the bottom drawer without dates or labelsThe freezer was observed to contain a box of Outshine Bars with a BB date of 3/31/25 with a resident's name on the box. An observation of the food cabinet revealed the following items: 1 large tub of peanut butter with a BB date of 1/19/261 container of homestyle chicken noodle soup with a BB date of 12/3/251 opened jug of Hawaiian Punch Berry Blue Typhoon Juice without an open date1 opened two liter of Dr Thunder soda labeled residents without an open date1 bottle of yellow mustard with a BB date of 7/11/251 opened container of instant coffee without an open date1 container of Folgers decaf coffee without an open date On 02/26/2026 at 8:46 AM, the A Wing nutrition room was observed to contain the following items:1 Apple pie on top of the refrigerator without a date1 dirty storage container on top of the refrigerator1 opened jar of peanut butter in the cabinet without an open date Registered nurse #1 (RN#1) made aware and stated that the apple pie was given to employees yesterday and was not for residents. RN#1 stated the dirty storage container most likely belonged to a staff member.On 2/26/2026 at 9:06 AM, licensed practical nurse #8 (LPN#8) was interviewed and stated the kitchen staff are supposed to bring carts of snacks to stock the pantries, but they do not do this very often.Requested and received a facility policy titled Food Storage which read in part, .7. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. A. Old stock is always used first (first in - first out method.).b. food should be dated as it is placed on the shelves.Date marking should be visible on all high-risk food to indicate the date by which a ready to eat.food should be consumed.or discarded.8. Plastic containers with tight fitting covers or sealable plastic bags must be used for storing.opened packages. All containers or storage bins must be legible and accurately labeled and dated.13. Refrigerated food storage.f. all foods should be covered, labeled and dated and routinely monitored to assure that foods.will be consumed by their use by dates, or frozen or discarded.Requested and received a facility policy titled Food Safety and Sanitation which read in part, .2. Employees.c. Employees.Hair restraints are required and should cover all hair on the head. [NAME] nets are required when facial hair is visible.No further information was provided to the survey team prior to exit on 2/26/26.

Based on observation, resident interview, staff interview, and facility document review, the facility staff failed to meet the daily nutritional and dietary needs of all residents that receive nutrition by oral means and the facility staff failed to maintain an overall system to manage and execute its food and nutritional services during a lapse in food service management. The findings included:Tray line was observed on 2/25/26 at 11:45 AM. The menu consisted of Swedish meatballs, egg noodles, and pacific blend vegetables. During observations of the tray-line, no special diets were noted to be called out other than regular diets, ground consistencies, and/or puree consistencies. When asked why no carbohydrate-controlled diets had been called out, other staff #1 stated, they only have one resident on a carb-controlled diet and that resident's spouse calls the kitchen to determine the resident's meal choice for that service. When asked who was cooking the evening meal, other staff #2 stated either the administrator or the human resource director, as they did not have another cook and the administrator and human resource director had been cooking since the dietary manager and other dietary staff had quit. On 2/25/26 at 12:38 PM, the registered dietician (RD) was interviewed about a carb-controlled diet for Resident #126 and informed the resident's tray ticket stated CCD (carbohydrate-controlled diet) but a medical provider order was for a regular diet. The RD was also asked about special dietary needs and/or diet orders other than regular diets. The RD stated they would do an audit and provide the audit with any corrections. On 2/25/26 at approximately 1:12 PM, the administrator stated that the human resource director had a ServSafe certification. On 2/25/26 at 1:19 PM, the administrator stated a fill-in cook was coming from within the company to prepare the dinner meal and the cook had a ServSafe certification. The administrator was asked to provide the certification. These concerns were discussed at the end of day meeting on 2/25/26 at 3:05 PM with the administrator, director of nursing, regional director of clinical services, unit manager #1, unit manager #2, unit manager #3, and assistant director of nursing. The RD provided the diet audit and stated there were 2 errors and the tray ticket system was updated. A review of the diet audit disclosed that 34 residents had a medical provider order for consistent carbohydrate diets and one resident had a medical provider order for a renal diet. On 2/25/26 at 4:13 PM, the administrator provided a ServSafe certification for the fill-in cook that was to prepare the evening meal. No further information was provided to the survey team prior to exit on 2/26/26.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide activities of daily living care for 7 of 25 resident's, Resident #6, #84, #42, #51, #62, #67, and #116.The findings included:1. For Resident #6, the facility staff failed to provide nail care. Resident #6 was observed to have long, jagged fingernails with debris present under the nails. Resident #6's diagnoses included sepsis, and chronic pulmonary edema. Section C (cognitive patterns) of Resident #6's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 01/30/26 included a brief interview for mental status (BIMS) score of 8, indicating Resident #6 was moderately impaired in cognitive skills for daily decision making. Section GG (functional abilities) was coded to indicate this resident required substantial/maximal assistance for personal hygiene. Resident #6's comprehensive care plan included the intervention remind the resident to use their call light to ask for assistance with activities of daily living. On 02/24/26 at 12:21 p.m., during an interview with Resident #6 their fingernails were observed to be long, jagged, with debris present. Resident #6 stated he did not like them that long and he had asked the staff to cut them and they said they would, but that time never comes. On 02/25/2026 at 8:45 a.m., Resident #6's fingernails were observed to be long with debris present under the nails. On 02/25/26 at 3:05 p.m., during an end of the day meeting with the Administrator, Director of Nursing, Regional Nurse, Assistant Director of Nursing (ADON), and Licensed Practical Nurses #7, #8, and #9 the issue regarding resident #6's nail care was reviewed. On 02/25/26 at 4:56 p.m., the ADON documented Nails trimmed and cleaned by ADON, per rsd [resident] request. On 02/25/26 the facility staff provided the survey team with a copy of their policy titled, Fingernails/Toenails. This policy read in part, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming . On 02/26/2026 at 2:55 p.m., during an interview with Resident #6 this resident stated the facility staff had trimmed their nails. No further information regarding this issue was provided prior to the exit conference. 2. For Resident #84, the facility staff failed to ensure the resident was offered a shower and/or full bath at least twice per week. Resident #84's diagnosis list indicated diagnoses that included, but were not limited to, chronic respiratory failure with hypoxia, atherosclerotic heart disease, history of transient ischemic attack, congestive heart failure, chronic obstructive pulmonary disease, morbid obesity, bilateral primary osteoarthritis of hips, shortness of breath, and muscle weakness. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 2/4/26 assigned the resident a brief interview for mental status (BIMS) summary score of 6 out of 15 for cognitive abilities indicating the resident was severely impaired in cognition. On 2/24/26 at 2:15 PM during an interview with Resident #84, the resident stated they missed their shower yesterday (2/23/26) due to having a room change and they would like to have a shower. A review of Resident #84's comprehensive person-centered care plan disclosed a focus which read in part, .Personal Hygiene.the resident requires assistance with their.personal hygiene. An intervention associated with the focus read in part, .Provide assistance with personal hygiene and grooming as needed. On 2/24/26 at 3:51 PM, licensed practical nurse #9 (LPN#9) was interviewed. LPN#9 was informed Resident #84 did not receive a shower on 2/23/26 and wanted a shower. LPN#9 stated they would take care of this. On 2/25/26 at approximately 9:30 AM, LPN#9 stated Resident #84 received a shower yesterday (2/24/26). Requested and received shower/bathing records for Resident #84. Resident #84 was admitted to the facility on [DATE]. A review of the shower/bathing records disclosed the resident received a shower on 2/12/26 and 2/24/26. The shower records contained no indications of refusals of showers, receiving bed baths, or receiving partial bed baths. On 2/26/26 at 2:35 PM, LPN#9 provided an email dated 2/26/26 from certified nursing assistant #5 (CNA#5) which read in part, .I forgot to document bath for [Resident #84] on 2/4/26 and 2/14/26.I had asked her a couple of those days and she stated she didn't feel up to it. It was usual for her to refuse to get in the shower at that point, so when taking her to the bedside commode, I'd wipe her down with a wet soapy rag.I tried to get her a little freshened up, even if it isn't a full shower.charting last minute baths slip {sic} my mind. This concern was discussed at the pre-exit meeting on 1/26/26 at 4:30 PM with the administrator, director of nursing, regional director of clinical services #1, regional director of clinical services #2, unit manager #1, assistant director of nursing, and unit manager #2. Requested and received a facility policy titled, Shower/Tub Bath which read in part, .Procedures.1. Qualified nursing staff will provide a bed bath to the resident as needed. At a minimum, the resident will be offered at least 2 full baths or showers per week.Documentation – 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath.5. If the resident refused the shower/tub bath, the reason(s) why and interventions taken.Reporting – 1. Notify the licensed nurse if the resident refuses the shower/tub bath. No further information was provided to the survey team prior to exit on 2/26/26. 3. For Resident #42 the facility staff failed to provide nail care and showers. Resident #42's clinical record listed diagnoses which included but not limited to need for assistance with personal care. Resident #42's most recent minimum data set with an assessment reference date of 02/03/26 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Section GG, functional abilities, coded the resident as needing substantial/maximal assistance with shower/bathe self, and as needing partial/moderate assistance with personal hygiene. Resident #42's comprehensive care plan was reviewed and contained a plan for Personal Hygiene/Dental: the resident requires assistance with their dental care and personal hygiene. Interventions for this care plan include Provide assistance with personal hygiene and grooming as needed. Resident #42 was interviewed on 02/24/26 at 4:40 pm. Resident stated she doesn't get her showers on time, sometimes doesn't get one for a week at a time. Resident stated, Not getting a shower aggravates me, I like to be clean. They have a shower girl here, but they use her for other things so she don't get to our showers. Resident's toenails were observed to be long and curling over the end of her toes. Resident stated, My toenails need to be cut now, but that doesn't bother me as much as not getting a shower. During an end of day meeting on 02/25/26 at 3:05 pm, director of nursing (DON) was asked who is responsible for nail care, and DON responded the assistant director of nursing. On 02/26/26 at 9:10 am, DON was again asked who is responsible for providing toenail care, and DON stated the certified nurse's aide's or shower team can clean and file, nurse's do the trimming. DON was asked how often this should be done, and DON stated nails should be cleaned and filed with every shower and trimmed as needed. Requested and provided with Resident #42's shower/bath records for the months of January and February 2026. These records indicated that the resident had received three showers and one bed bath in January, and three showers and three bed baths in February. Shower records indicate that resident went from 01/26/26 until 02/12/26 without a full shower. During this time, records indicate that resident received two bed baths. Requested and was provided with facility policies entitled Shower/Tub Bath and Fingernails/Toenails. The shower policy read in part, 1. Qualified nursing staff will provide a bed bath to the resident as needed. At a minimum, the resident will be offered at least 2 full baths or showers per week. The fingernail/toenail policy read in part, The purpose of this procedure are to clean the nail bed, to keep the nails trimmed, and to prevent infections. 1. Routine nail care may be performed by nursing staff and/or qualified activity team members. 3. Nail care includes daily cleaning and regular trimming. The concern of not providing showers and nail care for Resident #42 was discussed with the administrator, DON, assistant DON, regional director of clinical services and two (2) unit managers on 02/26/26 at 4:30 pm. No further information was provided prior to exit. 4. For Resident #51 the facility staff failed to provide nail care. Resident #51's clinical record listed diagnoses which included but not limited to type 2 diabetes mellitus without complications and need for assistance with personal care. Resident #51's most recent minimum data set with an assessment reference date of 12/18/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #51's comprehensive care plan was reviewed and contained a plan for Maintenance: the resident is a long-term care and requires assistance with their ADL's (activities of daily living) related to CVA (cerebrovascular accident) with left sided weakness. Resident #51 was interviewed on 02/25/26 at 1:30 pm. Resident stated that podiatry hasn't been in since June of 2025. Resident's toenails observed to be long. Resident stated that her mother will trim her toenails when she visits. Resident stated, My toenails sometimes start cutting into the toe next to them. During an end of day meeting on 02/25/26 at 3:05 pm, director of nursing (DON) was asked who is responsible for nail care, and DON responded the assistant director of nursing. On 02/26/26 at 9:10 am, DON was again asked who is responsible for providing toenail care, and DON stated the certified nurse's aide's or shower team can clean and file, nurse's do the trimming. DON was asked how often this should be done, and DON stated nails should be cleaned and filed with every shower and trimmed as needed. Requested and was provided with a facility policy entitled Fingernails/Toenails which read in part, The purpose of this procedure are to clean the nail bed, to keep the nails trimmed, and to prevent infections. 1. Routine nail care may be performed by nursing staff and/or qualified activity team members. 3. Nail care includes daily cleaning and regular trimming. The concern of not providing showers and nail care for Resident #51 was discussed with the administrator, DON, assistant DON, regional director of clinical services and two (2) unit managers on 02/26/26 at 4:30 pm. No further information was provided prior to exit. 5. For Resident #62 the facility staff failed to provide nail care. Resident #62's clinical record listed diagnoses which included but not limited to unspecified dementia. Resident #62's most recent minimum data set with an assessment reference date of 12/30/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #62's comprehensive care plan was reviewed and contained a plan for Personal Hygiene/Dental: the resident requires assistance with their dental care and personal hygiene. Interventions for this plan include Provide assistance with personal hygiene and grooming as needed. Resident #62 was observed at the nurse's station on 02/25/26 at 8:00 am. Resident was asking about having her toenails trimmed, stating they were long and hurting her. Resident's toenails were observed on 02/25/26 at 1:15 pm. Resident's nails were observed to be long, thick and ragged. Resident #62 stated, My toenails haven't been cut in pretty close to a year. They are too long and the strings on my pajamas get stuck in them and it hurts. I'm tired of everybody telling me they will do something, but nobody ever does. During an end of day meeting on 02/25/26 at 3:05 pm, director of nursing (DON) was asked who is responsible for nail care, and DON responded the assistant director of nursing. On 02/26/26 at 9:10 am, DON was again asked who is responsible for providing toenail care, and DON stated the certified nurse's aide's or shower team can clean and file, nurse's do the trimming. DON was asked how often this should be done, and DON stated nails should be cleaned and filed with every shower and trimmed as needed. Requested and was provided with a facility policy entitled Fingernails/Toenails which read in part, The purpose of this procedure are to clean the nail bed, to keep the nails trimmed, and to prevent infections. 1. Routine nail care may be performed by nursing staff and/or qualified activity team members. 3. Nail care includes daily cleaning and regular trimming. The concern of not providing showers and nail care for Resident #62 was discussed with the administrator, DON, assistant DON, regional director of clinical services and two (2) unit managers on 02/26/26 at 4:30 pm. No further information was provided prior to exit. 6. For Resident #67 the facility staff failed to provide nail care. Resident #67's clinical record listed diagnoses which included but not limited to unspecified dementia, unspecified severity, with mood disturbance. Resident #67's most recent minimum data set with an assessment reference date of 12/19/25 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Section GG, functional abilities, coded the resident as needing substantial/maximal assistance with personal hygiene. Resident #67's comprehensive care plan was reviewed and contained a plan for Maintenance: the resident is a long-term care or respite resident and requires assistance with their ADL's (activities of daily living) related to decline in status. Resident #67 was observed on 02/25/26 at 8:40 am. Resident was resting in bed. Resident's toenails were observed to be extremely long and ragged. Resident #67 was interviewed on 02/25/26 at 1:25 pm. Resident #67's toenails were observed to be very long, ragged, with dark debris observed under and around the nail bed of the left great toe. Resident stated her toe nails needed to be cut. Resident #67's fingernails were also observed to be long and ragged. Resident was asked if this bothers her, and resident stated, It don't bother me, but they are too long. During an end of day meeting on 02/25/26 at 3:05 pm, director of nursing (DON) was asked who is responsible for nail care, and DON responded the assistant director of nursing. On 02/26/26 at 9:10 am, DON was again asked who is responsible for providing toenail care, and DON stated the certified nurse's aide's or shower team can clean and file, nurse's do the trimming. DON was asked how often this should be done, and DON stated nails should be cleaned and filed with every shower and trimmed as needed. Requested and was provided with a facility policy entitled Fingernails/Toenails which read in part, The purpose of this procedure are to clean the nail bed, to keep the nails trimmed, and to prevent infections. 1. Routine nail care may be performed by nursing staff and/or qualified activity team members. 3. Nail care includes daily cleaning and regular trimming. The concern of not providing nail care for Resident #67 was discussed with the administrator, DON, assistant DON, regional director of clinical services and two (2) unit managers on 02/26/26 at 4:30 pm. No further information was provided prior to exit. 7. For Resident #116 the facility staff failed to provide nail care. Resident #116's clinical record listed diagnoses which included but not limited to respiratory conditions due to unspecified external agent. Resident #116's most recent minimum data set with an assessment reference date of 11/24/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #116's comprehensive care plan was reviewed and contained a plan for Personal Hygiene/Dental: the resident requires assistance with their dental care and personal hygiene. Resident #116 was interviewed on 02/25/26 at 1:10 pm. Resident #116's toenails were observed to be long, and resident stated, I usually go to podiatry, but I was in the hospital the last time I had an appointment, so I missed it. My daughter is checking on getting me another appointment. She is also checking to see if the facility will transport me, or if she has to. During an end of day meeting on 02/25/26 at 3:05 pm, director of nursing (DON) was asked who is responsible for nail care, and DON responded the assistant director of nursing. On 02/26/26 at 9:10 am, DON was again asked who is responsible for providing toenail care, and DON stated the certified nurse's aide's or shower team can clean and file, nurse's do the trimming. DON was asked how often this should be done, and DON stated nails should be cleaned and filed with every shower and trimmed as needed. Requested and was provided with a facility policy entitled Fingernails/Toenails which read in part, The purpose of this procedure are to clean the nail bed, to keep the nails trimmed, and to prevent infections. 1. Routine nail care may be performed by nursing staff and/or qualified activity team members. 3. Nail care includes daily cleaning and regular trimming. The concern of not providing nail care for Resident #116 was discussed with the administrator, DON, assistant DON, regional director of clinical services and two (2) unit managers on 02/26/26 at 4:30 pm. No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to include the resident and/or resident representative in reviews and/or revisions of the comprehensive person-centered care plan for (1) one of (25) twenty-five sample residents, Resident #50 and the facility staff failed to develop and implement a comprehensive person-centered care plan for (3) three of (25) sampled residents, Resident #116, Resident #11, and Resident #32. The findings included: 1. For Resident #50 the facility staff failed to include the resident and/or resident representative in reviews and/or revisions of the comprehensive person-centered care plan. Resident #50's diagnosis list indicated diagnoses that included, but were not limited to, depression, obstructive and reflux uropathy, chronic obstructive pulmonary disease, cardiomegaly, tachycardia, metabolic encephalopathy, weakness, and chronic respiratory failure with hypoxia. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 2/14/26 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities indicating the resident was cognitively intact. On 2/25/26 at 9:29 AM, during an interview with Resident #50, the resident could not recall being invited to care plan meetings. A review of Resident #50's clinical record did not disclose any evidence of the resident and/or resident's representative being invited to participate in care plan reviews. This concern was discussed at the end of day meeting on 2/25/26 at 3:05 PM with the administrator, director of nursing, regional director of clinical services, unit manager #1, unit manager #2, unit manager #3, and assistant director of nursing. On 2/26/26 at 11:03 AM, social worker #2 (SW#2) was interviewed and stated a care plan meeting had been scheduled for 3/3/26 with Resident #50. SW#2 agreed there was no evidence Resident #50 had been invited to attend a care plan meeting and stated the last documented evidence of the resident being invited to a care plan meeting was in May 2025. A review of a social services progress note dated 2/26/26 read in part, .Care Plan meeting scheduled for 3/3 (3/3/26) at 3:00 (3:00 PM) with resident and [family member relationship identification omitted]. Requested and received a facility policy titled, Care Planning – Comprehensive Person-Centered which read in part, .POLICY.To the extent practicable, the resident/resident representative will be provided with opportunities to participate in the care planning process.PROCEDURES.6. The resident/representative [s] is encouraged to participate in the development of and revisions to the resident's care plan.7. The resident/resident representative will be encouraged to: i. Participate in establishing the expected goals and outcomes of care.ii. Participate in the care planning process.10. Every effort will be made to schedule care plan discussions at the best time of the day for the resident/resident representative. No further information was provided to the survey team prior to exit on 1/26/26. 2. For Resident #116 the facility staff failed to develop and implement a care plan for self-administration of medications. Resident #116's clinical record listed diagnoses which included but not limited to respiratory conditions due to unspecified external agent. Resident #116's most recent minimum data set with an assessment reference date of 11/24/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #116's clinical record was reviewed and contained a physician's order summary which read in part, May keep Flonase and Chloroseptic at bedside. Resident #116's comprehensive care plan was reviewed, and no self-administration of medications care plan was located. Resident #116 was interviewed on 02/26/26 at 10:40 am and stated that she keeps her Flonase and Chloraseptic in the top drawer of her nightstand. Requested and was provided with a facility policy entitled, Care-Planning-Comprehensive and Person-Centered which read in part, A person-centered comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs shall be developed for each resident. 2. The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process. The concern of not developing and implementing a care plan for self-administration of medications for Resident #116 was discussed with the administrator, Director of Nursing (DON), assistant DON, regional director of clinical services, two (2) unit managers on 02/26/26 at 4:30 pm. No further information was provided prior to exit. 3. For Resident #11, the facility staff failed to develop a comprehensive care plan (CCP) for post-traumatic stress disorder (PTSD). Resident #11's diagnoses included PTSD, anxiety disorder, and depression. Section C (cognitive patterns) of Resident #11's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 02/09/26 included a brief interview for mental status (BIMS) score of 14, indicating Resident #11 was cognitively intact. A review of Resident #11's CCP revealed the facility staff had failed to develop a focus area for the diagnosis of PTSD. On 02/25/2026 at 11:42 a.m., Licensed Practical Nurse (LPN) #5 was interviewed regarding PTSD not being included on Resident #11's CCP. LPN #5 referred the surveyor to the social services department. On 02/25/2026 at 11:57 a.m., during an interview with the Assistant Social Worker this staff stated PTSD should have been on Resident #11's CCP. On 02/26/26 at 3:40 p.m., during a meeting with the Administrator, Director of Nursing, Nurse Consultants #1 and #2, Assistant Director of Nursing and Licensed Practical Nurses #8 and #9 the issue with the CCP not including PTSD was reviewed. Prior to the exit conference the facility staff provided the surveyor with an updated CCP that included PTSD. No further information regarding this issue was provided prior to the exit conference. 4. For Resident #32, the facility staff failed to develop a comprehensive care plan (CCP) for self-administration of medications. Resident #32's diagnoses included acute and chronic respiratory failure, chronic diastolic congestive heart failure, and diabetes. Section C (cognitive patterns) of Resident #32's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 02/06/26 included a brief interview for mental status (BIMS) score of 12 out of a possible 15 points, indicating Resident #32 was moderately impaired in cognitive skills for daily decision making. On 02/24/26 at 12:35 p.m., during an interview with Resident #32 an observation was made of a bottle of Systane eye drops on the top of Resident #32's over the bed table. Resident #32's clinical record included a provider order dated 10/22/25 for Systane eye drops instill one drop in both eyes two times a day for dry eye may leave at bedside. The surveyor was unable to find any evidence that the resident had been assessed for self-administration of medications or that this had been included in their CCP. No further information regarding this issue was provided prior to the exit conference.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide and/or review a baseline care plan (BCP) for 5 of 25 residents, Residents #6, #2, #13, #126, and #134 and failed to complete a BCP for 1 of 25 residents, Resident #84. The findings included:1. For Resident #6, the facility staff failed to provide the resident with a copy of their BCP. Resident #6's clinical record listed the resident as being their own responsible party. Diagnoses included sepsis and chronic pulmonary edema. Section C (cognitive patterns) of Resident #6's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 01/30/26 included a brief interview for mental status (BIMS) score of 8, indicating Resident #6 was moderately impaired in cognitive skills for daily decision making. During the clinical record review, the surveyor was unable to find evidence that Resident #6 was provided with a copy of their BCP. On 02/25/26 at 5:10 p.m., during an interview with Licensed Practical Nurse (LPN) #5 this nurse stated Resident #6's BCP was initiated on 01/27/26 and she had no proof anyone was provided with a copy. LPN #5 stated Resident #6's admission collection tool was closed, and she had no idea why. On 02/26/2026 at 2:55 p.m., Resident #6 was asked if the facility staff provided him with a copy of his BCP. Resident #6 stated not that I am aware of. On 02/26/26 at 3:40 p.m., during a meeting with the Administrator, Director of Nursing, Nurse Consultants #1 and #2, Assistant Director of Nursing, and Licensed Practical Nurses #8 and #9 the issue regarding the BCP not being provided to Resident #6 was reviewed. No further information regarding this issue was provided prior to the exit conference. 2. For Resident #2 the facility staff failed to provide the resident and/or resident representative with a summary and/or copy of a baseline care plan that was effective on 2/20/26. Resident #2's diagnosis list indicated diagnoses that included, but were not limited to, acute on chronic respiratory failure with hypoxia, atrial fibrillation, congestive heart failure, anxiety disorder, depression, intervertebral disc degeneration-lumbar region, obsessive-compulsive personality disorder, and chronic obstructive pulmonary disease. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 1/27/26 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities indicating the resident was cognitively intact. On 2/24/26 at 2:39 PM, during an interview with Resident #2, the resident did not recall getting a copy of the baseline care plan. A review of Resident #2's clinical record disclosed an admission Nursing Collection Tool dated 2/20/26. In Section Q Baseline Care Plan, section c. read in part, .Copy of baseline care plan and copy of medications have been given to the resident and/or responsible party. This section was not marked as being completed and was blank. This concern was discussed at the pre-exit meeting on 1/26/26 at 4:30 PM with the administrator, director of nursing, regional director of clinical services #1, regional director of clinical services #2, unit manager #1, assistant director of nursing, and unit manager #2. Requested and received a facility policy titled, Baseline Care Plans which read in part, .4. The resident and their representative will be provided with a summary of the baseline care plan. No further information was provided to the survey team prior to exit on 2/26/26. 3. For Resident #13 the facility staff failed to review the baseline care plan with the resident and/or resident representative and the facility staff failed to provide the resident and/or resident representative with a summary and/or copy of a baseline care plan that was effective on 1/28/26. Resident #13's diagnosis list indicated diagnoses that included, but were not limited to, psoas muscle abscess, sepsis due to streptococcus, atrial fibrillation, chronic kidney disease-stage 3, infrarenal abdominal aortic aneurysm, muscle weakness, and malnutrition. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 1/31/26, assigned the resident a brief interview for mental status (BIMS) summary score of 8 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. A review of Resident #13's clinical record disclosed an admission Nursing Collection Tool dated 1/28/26. In Section Q Baseline Care Plan, section b. read in part, .Baseline care plan has been reviewed with resident and/or responsible party. and section c. read in part, .Copy of baseline care plan and copy of medications have been given to the resident and/or responsible party. These sections were not marked as completed and were blank. This concern was discussed at the end of day meeting on 2/25/26 at 3:05 PM with the administrator, director of nursing, regional director of clinical services, unit manager #1, unit manager #2, unit manager #3, and assistant director of nursing. Requested and received a facility policy titled, Baseline Care Plans which read in part, .4. The resident and their representative will be provided with a summary of the baseline care plan. No further information was provided to the survey team prior to exit on 2/26/26. 4. For Resident #126, the facility staff failed to review the baseline care plan with the resident and/or resident representative and the facility staff failed to provide the resident and/or resident representative with a summary and/or copy of a baseline care plan that was effective on 2/5/26. Resident #126's diagnosis list indicated diagnoses that included, but were not limited to, surgical aftercare following surgery on the circulatory system, infection and inflammatory reaction due to cardiac valve prosthesis, presence of prosthetic heart valve, diabetes mellitus with hyperglycemia, chronic kidney disease, gastroparesis, and pleural effusion. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 2/9/26, assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. On 2/24/26 at 12:54 PM, Resident #126 and [family member #1] were interviewed. Both concluded that 2-3 days after the resident's admission the social worker and physical therapist met with them and [family member #1] stated they gave these two facility staff members a list of goals. Resident #126 and [family member #1] stated the physical therapist and the social worker did not give them a copy of a baseline care plan. A review of Resident #126's clinical record disclosed an admission Nursing Collection Tool dated 2/5/26. In Section Q Baseline Care Plan, section b. read in part, .Baseline care plan has been reviewed with resident and/or responsible party. and section c. read in part, .Copy of baseline care plan and copy of medications have been given to the resident and/or responsible party. These sections were not marked as completed and were blank. This concern was discussed at the end of day meeting on 2/25/26 at 3:05 PM with the administrator, director of nursing, regional director of clinical services, unit manager #1, unit manager #2, unit manager #3, and assistant director of nursing. Requested and received a facility policy titled, Baseline Care Plans which read in part, .4. The resident and their representative will be provided with a summary of the baseline care plan. No further information was provided to the survey team prior to exit on 2/26/26. 5. For Resident #134, the facility staff failed to review the baseline care plan with the resident and/or resident representative and the facility staff failed to provide the resident and/or resident representative with a summary and/or copy of a baseline care plan that was effective on 2/20/26. Resident #134's diagnosis list indicated diagnoses that included, but were not limited to, wedge compression fracture of first lumbar vertebra, displaced intertrochanteric fracture of right femur, congestive heart failure, chronic kidney disease-stage 3, atrial fibrillation, osteoarthritis, spondylosis of lumbar region, and muscle weakness. Resident #134's admission minimum data set (MDS) had not been completed during the time of the survey. A review of the resident's brief interview for mental status (BIMS) dated 2/24/26, disclosed a summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. On 2/24/26 at 12:33 PM, during an interview with Resident #134, the resident stated that facility staff had not reviewed or given a copy of a baseline care plan to the resident and/or the resident's representative. [Family member #2] stated some type of orientation would have been nice. On 2/25/26 at 5:01 PM, licensed practical nurse #5 (LPN#5) reviewed an admission Nursing Collection Tool dated 2/20/26 on the electronic clinical record. LPN#5 agreed Section Q-Baseline Care Plan containing section b. which read in part, .Baseline care plan has been reviewed with resident and/or responsible party. and section c. which read in part, .Copy of baseline care plan and copy of medications have been given to the resident and/or responsible party. were not completed and were blank. LPN#5 agreed the baseline care plan was not reviewed with, nor provided to the resident and/or the resident's representative. This concern was discussed at the pre-exit meeting on 1/26/26 at 4:30 PM with the administrator, director of nursing, regional director of clinical services #1, regional director of clinical services #2, unit manager #1, assistant director of nursing, and unit manager #2. Requested and received a facility policy titled, Baseline Care Plans which read in part, .4. The resident and their representative will be provided with a summary of the baseline care plan. No further information was provided to the survey team prior to exit on 2/26/26. 6. For Resident #84, the facility staff failed to develop a baseline care plan. Resident #84's diagnosis list indicated diagnoses that included, but were not limited to, chronic respiratory failure with hypoxia, atherosclerotic heart disease, history of transient ischemic attack, congestive heart failure, chronic obstructive pulmonary disease, morbid obesity, bilateral primary osteoarthritis of hips, shortness of breath, and muscle weakness. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 2/4/26 assigned the resident a brief interview for mental status (BIMS) summary score of 6 out of 15 for cognitive abilities indicating the resident was severely impaired in cognition. On 2/24/26 at 2:15 PM, Resident #84 was interviewed and did not recall reviewing and/or receiving a copy of a baseline care plan. A review of Resident #84's clinical record did not disclose any evidence of an admission Nursing Collection Tool that would include a baseline care plan. This concern was discussed at the pre-exit meeting on 1/26/26 at 4:30 PM with the administrator, director of nursing, regional director of clinical services #1, regional director of clinical services #2, unit manager #1, assistant director of nursing, and unit manager #2. Requested and received a facility policy titled, Baseline Care Plans which read in part, .Procedures.1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission.4. The resident and their representative will be provided with a summary of the baseline care plan. No further information was provided to the survey team prior to exit on 2/26/26.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to notify the office of the state long-term care ombudsman of a resident transfer/discharge for (1) one of (25) twenty-five sampled residents, Resident #13. The findings included:For Resident #13, the facility staff failed to notify the office of the state long-term care ombudsman of a transfer/discharge to a higher level of care on 1/30/26. Resident #13's diagnosis list indicated diagnoses that included, but were not limited to, psoas muscle abscess, sepsis due to streptococcus, atrial fibrillation, chronic kidney disease-stage 3, infrarenal abdominal aortic aneurysm, muscle weakness, and malnutrition. The most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 131/26, assigned the resident a brief interview for mental status (BIMS) summary score of 8 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. An order progress note dated 1/30/26 read in part, .May send to ER (emergency room at hospital) for evaluation/treatment related to Hgb 7 (A hemoglobin level of 7 g/dL (grams per deciliter) is a, medically significant, severe level of anemia indicating a critically low concentration of oxygen-carrying protein in the red blood cells) and severe left sided abdominal pain. Requested evidence that the office of the state long-term care ombudsman was notified of the transfer/discharge for Resident #13 on 1/30/26. On 2/26/26 at 12:27 PM, social worker #2 (SW#2) was interviewed and provided a transfer/discharge list of residents for the month of January 2026 and stated the list was printed today (1/26/26). Resident #13 was on the list of transfers/discharges. SW#2 stated the fax confirmation form is not kept and agreed there was no evidence the list was sent to the state long-term care ombudsman. This concern was discussed at the pre-exit meeting on 1/26/26 at 4:30 PM with the administrator, director of nursing, regional director of clinical services #1, regional director of clinical services #2, unit manager #1, assistant director of nursing, and unit manager #2. Requested, but did not receive a facility policy for transfer/discharge. No further information regarding this concern was presented to the survey team prior to the exit on 2/26/26.

Based on staff interview and facility document review the facility staff failed to provide 2 of 3 residents with the appropriate beneficiary notices, Residents #36 and #42. The findings included: The facility staff failed to provide Resident #36 with an Advance Beneficiary Notice of Non-Coverage (ABN) and failed to provide Resident #42 with a Notice of Medicare Non-coverage (NOMNC). Resident #36's diagnoses included sepsis and acute respiratory failure. Section C (cognitive patterns) of Resident #36's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 01/19/26 included a brief interview for mental status (BIMS) score of 15, indicating Resident #36 was cognitively intact. Resident #42's diagnoses included chronic systolic congestive heart failure and diabetes. Section C of Resident #42's quarterly MDS assessment with an ARD of 02/03/26 included a BIMS score of 15, indicating Resident #42 was cognitively intact. On 02/25/26, the surveyor requested from the Social Worker Assistant notices that were provided to Resident #36 and Resident #42 regarding their discharge from Medicare part A. On 02/26/26 at 9:10 a.m., during an interview with the Social Worker, this staff stated Resident's #36 and #42 were not given the appropriate notices. Resident #36 should have received an ABN and Resident #42 should have received a NOMNC. The Social Worker stated Resident #36 was provided with an ABN today. On 02/26/26 at 3:40 p.m., during a meeting with the Administrator, Director of Nursing, Nurse Consultants #1 and #2, Assistant Director of Nursing and Licensed Practical Nurses #8 and #9 the issue with the beneficiary notices not being provided to Residents #36 and #42 were reviewed. No further information regarding this issue was provided prior to the exit conference.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to assess 2 of 25 residents for self-administration of medications, Residents #32 and #116.The findings included:1. For Resident #32, the facility staff failed to assess the resident for self-administration of medications. Resident #32 had a provider order for Systane eye drops two times a day for dry eye may leave at bedside. Resident #32's diagnoses included acute and chronic respiratory failure, chronic diastolic congestive heart failure, and diabetes. Section C (cognitive patterns) of Resident #32's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 02/06/26 included a brief interview for mental status (BIMS) score of 12 out of a possible 15 points, indicating Resident #32 was moderately impaired in cognitive skills for daily decision making. On 02/24/26 at 12:35 p.m., during an interview with Resident #32 an observation was made of Systane eye drops, Voltaren cream, and Neosporin ointment on the residents over the bed table. Resident #32 stated she had to order the medications herself and the Voltaren was for her hip. Resident #32's clinical record included a provider order dated 10/23/25 for Systane eye drops instill one drop in both eyes two times a day for dry eye may leave at bedside. Resident #32's clinical record did not include orders for Voltaren or Neosporin ointment. Resident #32's clinical record did not include any evidence to indicate the resident had been assessed for self-administration of medications. On 02/25/26 at 3:05 p.m., during an end of the day meeting with the Administrator, Director of Nursing, Regional Nurse, Assistant Director of Nursing, and Licensed Practical Nurses #7, #8, and #9 the above issue was reviewed. On 02/25/26, the facility staff provided the survey team with a copy of their policy titled, Self-Administration of Medications and Treatments. This policy read in part, .As part of the overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities and choice to determine whether self-administering medications and/or treatments is clinically appropriate for the resident. On 02/26/26 the facility staff provided the surveyor with a document titled, Self Administration of Medications Safety Evaluation indicating the resident would like to self-administer Systane Ophthalmic Solution and indicated Resident #32 was appropriate to self-administer medications and/or treatments. This document was dated 02/25/26. No further information regarding this issue was provided to the survey team prior to exit conference. 2. For Resident #116 the facility staff failed to complete a self-administration of medication assessment prior to allowing resident to self-administer the medications Flonase nasal spray and Chloraseptic throat spray Resident #116's clinical record listed diagnoses which included but not limited to respiratory conditions due to unspecified external agent. Resident #116's most recent minimum data set with an assessment reference date of 11/24/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #116's clinical record was reviewed and contained a physician's order summary which read in part, May keep Flonase and Chloraseptic at bedside. Resident #116's electronic medication administration record for the month of February 2026 was reviewed and there was no documentation related to resident's Flonase or Chloraseptic. Resident #116's clinical record was reviewed on 02/25/26 and a self-administration of medications assessment was not located. On 02/26/26 at 8:15 am the director of nursing (DON) was asked to provide a self-administration of medication assessment for Resident #116. The self-administration of medication assessment was provided by the DON on 02/26/26 at 9:45 am and was dated 02/26/26 at 9:17 am. Resident #116 was interviewed on 02/26/26 at 10:40 am and stated that she keeps her Flonase and Chloraseptic in the top drawer of her nightstand. Requested and was provided with a facility policy entitled, Self-Administration of Medications and Treatments which read in part, 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities and choice to determine whether self-administering medications and/or treatments is clinically appropriate for the resident. 3. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, which may include (but not limited to) the resident's: a. Ability to read and understand medication labels/treatment instructions; b. Comprehension of the purpose and proper administration for his or her medication/treatments. c. Ability to remove medications and/or treatment supplies from a container d. Ability to recognize risks and major adverse consequences of his or her medications/treatments. 6. For self-administering residents, the nursing staff will determine who will be responsible for (the resident or the nursing staff) for documenting those medications were taken and/or that treatments were administered. 12. Nursing staff will review the self-administered medication/treatment record on each nursing shift, and they will transfer pertinent information to the medication/treatment administration record (MAR/TAR) appropriately noting that the doses were self-administered. The concern of not completing a self-administration of medications assessment prior to allowing Resident #116 to self-administer medications was discussed with the administrator, DON, assistant DON, regional director of clinical services, two (2) unit managers on 02/26/26 at 4:30 pm. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to safely store drugs and/or biologicals in a locked and secure manner for 2 of 25 residents, Resident #4 and #32.Joy1. For Resident #4, the facility nursing staff left hydrocortisone in the resident's room unattended.Resident #4's diagnoses included, Parkinson's disease, respiratory failure, and epilepsy.Section C (cognitive patterns) of Resident #4's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 02/13/26 included a brief interview for mental status (BIMS) score of 10, indicating Resident #4 was moderately impaired in cognitive skills for daily decision making.On 02/24/2026, during initial tour, the surveyor observed a white cream in a clear plastic medicine cup sitting on the top of an extended outlet box. On 02/24/2026, during an interview with Licensed Practical Nurse (LPN) #1 this staff stated the cream was hydrocortisone and she had placed it there. Resident #4's clinical record included a provider order dated 02/21/26 for hydrocortisone cream apply to right lower leg topically two times a day for 5 days. On 02/25/26 at 3:05 p.m., during an end of the day meeting with the Administrator, Director of Nursing (DON), Regional Nurse, Assistant Director of Nursing, and LPN's #7, #8, and #9 the above issue was reviewed. The DON stated the hydrocortisone should not have been left in the room.On 02/26/26, the facility staff provided the surveyor with evidence that they had provided LPN #1 with education regarding medications being left at the bedside.No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #32, the facility staff failed to safely store Voltaren and Neosporin ointment. Both medications were observed on the residents over the bed table unattended. Resident #32's diagnoses included acute and chronic respiratory failure, chronic diastolic congestive heart failure, and diabetes.Section C (cognitive patterns) of Resident #32's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 02/06/26 included a brief interview for mental status (BIMS) score of 12 out of a possible 15 points, indicating Resident #32 was moderately impaired in cognitive skills for daily decision making.On 02/24/26 at 12:35 p.m., Systane eye drops, Voltaren cream, and Neosporin ointment were observed on Resident #32's over the bed table. Resident #32 stated she had to order the medications herself and the Voltaren was for her hip. Resident #32's clinical record included a provider order for Systane eye drops two times a day for dry eye may leave at bedside. Resident #32's clinical record did not include orders for Voltaren or Neosporin ointment.On 02/25/26 at 8:58 a.m., the provider ordered Diclofenac (Voltaren) Sodium External Gel 1% apply to left hip topically four times a day for pain. On 02/25/26 at 3:05 p.m., during an end of the day meeting with the Administrator, Director of Nursing, Regional Nurse, Assistant Director of Nursing, and Licensed Practical Nurses #7, #8, and #9 the above issues were reviewed.On 02/26/26, the facility staff provided the survey team with a copy of their policy titled, Medication Storage. This policy read in part, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview and facility document review the facility staff failed to follow established infection control procedures.The findings included:During a medication pass and pour observation, observed the nurse touching medications with her bare hands. For Resident # 42 observed an incentive spirometer under the resident's bed, and for Resident #92, failed to bag CPAP (continuous positive airway pressure) mask. Linens were observed on the floor in room B-6 and A-6, A-bed side.On 02/25/26 at 8:00 am, while preparing to observe a medication pass and pour, registered nurse (RN) #2 was observed dispensing medication from the medication card into her bare hand and placing them in the medication cup. During the medication pass and pour observations, RN #2 removed a capsule from the medication cup with her bare hand, opened it and poured the contents into a cup of pudding.Linens were observed laying on the floor of room B-6 on 02/25/26 at 8:40 am. A wet washcloth was observed laying on the floor of room A-6 on 02/25/26 at 1:20 pm.An incentive spirometer was observed under the head of Resident #42's bed on 02/25/26 at 10:50 am and 4:00 pm and on 02/26/26 at 10:40 am.Resident #92's CPAP (continuous positive airway pressure) mask was observed lying on the nightstand, uncovered on 02/25/26 at 9:15 am and 4:00 pm and on 02/26/26 at 8:30 am and 10:45 am.Assistant director of nursing (ADON) was interviewed on 02/26/26 at 10:50 am regarding infection control issues. ADON stated that linens should not be left on the floor, and respiratory equipment should be bagged when not in use.Requested and was provided with facility policies entitled Medication Administration General Guidelines, Prevention of Infection-Laundry and Linen, and Prevention of Infection While Providing Respiratory Care. The policy for medication administration read in part, If breaking tablets is necessary to administer the proper dose, hands are washed with soap and water and gloves applied prior to handling tablets. The policy for linens read in part, Bagging and Handling Soiled Linen. 1. All soiled linen must be placed directly into a covered laundry hamper which can contain the moisture. The policy for respiratory care read in part, 1. Respiratory equipment, when not in use by the assigned resident, will be stored in a safe manner to prevent injury and/or contamination. 5. CPAP/BiPAP or other Mechanical Respiratory Support Devices. C. Equipment will be cleaned and disinfected between resident use and will be stored in a clean environment.The concern of not following established infection control practices was discussed with the administrator, DON, assistant DON, regional director of clinical services, two (2) unit managers on 02/26/26 at 4:30 pm.No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review the facility staff failed to follow up on pharmacy recommendations for 2 of 25 residents, Resident #5 and Resident #72.The findings included:1. For Resident #5 the facility staff failed to follow up on pharmacist recommendations. Resident #5's clinical record listed diagnoses which included but not limited to personal history of traumatic brain injury, major depressive disorder, and metabolic encephalopathy.Resident #5's most recent minimum data set with an assessment reference date of 12/14/25 assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Section N, medications, coded the resident as receiving antipsychotic, antidepressant, and antibiotic.Resident #5's clinical record was reviewed and contained a Pharmacy/Pharmacy Consultant Note dated 09/23/25 which read in part, Medication Regimen Review Completed (X) Recommendations written to provider, please see pharmacy report for detail. A pharmacy report related to this medication regimen review could not be located.The director of nursing (DON) was informed of the missing pharmacy report but could not locate it.Requested and received a facility policy entitled, Medication Regimen Review which read in part, Specific Procedures/Guidance 3. The Consultant Pharmacist will perform a medication regimen review (MRR) for every resident in the facility. 8. The pharmacist will report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.9. Any irregularities noted by the pharmacist during this review will be documented on a separate, written report that is sent to the attending physician and the facility's medical director and the director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. a) The consulting pharmacist will provide a copy of recommendations to the attending physician, medical director, and director of nursing within 5 working days of completion of the review. i) The attending physician and director of nursing will be contacted immediately if the pharmacist identifies an irregularity that requires urgent action to protect the resident. b) The director of nursing or designee will review the recommendations and the attending physician will be contacted for review and response. c)If the attending physician does not respond within 30 days, the medical director will be asked to review the recommendations and/or contact the attending physician. 10. The attending physician or medical director will document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.The concern of not following up on pharmacist recommendations was discussed with the administrator, DON, assistant DON, regional director of clinical services, two (2) unit managers on 02/26/26 at 4:30 pm.No further information was provided prior to exit. 2. For Resident #72 the facility staff failed to follow up on pharmacy recommendations.Resident #72's clinical record listed diagnoses which included but not limited to unspecified dementia, delusional disorders, psychotic disorder, and major depressive disorder.Resident #72's most recent minimum data set with an assessment reference date of 11/25/25 assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Section N, medications, coded the resident as receiving antipsychotics, antianxiety, antidepressants, opioids, and anticonvulsants.Resident #72's comprehensive care plan was reviewed and contained a plan for Psychoactive medication: the resident is at risk for complications related to psychoactive (anxiolytic, antidepressant) medications used secondary to diagnoses of: anxiety disorder, depression, insomnia.Resident #72's clinical record was reviewed and contained Pharmacy/Pharmacy Consultant Note dated 09/22/25 which read in part, Medication Regimen Review Completed (X) Recommendations written to provider, please see pharmacy report for detail. A pharmacy report related to this medication regimen review could not be located.The director of nursing (DON) was informed of the missing pharmacy report but could not locate it.Requested and received a facility policy entitled, Medication Regimen Review which read in part, Specific Procedures/Guidance 3. The Consultant Pharmacist will perform a medication regimen review (MRR) for every resident in the facility. 8. The pharmacist will report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.9. Any irregularities noted by the pharmacist during this review will be documented on a separate, written report that is sent to the attending physician and the facility's medical director and the director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. a) The consulting pharmacist will provide a copy of recommendations to the attending physician, medical director, and director of nursing within 5 working days of completion of the review. i) The attending physician and director of nursing will be contacted immediately if the pharmacist identifies an irregularity that requires urgent action to protect the resident. b) The director of nursing or designee will review the recommendations and the attending physician will be contacted for review and response. c)If the attending physician does not respond within 30 days, the medical director will be asked to review the recommendations and/or contact the attending physician. 10. The attending physician or medical director will document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.The concern of not following up on pharmacist recommendations was discussed with the administrator, DON, assistant DON, regional director of clinical services, two (2) unit managers on 02/26/26 at 4:30 pm.No further information was provided prior to exit.

Based on observations, resident interviews, staff interviews, and facility document review, the facility staff failed to address resident concerns regarding food services. The findings included:For the facility, the facility staff failed to adequately address resident complaints about the food. During the course of the survey, multiple resident interviews were conducted and multiple residents complained about the taste and temperature of the food and not having snacks available. A review of Resident Council Minutes dated 12/30/25 read in part, .Residents stated it is a waste of time to voice any concerns with dietary.nothing is getting done.still not receiving snacks A review of Resident Council Minutes dated 1/27/26 read in part, .Residents stated the eggs and vegetables are watery when served.Residents are stating the hot plates are not hot when meals arrive and their food is cold .will send an email to Dietary Manager to follow up with these concerns. A review of Resident Council Minutes dated 2/24/26 read in part, .All residents agree the food is cold when they receive it.All residents agree the trays are lacking condiments.All residents agree the food is hit or miss but mostly not good.All residents agree there are no snacks at night.stated phone is not being answered when they call for an alternate meal.Residents want to know when they will get soda back. A test tray was requested on 2/25/26 and was observed to be the last tray off the cart at 1:10 PM. The menu consisted of Swedish meatballs, egg noodles, and pacific blend vegetables. The meal was palatable and at a temperature that would have been enjoyed. These concerns were discussed at the end of day meeting on 2/25/26 at 3:05 PM with the administrator, director of nursing, regional director of clinical services, unit manager #1, unit manager #2, unit manager #3, and assistant director of nursing. On 2/26/26 the (4) four-unit pantries were observed and identified to have several out-of-date items with limited snacks available or for safe consumption by the residents. On 2/26/2026 at 9:06 AM, licensed practical nurse #8 (LPN#8) was interviewed and stated the kitchen staff are supposed to bring carts of snacks to stock the pantries, but they do not do this very often. The CNAs (certified nursing assistants) have to go to the kitchen to ask for snacks for the residents. LPN#8 stated the residents enjoy peanut butter and jelly sandwiches, oatmeal cream pies, and fudge rounds. LPN#8 agreed there is no bread or soup in the pantries for nursing staff to use for the residents. LPN#8 stated they (nursing staff) keep snacks in her office such as peanut butter crackers, cookies, and left-over fruit cups. LPN#8 stated at one point, nursing staff members were bringing in their own peanut butter, jelly, and bread to make the residents sandwiches. LPN#8 stated nursing staff also have to ask for Magic Cups for the residents that have an order for them, as they are not kept in the unit pantries. On 2/26/26 at 9:35 AM, the facility administrator (ADM) was interviewed and asked about the concerns of the residents and Resident Council regarding the food at the facility. The ADM agreed food had been mentioned in Resident Council and the previous dietary manager met with the Resident Council about the food, but he did not have any notes or documentation from the previous dietary manager regarding the response to the complaints. No further information was provided to the survey team prior to exit on 2/26/26.

Based on observations and staff interviews, the facility staff failed to provide adequate training and skill sets for dietary staff to carry out the functions of the food and nutrition services of the facility. The findings included: For the facility, the facility staff failed to ensure dietary employees received adequate training and skill sets to safely and effectively carry out meal preparation and other food and nutrition services of the facility. Entered the facility kitchen on 2/25/26 at 11:45 AM to observe the lunch meal tray line. Other staff #3 (OS#3) was observed to be preparing resident trays with visible facial hair. OS#3 was not observed to be wearing a beard net. When asked why a beard net was not utilized, the regional director of dining services (RDDS) requested OS#3 to utilize a beard net and OS#3 place a beard net over his facial hair. On 2/25/26 at 12:00 PM, other staff #4 (OS#4), other staff #5 (OS#5), and other staff #6 (OS#6) entered the facility kitchen to begin their scheduled shift and proceeded to the hand-washing sink. None of the dietary employees wore a hair restraint. OS#6 had visible facial hair and a beard net was not visible. When asked why they entered the facility kitchen without hair restraints and beard nets, OS#4 stated there are no hair restraints outside of the kitchen door for them to use. OS#5 stated this is how they have been entering the kitchen. OS#6 stated he was never educated on hair nets or beard restraints and he had started in the kitchen in February 2026. On 2/25/26 at 12:06 PM, the RDDS stated he was going to put in a work order to have hair and beard restraints provided outside of the facility kitchen entrance for the dietary employees to utilize prior to entering the facility kitchen. RDDS also stated he would provide education for the dietary staff, as they had not had a dietary manager for a few weeks. On 2/25/26 at 12:14 PM, other staff #2 (OS#2) who was the cook, was observed to put oven mitts over her gloves to remove a pan of egg noodles from the steamer to add to the serving station. OS#2 replaced the pan of egg noodles and then removed the oven mitts. The RDDS reminded OS#2 to change gloves. OS#2 was not observed to practice hand hygiene and put on new gloves. On 2/25/26 at 12:26 PM, OS#2 was observed to take a break for a drink of water. OS#2 changed gloves and did not practice hand hygiene. The RDDS asked OS#2 to wash hands and OS#2 washed her hands and put on new gloves. On 2/25/26 at 12:44 PM, OS#2 was observed to put oven mitts over her gloves to add more egg noodles to the serving station. OS#2 removed the oven mitts and changed gloves but did not practice hand hygiene. These concerns were discussed at the end of day meeting on 2/25/26 at 3:05 PM with the administrator, director of nursing, regional director of clinical services, unit manager #1, unit manager #2, unit manager #3, and assistant director of nursing. On 2/26/26 at 9:35AM the facility administrator (ADM) was interviewed. The ADM stated the dietary manager quit on 2/6/26 and 3-4 other dietary staff quit not long afterwards. The facility has hired new dietary staff and they just hired a new cook and dietary aide. The ADM stated an offer to a new dietary manager was about to be made. The ADM agreed that the RDDS was in the process of establishing training for the dietary employees. No further information was provided to the survey team prior to exit on 2/26/26.

Based on observations, staff interview, and facility document review, the facility staff failed to employ an infection preventionist with the required training prior to assumption of the role.The findings included:On 9/5/25, members of the survey team made multiple observations of residents requiring EBP (enhanced barrier precautions) and/or TBP (transmission-based precautions) without proper notification/signage and PPE available to staff, residents and/or visitors. On 9/5/25 at 2:54 PM-surveyors met with interim administrator (ADM), interim director of nursing (DON), regional director of clinical services and licensed practical nurse #1 (LPN#1). This surveyor inquired about the facility IP (infection preventionist) and the DON informed surveyor the previous IP left employment at the facility on 7/4/25 and she and the ADM are acting IPs and both agreed neither of them has an IP certification. LPN#1 has an IP certification from 2022 and she agreed that she does not perform the IP role at the facility. Surveyor requested evidence of staff education on infection control procedures for EBP/TBP and was provided evidence of staff education. Surveyor requested and received a facility job description for Infection Preventionist which read in part, .Infection Prevention Responsibilities.Education.Be able to obtain certification in Infection Control. No further information was provided to the survey team prior to exit on 9/5/25.

Based on observation, staff interview, resident interview and facility document review the facility staff failed to provide a reasonable accommodation of needs for 1 of 16 residents, Resident #15.The findings included:For Resident #15 the facility staff failed to answer the resident's call bell in a timely manner. Resident #15's clinical record listed diagnoses which included but not limited to chronic obstructive pulmonary disease, dysphagia, and major depressive disorder.Resident #15's most recent minimum data set with an assessment reference date of 07/17/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact.Surveyor spoke with Resident #15 on 09/05/25 at 11:05 am regarding call bell response times. Resident stated that call bell response has been addressed at resident council meetings, but times never get any better, and they have waited up to an hour after ringing call bell. Resident stated that their call bell is currently on, and they thought surveyor was facility staff coming in to answer the call bell. Surveyor asked resident how long their call bell had been on, and resident stated, about 5 minutes. Surveyor thanked resident and exited room. Surveyor observed light over resident's door for call bell on. Surveyor walked to end of hallway and observed several staff at nurse's station and could hear call bell from behind nurse's station. Surveyor waited until 11:20 am, observing multiple staff members walking by Resident #15's room without acknowledging call bell. At 11:20 am, surveyor spoke with assistant director of nursing (ADON) regarding call bell response times, and what their expectations are for response time. ADON stated their expectation would be 5ish minutes or so. Surveyor informed ADON of resident's call bell being on for at least 20 minutes. ADON exited their office, walked by Resident #15's room, and went to the nurse's station and asked which certified nurse's aide was responsible for Resident #15.Surveyor spoke with the director of nursing (DON)/interim administrator on 09/05/25 at 12:20 pm regarding call bell response times. DON stated their expectations would be 20 minutes or less. Surveyor asked DON who can answer call bells and DON stated anyone who sees the light on can answer, because resident's needs are not always clinical. DON stated that resident's light should not be turned off until resident's needs are met. Surveyor informed DON of observing several staff walking by Resident #15's room without acknowledging call bell.Surveyor requested and was provided with a facility policy entitled, Answering the Call Light which read in part, The facility will maintain a functional call light system and will make all reasonable efforts to ensure timely response to the resident's requests and needs. DEFINATIONS: 'Timely Response': is not defined by a 'pre-set' measure of minutes but rather is defined that the response time was appropriate t situation and/or need. Response time varies based on each situation and is impacted from the resident's need and perception/understanding of the urgency and time lapse. General Guidelines-1. Call lights may be answered by any staff member; if the resident needs assistance that cannot be provided by the staff member answering the light, the staff member will promptly notify a staff member who can assist the resident.The concern of not answering the resident's call bell in a timely manner was discussed with DON, ADON, regional director of clinical services, UM/LPN #1, UM/LPN #3, and UM/LPN #4 on 09/05/25 at 3:35 pm. No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to follow the medical provider orders for medication administration for 1 of 16 sampled residents (Resident #6). The findings included:For Resident #6, the facility staff failed to administer the oral medication, Cyclobenzaprine as ordered by the medical provider. Cyclobenzaprine is a muscle relaxant used to treat skeletal muscle conditions such as pain and injury. Resident #6's diagnosis list indicated diagnoses, which included, but not limited to Encephalopathy, Hemiplegia and Hemiparesis, Congestive Heart Failure, Epilepsy, Multiple Rib Fractures Left Side, Fracture of Nasal Bones, Fracture of Left Thumb, and Fracture of Shaft of Left Clavicle. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/23/25 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #6's clinical record included a medical provider order for Cyclobenzaprine HCL 10 mg by mouth three times a day for muscle spasms. A review of Resident #6's September 2024 Medication Administration Record (MAR) revealed an omission for the administration of Cyclobenzaprine on 9/08/24 at 6:00 AM. On 9/05/25 at 12:25 PM, surveyor spoke with the Interim Administrator concerning the Cyclobenzaprine omission. She stated the medication was not signed off and she would assume that meant it was not given. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/25.

Based on observation, staff interview, resident interview, clinical record review and facility document review the facility staff failed to follow and established infection control program for 3 of 10 residents, Resident #15, Resident #12, and Resident #16.The findings included:1.For Resident #15 the facility staff failed to provide and don personal protective equipment (PPE) while providing incontinence care. Resident #15's clinical record listed diagnoses which included but not limited to personal history of urinary (tract) infections and resistance to multiple antimicrobial drugs. Resident #15's most recent minimum data set with an assessment reference date 07/17/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #15's comprehensive care plan was reviewed and contained a plan for ISOLATION: the resident requires Enhanced Barrier precautions (EBP) due to colonization of MDRO (multi drug-resistant organism). Interventions for this plan include appropriate PPE (personal protective equipment) per policy. Resident #15's clinical record was reviewed and contained a physician's order summary which read in part, Enhanced Barrier precautions due to MDRO colonization. Surveyor observed Resident #15's room from hallway on 09/05/25 at 1:15 pm and no EBP signage was seen, nor was any PPE observed to be in the general area of resident's room. Surveyor went to speak with Resident #15 on 09/05/25 at 1:20 pm and observed certified nurse's aide (CNA) #4 and CNA #5 providing incontinence care for resident. Both CNAs were wearing gloves, but neither one was wearing a gown. Surveyor spoke with CNA #4 and CNA #5 on 09/05/25 at 1:55 pm. Surveyor asked CNAs what type of PPE they were wearing while caring for Resident #15, and both stated they were wearing gloves. Surveyor asked both CNA's if they had been wearing a gown, and both stated they were not. CNA #4 stated, Nobody told me I was supposed to. Surveyor asked CNA's if they knew that resident was on enhanced barrier precautions, and both stated they did not. CNA #5 stated, I always dress out when I know someone is on precautions, I have a baby at home and then asked if there is a sign for EBP. Surveyor requested and was provided with a facility policy entitled Enhanced Barrier Precautions (EBP) Process which read in part, To ensure proper implementation of Enhanced Barrier Precautions (EBP) to prevent the spread of multidrug-resistant organisms (MDROs) while maintaining resident dignity. Procedure: 1. Identification of Resident on EBP: *When a resident is determined to require EBP, the designated staff member (e.g., nurse or infection preventionist) will initiate the protocol. 2. Visual Identification: *A colored dot sticker will be placed on the nameplate outside the resident's door to discretely indicate EBP status. *This ensures staff awareness without compromising resident privacy. 3. Resident Room Signage: *An EBP sign will be hung over the resident's bed rather than on the door to protect their dignity while ensuring compliance. 4. EBP Supply Storage: *Gowns and other necessary EBP supplies with be stored on the linen carts located on the unit. *Staff must ensure adequate supply availability and replenish as needed .5. *All staff must follow EBP guidelines, including donning appropriate PPE (gowns and gloves) before performing high-contact resident care activities .7. Education and Reinforcement: *Staff will receive ongoing education on EBP, including when and how to implement precautions . Surveyor observed Resident #15's room on 09/05/25 at 2:05 pm. Surveyor observed a green dot sticker on the resident's nameplate and EBP sign above the resident's bed. Surveyor observed two linen carts on the unit on 09/05/25 at 2:10 pm. Neither linen cart contained PPE. Surveyor spoke with Resident #15 on 09/05/25 at 2:15 pm. Surveyor asked Resident #15 is staff were wearing gowns while providing care for them, and resident stated, No, why would they? Surveyor observed the two linen carts along with unit manager, licensed practical nurse (LPN) #1 on 09/05/25 at 2:40 pm. LPN#1 confirmed there was no PPE on either cart. The concern of not following and established infection control plan was discussed with the DON/interim administrator, assistant director of nursing, regional director of clinical services, LPN #1, LPN #3, and LPN #4 on 09/05/25 at 3:35 pm. No further information was provided prior to exit. 2. For Resident #12 the facility staff failed to follow the facility established Enhanced Barrier Precautions (EBP) process. Resident #12's clinical record included diagnoses which included but not limited to urinary tract infection, site not specified. Resident #12's most recent minimum data set with an assessment reference date of 08/29/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #12's comprehensive care plan was reviewed and contained a care plan for Catheter: .Catheter for post op urinary retention until follow up. Interventions for this care plan included enhanced barrier precautions. Resident #12's clinical record was reviewed and contained a physician's order summary which read in part, Enhanced Barrier Precautions secondary to Foley Catheter. Resident #12's room was observed on 09/05/25 at 2:10 pm. There was no sticker on the nameplate, nor any signage in the room to indicate that resident is on EBP. Surveyor requested and was provided with a facility policy entitled Enhanced Barrier Precautions (EBP) Process which read in part, To ensure proper implementation of Enhanced Barrier Precautions (EBP) to prevent the spread of multidrug-resistant organisms (MDROs) while maintaining resident dignity. Procedure: 1. Identification of Resident on EBP: *When a resident is determined to require EBP, the designated staff member (e.g., nurse or infection preventionist) will initiate the protocol. 2. Visual Identification: *A colored dot sticker will be placed on the nameplate outside the resident's door to discretely indicate EBP status. *This ensures staff awareness without compromising resident privacy. 3. Resident Room Signage: *An EBP sign will be hung over the resident's bed rather than on the door to protect their dignity while ensuring compliance. 4. EBP Supply Storage: *Gowns and other necessary EBP supplies with be stored on the linen carts located on the unit. *Staff must ensure adequate supply availability and replenish as needed .5. *All staff must follow EBP guidelines, including donning appropriate PPE (gowns and gloves) before performing high-contact resident care activities .7. Education and Reinforcement: *Staff will receive ongoing education on EBP, including when and how to implement precautions . Surveyor observed two linen carts on the unit on 09/05/25 at 2:10 pm. Neither linen cart contained PPE. Surveyor observed the two linen carts along with unit manager, licensed practical nurse (LPN) #1 on 09/05/25 at 2:40 pm. LPN #1 confirmed there was no PPE on either cart. The concern of not following the facility established Enhanced Barrier Precautions (EBP) process was discussed with the DON/interim administrator, assistant director of nursing, regional director of clinical services, LPN #1, LPN #3, and LPN #4 on 09/05/25 at 3:35 pm. No further information was provided prior to exit. 3. For Resident #16 the facility staff failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infection by failing to follow the facility Transmission-Based Precautions (TBP) process for the resident due to an active infection of Acinetobacter (a common environmental bacterium that can cause various infections, including UTIs, and can pose a serious health threat, especially in healthcare settings due to its increasing antibiotic resistance) in the urine. Resident #16's diagnosis list indicated diagnoses, which included, but not limited to Venous Thrombosis and Embolism, Edema, Overactive Bladder, Hypertension, Chronic Pain, Metabolic Encephalopathy, Atrial Fibrillation, Urinary Tract Infection, and Weakness. The most recent MDS (minimum data set) with an assessment reference date (ARD) of 8/19/25 assigned the resident a brief interview for mental status (BIMS) summary score of 11 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. A review of the clinical record disclosed a medical provider order with a start date of 8/8/25 which read in part, “…Contact isolation for positive Acinetobacter in the urine…” A review of the person-centered comprehensive care plan revealed a focus which read in part, “…ISOLATION…Contact isolation precautions due to VRE (Vancomycin-Resistant Enterococci-a type of antibiotic-resistant infection enterococcus bacteria that can cause infections in healthcare settings)…” An intervention related to the focus read in part, “…appropriate PPE (personal protective equipment) per policy…” On 9/5/25 at 1:42 PM, surveyor observed Resident #16 and did not observe the resident's room to have any signage or PPE available outside the room. On 9/5/25 at 2:12 PM, surveyor observed certified nursing assistant #3 (CNA#3) enter and exit Resident #16's room without donning or doffing appropriate PPE. On 9/5/25 at 2:15 PM, surveyor spoke with licensed practical nurse #5 (LPN#5) and inquired if Resident #16 was on precautions and she informed surveyor she believed the resident to be on EBP (enhanced barrier precautions) because the resident had a catheter. Surveyor and LPN#5 reviewed Resident #16's medical provider orders together and the orders disclosed Resident #16 was on contact isolation (TBP) with an order start date of 8/8/25. Surveyor asked LPN#5 the protocol for someone on TBP and she stated an isolation cart should be placed outside of door, PPE should be available, and a sign should be placed on the door for residents on TBP. On 9/5/25 at 2:18 PM, surveyor observed a male nursing staff member sitting at Resident #16's bedside without PPE and surveyor observed licensed practical nurse #3 (LPN#3) enter Resident #16's room without donning PPE. Surveyor spoke with LPN#3 and informed her Resident #16 is on contact precautions, she stated she would take care of this right away. This concern was discussed on 9/5/25 at 2:54 PM in a meeting with interim administrator, interim director of nursing, regional director of clinical services, and licensed practical nurse #1. Regional director of clinical services informed the survey team that the issues are corrected now and there are signs and PPE carts available outside the resident rooms. Surveyor requested and received a facility policy titled, “Transmission-Based Precautions” which read in part, “…The facility will ensure systems and processes are in place for the prevention and spread of infectious diseases…Contact Precautions may be implemented for resident's known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment…1. Signs will be placed outside to each resident's room requiring transmission-based precautions…the signs will identify the type of PPE and special instructions…2. An adequate supply of PPE will be accessible and maintained outside of each resident room for staff and visitor use…” No further information was provided to the survey team prior to exit on 9/5/25.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to provide Activity of Daily Living (ADL) care for 5 of 18 dependent care residents, Resident's #2, #1, #12, #13 and #17. The findings included: 1. For Resident #2, the facility staff failed to provide ADL care regarding bathing. Resident #2 was at the facility for 21 days. During this 21 day timeframe the facility staff documented the resident had received 1 shower. This was a closed record review. Resident #2's diagnoses included, but were not limited to, Alzheimer's disease, muscle weakness, depressive disorder, and dementia. Section C (cognitive patterns) of Resident #2's admission minimum data set (MDS) assessment with and assessment reference date (ARD) of 11/02/23 included a brief interview for mental status (BIMS) score of 3 out of a possible 15 points. Section GG (functional abilities and goals) was coded to indicate Resident #2 was dependent in the area of shower/bathe self. Resident #2's comprehensive care plan included the focus area has ADL care self-care performance deficit. Interventions included physical assist as needed for ADL's. A review of Resident #2's clinical record revealed Resident #2 received a shower on 10/30/23, a partial bath on 10/29/23, 10/30/23, and 11/07/23. A bed bath was documented for 11/10/23 and 11/14/23. The facility staff documented the resident refused on 11/17/23. On 01/02/24 at 3:30 p.m., during a meeting with the Director of Rehab this staff stated the rehab department had worked with this resident on the components of bathing but did not provide any actual bath(s). On 01/04/24 at 11:50 a.m., during a meeting with the Administrator, Nurse Consultant, and DON the issue regarding Resident #2's ADL assistance regarding bathing was reviewed. The DON stated the residents should receive 2 showers/baths a week at a minimum. The facility staff provided the survey team with a copy of a policy titled, Activities of Daily Living (ADLs). This policy read in part, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .each resident shall receive tub or shower baths as often as needed, but not less than twice weekly or as required by state law . No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #1, the facility staff failed to provide ADL care regarding bathing. In a 30-day period Resident #1 had not received any baths. Resident #1's diagnoses included, but were not limited to, repeated falls, diabetes, hearing loss, and difficulty in walking. Section C (cognitive patterns) of Resident #1's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/28/23 included a brief interview for mental status (BIMS) summary score of 14 out of a possible 15 points. Section GG (functional abilities and goals) was coded with a (2) to indicate Resident #1 required substantial/maximal assistance for shower/bathe self and personal hygiene. Resident #1's care plan included the focus area resident has an ADL self-care performance deficit, impaired mobility, weakness/deconditioning. Interventions included, physical assist as needed with ADLs and requires total assistance by staff to move between surfaces as necessary. The surveyor reviewed the last 30 days of showers/baths. Per the clinical record Resident #1 had been provided with (3) bed baths and had (2) refusals. There were no documented showers/baths. On 01/04/24 at 11:50 a.m., during a meeting with the Administrator, Nurse Consultant, and DON the issue regarding Resident #1's ADL assistance in the area of bathing was reviewed. The DON stated the residents should receive 2 showers/baths a week at a minimum. The facility staff provided the survey team with a copy of a policy titled, Activities of Daily Living (ADLs). This policy read in part, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .each resident shall receive tub or shower baths as often as needed, but not less than twice weekly or as required by state law . No further information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #12, the facility failed to provide ADL care. Resident #12's fingernails were observed to be long with debris observed under the nails. Resident #12's diagnoses included, but were not limited to, diabetes, hemiplegia and hemiparesis, difficulty in walking, age-related macular degeneration, and muscle weakness. Section C (cognitive patterns) of Resident #12's quarterly minimum data (MDS) assessment with an assessment reference date (ARD) of 11/04/23 included a brief interview for mental status (BIMS) summary score of 4 out of a possible 15 points. Resident #12's care plan included the focus area has an ADL self-care performance deficit activity intolerance, impaired balance, hemiplegia, and visual impairment. Interventions included physical assist as needed with ADL's. On 01/03/24 at 4:25 p.m., the surveyor observed Resident #12 up in their wheelchair. Resident #12 was observed to have long nails with debris present underneath the nails. Resident #12 was asked about their nails and stated their nails needed cutting. On 01/03/24 at 4:40 p.m. during an end of the day meeting with the Administrator, Director of Nursing, and Nurse Consultant the issue with Resident #12's nails was reviewed. On 01/04/24 at 8:24 a.m., Resident #12 was observed up in their wheelchair. Resident #12 stated the facility staff had cut their nails and then added that's the way I use to keep them. No further information regarding this issue was provided to the survey team prior to the exit conference. 4. For Resident #13, the facility staff failed to provide ADL in the area of bathing. In a 30-day period Resident #13 received 1 partial bath and 6 bed baths. Resident #13's diagnoses included, but were not limited to, dementia, chronic obstructive pulmonary disease, depressive disorder, and osteoarthritis. Section C (cognitive patterns) of Resident #13's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/28/23 included a brief interview for mental status (BIMS) summary score of 10 out of a possible 15 points. Resident #13's comprehensive care plan included the focus area has an ADL self-care performance deficit and impaired visual function. Interventions included physical assist as needed with ADLs. The surveyor reviewed the last 30 days of showers/baths. Per the clinical record Resident #13 had 1 partial bath on 12/25/23 and 6 bed baths in the last 30 days 12/07/23, 12/11/23, 12/14/23, 12/21/23, 12/28/23, and 01/01/24. Due to the residents decline the surveyor was unable to interview this resident. On 01/04/24 at 11:50 a.m., during a meeting with the Administrator, Nurse Consultant, and Director of Nursing (DON) the issue regarding Resident #13's ADL assistance regarding bathing was reviewed. The DON stated the residents should receive 2 showers/baths a week at a minimum. The facility staff provided the survey team with a copy of a policy titled, Activities of Daily Living (ADLs). This policy read in part, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .each resident shall receive tub or shower baths as often as needed, but not less than twice weekly or as required by state law . No further information regarding this issue was provided to the survey team prior to the exit conference. 34307 5. For Resident #17 the facility staff failed to provide nail care. Resident #17's face sheet listed diagnoses which included but not limited to adult failure to thrive and other specified disorders of the skin and subcutaneous tissues related to radiation. Resident #17's most recent minimum data set with an assessment reference date of 10/13/23 assigned the resident brief interview for mental status score of 5 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Section GG, functional abilities and goals, coded the resident as dependent in personal hygiene. Resident #17's comprehensive care plan was reviewed and contained a care plan for The resident has an ADL (activities of daily living) self-care performance deficit AEB (as evidence by) Malnutrition, Adult FTT (failure to thrive), Hx (history) of CVA (cerebrovascular accident [stroke]). Interventions for this care plan included Physical assist as needed with ADL's. Surveyor observed Resident #17 in his room on 01/03/24 at 4:30 pm. Resident was resting in bed with family member at bedside. Resident appeared clean and was dressed in clean hospital gown at this time. Surveyor observed that Resident #17's fingernails had a brownish debris underneath them. Staff Development Coordinator was in the room, and stated, I came and soaked and trimmed his nails about a month ago. Surveyor requested and was provided with a facility policy entitled Activities of Daily Living (ADLs) which read in part, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 3. Each resident shall be given proper daily personal attention and care, including skin, nail, hair, and oral hygiene, in addition to any specific care ordered by the attending physician. The concern of not providing nail care was discussed with the administrator, director of nursing, and risk management nurse on 01/04/24 at 11:50 am. No further information was provided prior to exit.

Based on observation and staff interview the facility staff failed to ensure a clean, comfortable, and homelike environment for 1 of 13 current residents, Resident #17. The findings included: For Resident #17 the facility staff failed to ensure a clean environment. Resident #17's face sheet listed diagnoses which included but not limited to adult failure to thrive and other specified disorders of the skin and subcutaneous tissues related to radiation. Resident #17's most recent minimum data set with an assessment reference date of 10/13/23 assigned the resident brief interview for mental status score of 5 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Surveyor observed Resident #17 in his room on 01/03/24 at 4:30 pm. Resident was resting in bed with family member at bedside. Resident's room was clean in appearance at this time. Surveyor asked resident and family member if room was cleaned regularly, and family member stated that at times there was debris (food scraps) on the floor when they came to visit. Surveyor observed the over bed table and family member stated, They just came in and cleaned it off. While surveyor was in the room, staff development coordinator (SDC) entered the room and began wiping the overbed table. At this time, surveyor observed a white cloth on the bottom of the resident's overbed table frame. Surveyor asked SDC what the cloth was, and SDC stated it was a wet wipe, and they had put it there. SDC stated, I had to wet it and let it set, because it looks like someone spilled a berry magic cup. It's so dry, I about need a scraper to get it off. It might be strawberry ice cream, because I think I just found a strawberry. Resident then stated, it's probably ice cream because I had some a couple of days ago. When the wet wipe was removed, surveyor observed a dried reddish substance on the bottom of the overbed table. The concern of ensuring a clean environment was discussed with the administrator, director of nursing, and nurse consultant on 01/04/24 at 11:50 a.m. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure the residents call system was within reach for 1 of 13 current residents, Resident #1. The findings included: The facility staff failed to ensure Resident #1's call system was in reach. Resident #1 was observed up in their wheelchair the call system was placed on the bed and out of reach of this resident. Resident #1's diagnoses included, but were not limited to, repeated falls, diabetes, hearing loss, and difficulty in walking. Section C (cognitive patterns) of Resident #1's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/28/23 included a brief interview for mental status (BIMS) summary score of 14 out of a possible 15 points. Resident #1's comprehensive care plan included the interventions encourage the resident to use bell to call for assistance, ensure/provide a safe environment, and call light in reach. On 01/02/24 at 10:59 a.m., two surveyors observed Resident #1 up in their wheelchair in their room. Resident #1's call light was observed to be on their bed and was not in reach of this resident. Resident #1 asked the surveyors to assist them to the bathroom. On 01/02/24 at 12:13 p.m., Resident #1 was observed up in their wheelchair, their call light was out of reach, Resident #1 requested a drink from the other side of the room when the surveyor entered the room. When asked about their call light Resident #1 stated staff did not answer it timely. On 01/02/24 at 3:00 p.m., during an end of the day meeting with the Director of Nursing (DON) and Administrator the issue with the call light being out of reach was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interviews, clinical record review, and facility document reviews the facility staff failed to provide supervision and assistance devices to prevent injury during a bed transfer for 1 of 8 residents, Resident #3. For Resident #3, the facility staff failed to provide a 2-person assist or Hoyer lift during a transfer to the bed resulting in a broken arm. The findings were: Resident #3's admission record noted their diagnoses included, but were not limited to, transient cerebral ischemic attack (stroke), Alzheimer's disease (progressive disease destroying memory and other mental functions), dementia (impaired brain functions), [CONDITION(S)] (deteriorating cartilage at end of bones), muscle weakness, stiffness of unspecified joint, and dysphagia (difficulty swallowing). Resident #3's quarterly minimum data set with an assessment reference date of 03/08/2022 did not assign a brief interview for mental status (BIMS) summary score but documented a staff assessment for mental status which coded the resident as having short and long-term memory problems but able to recall staff names and faces. The resident's cognitive skills were coded as moderately impaired (decisions poor; cues/supervision required). Section G (Functional Status) codes Resident #3 required 2+ persons physical assist for bed mobility, transfers, dressing, toilet use and personal hygiene. The resident's care plan noted a focus area of limited physical mobility, needing assistance from staff for transfers and mobility with interventions that included but were not limited to Transfer with lift with two person assist. Resident #3's order summary report indicated the resident was admitted to hospice services on 07/17/2021. The behavior observation weekly summary dated 04/27/2022 noted staff attempts to redirect resident without success (yelling and screaming) with antianxiety medication administered as directed. A nurse's note dated 04/30/2022 at 11:19 a.m. read a CNA (certified nursing assistant) retrieved the nurse to assess Resident #3's left arm. The nurse noted swelling and pain to the left shoulder and upper arm with discoloration to left should and arm. The resident yelled out in pain when that arm was touched or moved. The nurse called the on call provider and obtain new orders for a stat X-ray to left humerus, forearm, shoulder and elbow. The nurse notified the DON (director of nursing), left a message for the CCP (care contact person) to return the call, and notified hospice. The X-ray was obtained at 2:15 p.m. and the hospice nurse notified the CCP of a new order to send to E.D. (emergency department). The resident was transported to the ED at 3:38 p.m. The nursing home's nurse practitioner wrote a note that read in part, Patient found to have left humurus [sic] fracture and was sent to the ER and subsequently admitted . The DON (director of nursing) was interviewed in her office on 05/19/2022 at approximately 12:15 p.m. with the administrator present. The DON reported the facility's investigation pointed to an incident with Resident #3 on 04/28/2022 that was not reported until after the resident's broken arm was identified on 04/30/2020. A CNA reported to the DON that while transferring the resident to the bed by herself, she heard a pop but was unsure what it was. Other staff in the room indicated the resident had popping sounds frequently. The surveyor was unable to find evidence of Resident #3 making popping sounds within the clinical record however, the care plan included a focus area related to the resident's diffuse [CONDITION(S)] and history of [CONDITION(S)] with potential for pain. The care plan interventions included but were not limited to observe/document/report contracture formation/join shape changes, crepitus (creaking or clicking with joint movement), etc . The DON reported that although there were two CNAs in the room along with a nurse, only one CNA transferred Resident #3 to the bed. The DON acknowledged the resident was a two plus person assist for transfers. The DON provided a statement written by the CNA who transferred Resident #3 by herself. The statement read in part that there was no lift pad under the resident and the CNA didn't feel there was a safe way to get a lift pad under her so she had the resident hug her as she explained what they were going to do, trying to keep the resident calm. The statement described how she lifted Resident #3 on a count of three to move her to the bed and in mid transfer she heard a pop. After sitting the resident on the side of the bed, the resident did not make any noise and the CNA asked, What was that? Both CNAs adjusted the resident in the bed and changed her without the resident complaining of pain or anything. The CNA's statement said Resident #3 never mentioned any pain throughout the night. The CNA documented when she asked the nurse about the pop sound the CNA heard, the nurse said the resident pops like that. The nurse who was in the room wrote a statement that read in part, Resident #3 was in a Geri chair with no Hoyer pad under her. The CNA squatted down and used a bear hug to lift resident from her chair. As the CNA lifted the resident, the CNA stated she heard a popping sound. No obvious sign of pain was noted, no facial grimace, jerking, yelling out or moaning noted. The resident did not voice complaints of pain or discomfort. No obvious sign of injury noted anywhere. The DON reported neither CNA knew the resident's transfer status and did not ask or check the resident's record. The DON stated her expectation would be that if a resident's transfer status was not known, the Hoyer life should have been used to provide the highest level of safety. Both CNAs involved in the incident had been terminated due to improper transfer resulting in injury. The DON reported that between the transfer on 04/28/2022 and when Resident #3's arm was found to be broken on 04/30/2020, the resident had received a bath on 04/29/2022 with no mention or documentation of any problems with the resident's arm. The DON stated only one CNA bathed the resident and that CNA asked another staff member to chart the bath for her. The DON questioned whether the resident actually received a bath on 04/29/2022 and stated that same CNA had made statements that were later found to be untrue and had been terminated. Later on 04/29/2022, two different CNAs were changing the resident's brief and sheets. When CNA #2 moved the resident's left arm, the resident yelled out in pain. Both CNAs thought the resident's shoulder looked like it had shifted or stuck out. CNA#2 notified the nurse and asked if something had recently happened to the resident's left arm and the nurse stated she (the nurse) had just put medication on it. The DON provided completed staff evaluation forms related to resident transfers on the two CNAs involved in Resident #3 transfer incident as well as for the CNA who bathed the resident on 04/29/2022. All three had been evaluated for resident transfers between October 2021 and March 2022. The administrator and DON were informed on 05/19/2022 at 12:45 p.m. that since this incident had resulted in an injury, there was the potential for findings of harm. In the afternoon of 05/19/2022, the administrator, DON and Regional Director of Operations provided documentation of their quality plan related to this incident. The documentation included: 1. QA (Quality Assurance) meeting dated 05/02/2022 attended by the DON, Assistant Director of Nursing, Therapy, Nurse Practitioner, the Corporate Vice President of Clinical Programming, with the Regional Director of Operations attending via phone in place of the administrator who was on vacation. 2. QAPI (Quality Assessment Performance Improvement) Action Plan with the latest projected completion date being 06/01/2022 for in-servicing all staff on transfers, following plans of care, and reporting. 3. An observation audit of all resident transfers would be completed on 20% of residents weekly for 4 weeks. Those observation audits began on 05/02/2022 and continued throughout the survey. 4. They ordered split pads for lifts with plans to provide education on their use after the split pads were delivered. 5. A completed assessment of all residents' transfer statuses to identify those residents at higher risk. 6. A transfer skill check off/competencies log for all clinical staff. 7. Staff education in-service sheets documented education started on 05/02/2022. 8. Staff evaluation sheets for transfers were provided for many clinical staff members however, the DON acknowledged not everyone had been evaluated yet. The DON was unsure how many staff were yet to be evaluated but stated it was mostly their prn staff (work as needed staff). The survey team made no observations of lift transfers however, on the afternoon of 5/19/22, six facility staff members were interviewed about resident transfers, including transfers with a mechanical lift. One TNA (temporary nursing assistant, three CNAs, and two LPNs were interviewed; these staff members worked on multiple units of the facility. All six (6) staff members reported they had received education and training related to transfers and mechanical lifts. All six staff members reported that if they were caring for a resident and needed to know how to transfer the resident the information would be found in the resident's clinical record. It was also reported that staff could check with the facility's therapy staff to see what a resident's transfer needs were. The facility requested past non-compliance, but had not completed the training and evaluation of all facility staff prior to, or during the survey. The facility reported that they planned to complete the training (including transfers, following plans of care, reporting requirements) on June 1, 2022. The facility began weekly observation audits of 20% of resident transfers on 5/2/22. The facility completed an assessment of all residents' transfer statuses. The facility ordered, but had not received split pads for lifts, which the staff had not yet been trained to use. No further information was provided before the exit conference.

Based on clinical record review, staff interview, facility document review and during the course of a complaint investigation, the facility staff failed to ensure that two of 26 residents in the survey sample received adequate supervision and assisted devices to prevent accidents. (Resident #4, and Resident #10) The findings included: 1. Resident #4 was transferred from the bed to the wheelchair by one CNA which resulted in the resident falling and received fractures of both legs from this incident on 12/20/2018. Resident #4 was admitted to the facility with the following [DIAGNOSES REDACTED]. On the MDS (Minimum Data Sheet) that was completed before the resident fell on [DATE], the resident was coded as being totally dependent on 2 staff members for transfers. Resident #4 was also coded as requiring extensive assistance of 2 staff members for toilet use and personal hygiene. A complaint was received in the Office of Licensure and Certification on 6/24/2019 in which the complainant questioned why this resident was being transferred by one CNA when the resident was in such a weakened state. During the course of a complaint investigation, the surveyor reviewed the clinical record of Resident #4 on 2/13 and 2/14/2020. On 12/20/2018 at 21:03 (9:03 PM) the following was documented in the nurses notes' which read, .Resident admitted to _____ (name of hospital) . The surveyor reviewed the comprehensive care plan and noted the following interventions: .Assist _____ (name of resident) with transfers and mobility . Red dot fall system: red dot on door to identify resident as a fall risk to staff . Assist resident w/ADLs (with activities of daily living) as needed (CNA) (certified nursing assistant) . Encourage the resident to participate to the fullest extent possible with each interaction . The surveyor interviewed the interim DON (director of nursing) on 2/13/2020 at 2 PM in the conference room. The surveyor asked the interim DON what the findings were from investigation of Resident #4's fall on 12/20/2018. The interim DON stated Let me go pull that investigation on this fall. I wasn't the DON at the time this occurred. The interim DON returned to the conference room with the investigation tool that the facility used to investigate this fall. On this tool, the surveyor noted the following documentation: .Resident should have been a 2-person transfer-but was being transferred by one CNA . Traumatic injury from fall . Admission [DIAGNOSES REDACTED].Bilateral Distal femur Prosthetic fractures r/t (related to) fall . The surveyor could not interview the CNA that transferred Resident #4 because she was no longer working at the facility. The interim DON also stated We started a QAPI plan on this fall. The surveyor requested to review this plan. The interim DON provided the surveyor with a copy of this plan on 2/14/2020 at 1 PM. The surveyor noted the following documentation on this quality improvement plan which was dated for 1/4/2019: .Resident had a fall on 12/20/2018 while being transferred from the bed to the wheelchair resulting in bilateral femur fractures .One CNA was transferring the resident at the time of the fall. Resident was assessed as a high fall risk but did not have a red dot on the door to signify . The surveyor requested copies of any education and evidence to show that this plan was completed. The interim DON stated, This is all I have. I have only been in this position for 2 days and I cannot find what you are asking for. The surveyor notified the administrator, interim DON, ADON (assistant director of nursing) and the regional nurse consultant on 2/14/2020 at 2 PM. The administrative team was provided time to give any further information to the survey team prior to the exit conference. The administrator stated, We don't have any further information to provide. 2. The facility staff failed to follow the comprehensive plan of care for Resident # 10, which resulted in Resident # 10 spilling coffee and sustaining second-[MEDICAL CONDITION] inner thighs. This is harm. Resident # 10 had [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment for Resident # 10 was a significant change assessment with an ARD (assessment reference date) of 11/21/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 10 had a BIMS (brief interview for mental status) score of 04 out of 15, which indicated that Resident # 10's cognitive status was severely impaired. Section G of the MDS assesses functional status. In Section G0110, the facility staff documented that Resident # 10 required set up assistance and supervision with eating. The comprehensive plan of care for Resident # 10 was reviewed and revised on 2/10/20. The facility staff documented a focus area for Resident # 10 as, Resident # 10 is at risk for injury/burns due to spilling hot liquids related to dementia/cognitive loss, [MEDICAL CONDITION]. Interventions included but were not limited to, Serve hot beverages in mug with sip lid, and Provide supervision with meals. Resident # 10 had orders that included but were not limited to, Santyl Ointment 259 unit/GM (gram) Apply to right medial thigh topically every day shift for wound healing Irrigate area with wound cleanse or sterile water, do not scrub, or wipe area, pat dry, apply thin layer of Santyl to yellow/necrotic tissue only, Apply [MEDICATION NAME] oint (ointment) to pink/granulation tissue and surrounding skin, and wrap with roll gauze and apply to right medial thigh topically as needed for soiled or dislodged dressing, which was initiated by the physician on 1/17/20. Resident # 10 also had orders for Santyl Ointment 259 unit/GM (gram) Apply to left medial thigh topically every day shift for wound healing Irrigate area with wound cleanse or sterile water, do not scrub, or wipe area, pat dry, apply thin layer of Santyl to yellow/necrotic tissue only, Apply [MEDICATION NAME] oint to pink/granulation tissue and surrounding skin, which was initiated by the physician on 1/17/20. On 2/13/20 at 1:45 pm, the surveyor observed a nurse's note in Resident # 10's clinical record that has been documented on 1/7/2020 at 5:20 pm. The nurse's note was documented as, While in dining room resident poured half a cup of hot coffee into her lap due to shaking in hands. Rsd (resident) has blistering bilaterally on inner thighs, she also has redness on her right breast. Sent to (Hospital name withheld) ER (emergency room ) with appropriate transfer documentation in place, Rp (responsible party) notified. The surveyor observed a progress note from the facility nurse practitioner that reflected the date of service was 1/8/2020. The nurse practitioner's progress note contained documentation that included but was not limited to, .History of Present Illness: Pt (patient) is seen today after reportedly spilling a cup of hot coffee on her lap yesterday at dinner. Staff report that skin to inner thighs started to blister almost immediately. Verbal orders were given to send pt to ER for evaluation. Dx (diagnosis) with second [MEDICAL CONDITION] discharged back to the facility with new orders for [MEDICATION NAME] ointment. Pt does not endorse pain today, states, I have been through it. Pt is a very poor historian at baseline 2/2 (secondary to) advanced dementia. Currently has no medications ordered for pain. The surveyor reviewed the clinical record for Resident # 10 and observed that the most recent Hot Liquid/Risk Assessment prior to the incident on 1/7/20 had been conducted on 4/10/19. The Hot Liquid/Risk Assessment for Resident # 10 contained documentation that included but was not limited to, .A. Decision Making/Behavior 1. Resident has moderate/severe cognitive loss a. Yes B. Functionality/Sensation/Vision 1. Resident has tremors in upper extremities that create risk for spillage a. Yes 3 Resident has weakness in upper extremities that create risk for spillage a. Yes 8. Resident requires supervision for eating a. Yes . The facility policy for Hot Liquid Assessment contained documentation that included but was not limited to, .Specific Procedures/Requirements: 1) On admission/readmission, quarterly and with significant change, the resident will be assessed for risk of use of hot liquids (i.e. beverages, soups, etc.) by a licensed nurse or therapist. 2) If the resident is determined to be at risk of spillage and/or injury from hot liquids, the interdisciplinary team will make recommendations to minimize the resident's risk. Recommendation to the physician for referral to therapy for screening/and or evaluation for improved skills or assessment of appropriate equipment/devices to promote resident safety will be made as appropriate. On 2/13/20 at 3:30 pm, the surveyor spoke with the acting director of nursing and the administrator. The surveyor asked the acting director of nursing for any investigative information the facility had regarding Resident # 10 spilling coffee on 1/7/2020. On 2/13/20 at 4:02 PM, the acting director of nursing provided the surveyor with a copy of the facility investigation and a copy of a Record of Verbal Warning form for a CNA (certified nursing assistant). The record of verbal warning contained documentation that included but was not limited to, .Description of Education Provided: Be careful when administering hot liquids to residents. Place several ice cubes in liquid to ensure safe temperature. Ensure lid is in place. Monitor residents for safety while consuming hot liquids. The acting director of nursing stated, The CNA did not follow the plan of care in this situation, and was counseled. Along with the facility investigation, the acting director of nursing provided a QAPI (quality assurance performance improvement) ACTION PLAN. The QAPI action plan contained documentation that included but was not limited to, .Correction: 3. Staff education on hot liquid policy. The acting director of nursing presented the surveyor two in-service logs dated 1/8/2020 with a subject Hot Liquid Safety. The surveyor observed that the one in-service log contained 12 CNA signatures, and the other in-service log contained 11 CNA signatures. The surveyor asked the acting director of nursing if CNAs were the only staff members that supervised or assisted residents with meals. The acting director of nursing stated, No, our nurses assist with feeding as well. The surveyor explained that the QAPI plan did not have sufficient evidence that reflected that the necessary staff had been educated. The acting director of nursing voiced understanding in the presence of the administrator and the survey team. On 2/14/20 at 1:10 PM, the surveyor interviewed CNA # 1 via telephone. The surveyor asked CNA # 1 if he/she was responsible for providing care to Resident # 10 on 1/7/20. CNA # 1 stated that he/she had been responsible for providing care to Resident # 10 on 1/7/20. CNA # 1 stated that Resident # 10 had requested more coffee. CNA # 1 stated that he/she had poured a half cup of coffee and added milk to the coffee for Resident # 10. CNA # 1 stated that when he/she turned around, Resident # 10 grabbed the cup of coffee and the coffee spilled on Resident # 10. The surveyor asked CNA # 1 if the coffee cup that had been prepared for Resident # 10 had a lid on it. CNA # 1 stated, No it did not. On 2/14/20 at 1:40 PM, the administrator, acting director of nursing, assistant director of nursing, and regional director of clinical services were made aware of the findings as stated above. No further information regarding these issues was presented to the survey team prior to the exit conference on 2/14/20.