Every finding on record at Holmes County Long Term Care Center - Durant

Based on observations, staff interviews, and facility policy review, the facility failed to ensure food was reheated and held in accordance with safe food handling standards for one (1) of 1 meal service observed.Findings include:Review of the facility policy titled Monitoring Temperatures of Cooked Foods with review date 3/24, revealed, 1 .cooked foods, after being cooked to the required minimum internal temperature, will be held on hot holding equipment that will keep the food at a minimum 135 degrees Fahrenheit or higher .2 .b. When the food is placed in the hot holding equipment. The temperature of the food should be 135 degrees Fahrenheit or higher. If it is below 135 degrees Fahrenheit, the food is reheated to 165 degrees Fahrenheit for 15 seconds and placed back in the holding equipment .All parts of reheated cooked foods must reach 165 degrees Fahrenheit for 15 seconds .5. Foods are discarded after being reheated once .During a follow-up visit to the kitchen on 7/8/2026 at 10:49 AM to check temperatures on the holding/steam table, the following food items did not meet the required hot holding temperature of 135 degrees Fahrenheit:Pureed Pork Chops read 120 degrees FahrenheitPureed Tomatoes read 100 degrees FahrenheitPureed Roll 110 degrees FahrenheitChopped Pork Chops 125 degrees FahrenheitHamburger Patty (Alternate) 125 degrees FahrenheitThe Dietary Manager instructed her staff to reheat the above items in the oven.After the first reheating, the following items reached temperatures above the minimum hot holding temperature of 135 degrees Fahrenheit; however, they did not reach the required reheating temperature of 165 degrees Fahrenheit for 15 seconds:Pureed Roll reached 140 degrees FahrenheitChopped Pork Chops reached 140 degrees FahrenheitHamburger Patty reached 145 degrees FahrenheitThe Dietary Manager instructed staff to reheat the pureed pork chops and pureed tomatoes a second time. The pureed pork chops then reached 140 degrees Fahrenheit, and the pureed tomatoes reached 130 degrees Fahrenheit.The Dietary Manager then instructed her staff to reheat the pureed tomatoes in a pot on the stove. The pureed tomatoes then reached 150 degrees Fahrenheit. In an interview on 07/08/26 at 11:00 am with the Dietary Manager about the reheating process, the Dietary Manager stated, They normally do reheat the food items twice, sometimes three times. It was observed during that interview that one of the reheated food items reached the required reheating temperature of 165 degrees Fahrenheit for 15 seconds before being returned to hot holding equipment.During an interview on 7/8/2026 at 11:34 AM, the Registered Dietitian (RD) confirmed food items should only be reheated one time. She stated reheating food multiple times increased the potential for bacterial growth and contamination, and food should be discarded after one reheating.

Based on observations, interviews, and facility policy review, the facility failed to implement and maintain an effective infection prevention and control program by failing to ensure staff disinfected multi-use glucometers using the manufacturer's required two-minute wet contact time and handled blood-contaminated soiled linens in accordance with facility policy. Specifically, staff failed to properly disinfect multi-use glucometers between resident use for three (3) of four (4) finger-stick blood glucose observations and failed to properly contain and remove blood-contaminated linens for one (1) resident observed on two (2) of three (3) survey days, creating the potential for the transmission of infectious organisms.Findings Include: Review of facility policy titled Handling Soiled Linen updated July 2019, revealed, Policy: It is the policy of this facility to handle, store, process, and transport linen in a safe and sanitary method to prevent the spread of infection. Review of facility policy titled, Glucometer Control Monitoring and Cleaning, dated, 11/25, revealed, The glucose monitors are to be cleaned before and after each use by a moist cloth dampened with a multi-germicidal cleaning solution per manufacturer's recommendations. Review of facility, Disposable Germicidal Wipes, revealed, This product kills bacteria in two (2) minutes . On 07/08/2026 at 11:02 AM through 11:19 AM during observation of finger stick blood glucose (FSBG) with a multi-use glucometer for three (3) residents it was observed that Licensed Practical Nurse (LPN) #2 wiped the glucometer between resident FSBG checks for four to five seconds with the disposable germicidal wipe and each time then laid the glucometer machine back on top of the medication cart without a barrier present. Interview with LPN#2 on 07/08/26 at 11:50 AM with the Administrator present, stated she wasn't sure how long she was supposed to clean and keep the glucometer wet with the germicidal wipe or how long she should wipe it and stated I think I wiped it for about 10 seconds. LPN #2 stated, I just wipe it off and reuse it. Interview with the Administrator confirmed that the wipe showed it was a two-minute wet contact time in order to properly disinfect the glucometer machine and confirmed that a few seconds wasn't an appropriate kill time for bacteria. During a medication pass observation on 7/8/2026 at 12:05 PM with LPN #4, she performed a blood glucose check for Resident #6. After obtaining the blood sample, LPN #4 placed the used glucometer, with the used lancet still inserted, directly on the resident's bedside table without a protective barrier while the glucometer processed the blood sample. After obtaining the blood glucose reading, she placed the used glucometer directly onto the medication cart without a protective barrier. LPN #4 then wiped the glucometer with a Disposable Germicidal Surface Wipe for approximately four (4) to five (5) seconds before storing the glucometer in the medication cart. Soiled Linen During initial rounds on 7/7/2026 at 10:35 AM, observation of Resident #47's room (A2-A) revealed soiled linens lying on the floor. Upon further observation, the towels contained a red substance consistent with blood. During an interview on 7/7/2026 at 10:43 AM, Certified Nursing Assistant (CNA) #2 stated Resident #47 had fallen earlier that morning and had been transported to the emergency department. She stated, I came in late and didn't get here until 8:30 AM today so this was left by the other shift. She further stated the towels contained blood because the resident sustained a head laceration. When questioned regarding proper handling of the soiled linens, she stated, I have to put gloves on and put the items in the laundry cart in the hall. During an interview on 7/7/2026 at 10:47 AM with LPN #5, she confirmed the linens were contaminated with blood from the resident's fall and should have been placed in a yellow biohazard bag and transported to the laundry biohazard barrel for processing. During an interview on 7/9/2026 at 9:52 AM, the Director of Nursing (DON) confirmed blood-contaminated soiled linens should not be left on the floor. She stated the linens should be placed in a yellow biohazard bag and transported to the laundry biohazard barrel for processing. She further confirmed this process should be followed by all clinical staff to help prevent the spread of infection.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure prescribed pain medication was administered and available as ordered for one (1) of six (6) residents interviewed during a Resident Council Meeting. Resident #16Findings Include:Review of the facility policy titled Pain Assessment/Management revealed, It is the policy of this facility to provide guidelines in the identification and treatment of the residents at risk for acute and chronic pain. Each resident's pain will be assessed in an approach designed to increase comfort and promote dignity through administering alternative interventions or medications .During the Resident Council Meeting on 7/08/2026 at 2:00 PM, Resident #16 stated she had not received her prescribed pain medication since returning from the hospital a week ago. During a resident interview, Resident #16 stated she had requested the medication daily for one week and rated her pain as an 8 to 10.Record review of the physician orders and Medication Administration Record (MAR) revealed an active order for HYDROcodone-Acetaminophen Oral Tablet 5-325 MG (milligrams) give one tablet by mouth every six (6) hours as needed for pain dated 7/2/2026.Record review of the MAR and pain assessments revealed documented pain scores of 0 during the period the ordered HYDROcodone-Acetaminophen Oral Tablet 5-325 MG was unavailable.Observation of the medication cart on 7/8/2026 at 3:00 PM, revealed HYDROcodone-Acetaminophen Oral Tablet 5-325 MG was not available on the medication cart for administration for Resident #16.During an interview with Licensed Practical Nurse (LPN) #1 at 3:01 PM confirmed there was no Hydrocodone-Acetaminophen Oral Tablet 5-325 MG available in the medication cart for Resident #16. LPN #1 confirmed there was an active physician order on the MAR for Hydrocodone-Acetaminophen Oral Tablet 5-325 MG but that they did not have it to administer.On 7/08/2026 at 3:30 PM, an interview was conducted with the Administrator confirmed the medication order had been submitted to the pharmacy following the resident's return from the hospital; however, the medication had not been received by the facility. The Administrator confirmed Hydrocodone-Acetaminophen Oral Tablet 5-325 MG was not available for administration and acknowledged no follow-up had occurred to ensure the medication had been received from the pharmacy.Record review of the admission Record revealed Resident #16 was admitted to the facility on [DATE] with a diagnosis of Heart Failure. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/21/2026 revealed, under Section C, a Brief Interview for Mental Status (BIMS) was 15, indicating Resident #16 was cognitively intact.

Based on observation, record review, interviews and facility policy review, the facility failed to provide pharmaceutical services to assure the accurate acquiring, receiving, and administering of all drugs and biologicals to meet the needs of each resident for one (1) of 29 medication administrations. Resident #21 Findings Include: Review of facility policy titled, Transcribing Physicians Orders, with no date, revealed, .Orders will be followed and medications will be administered according to the prescribed physician's instructions . Record review of the July 2026 Medication Administration Record (MAR) revealed an active physician's order dated 06/03/23, Scopolamine Transdermal Patch 72 hour, apply one (1) patch transdermal one time a day every three (3) days for increased secretions and remove per schedule. Review of the MAR revealed that on 07/05/26 and 07/08/26 it was initialed by LPN #1 that it was removed and applied for both days. On 07/08/26 at 8:24 AM an observation during medication administration with Licensed Practical Nurse (LPN) #1 it was observed that the nurse did not remove nor apply the Scopolamine patch as ordered by the physician. During record review reconciliation of medications, it was observed on the MAR that LPN #1 had initialed that she had removed and applied the Scopolamine patch on 07/05/26 and 07/08/26. On 07/08/2026 at 9:30 AM interview with LPN #1 confirmed that she had initialed that she had removed and applied a Scopolamine patch and had marked it as completed on the Medication Administration Record (MAR) but confirmed that she had not completed the medication administration. She stated, I don't have a patch to remove, she is out of the medicine. LPN #1 stated that the resident was out of the patch to administer when she was working on 07/02/26 and thinks she reordered it then but will have to check to make sure. LPN #1 then looks into the computer system and discovered that the scopolamine patch had not been reordered and she ordered it during the interview on 07/08/26 at 9:30 AM. LPN #1 confirmed that she thought it had been reordered but she just realized it had not and confirmed that the resident has been without the medication since 07/02/26 and the nurse on the medication cart who administered the last patch should have reordered the medication. Record review of a Progress Note, dated 07/05/26 at 15:25 (3:25 PM), Reorder. Patch not available, signed by LPN #1 On 07/09/2026 at 8:45 AM interview with the Infection Control (IC) nurse confirmed that it has been a concern for a while now that the nurses are not reordering medications when the residents run out and stated, I might just need to go through the carts and reorder the medications myself. On 07/09/26 at 2:05 PM interview with the DON confirmed that the nurse who gives the last of a medication should always reorder the medication and that it is just one click on the reorder button in the computer. Record review of the admission Record revealed that Resident #21 was admitted to the facility on [DATE] with diagnosis that Dysphagia and Encounter for Attention to Gastrostomy. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/22/26 revealed Item C0100 was coded 0 on the Brief Interview for Mental Status Score (BIMS) indicating that the resident is rarely or never understood and interview should not be conducted.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the medication error rate was five (5) percent (%) or less for two (2) of twenty-nine medication opportunities. Medication error rate of 6.90%Findings Include: Review of facility policy titled Medication Error Rate Policy dated 3/2026, revealed, Policy: The facility is committed to maintaining a medication error rate of less than 5%, in accordance with Centers for Medicare and Medicaid Services (CMS) requirements for long-term care facilities. Medication administration practices will be monitored through routine medication pass observations, audits, and Quality Assurance and Performance Improvement (QAPI) activities . Resident #21 Record review of the [DATE] Medication Administration Record (MAR) revealed an active physician's order dated [DATE], Scopolamine Transdermal Patch 72 hour, apply one (1) patch transdermal one time a day every three (3) days for increased secretions and remove per schedule. Review of the MAR revealed that on [DATE] and [DATE] it was initialed by LPN #1 that it was removed and applied for both days. An observation of medication administration on [DATE] at 8:24 AM with Licensed Practical Nurse (LPN) #1 it was observed that the nurse did not remove nor apply the Scopolamine patch as ordered by the physician. During record review reconciliation of medications, it was observed on the MAR that LPN #1 had initialed that she had removed and applied the Scopolamine patch on [DATE] and [DATE]. Interview on [DATE] at 9:30 am with LPN #1 confirmed that she had initialed that she had removed and applied a Scopolamine patch and had marked it as completed on the Medication Administration Record (MAR) but confirmed that she had not completed the medication administration. She stated, I don't have a patch to remove, she is out of the medicine. LPN #1 stated that the resident was out of the patch to administer when she was working on [DATE] and thinks she reordered it then but will have to check to make sure. Record review of a Progress Note, dated [DATE] at 15:25 (3:25 PM), Reorder. Patch not available, signed by LPN #1. Record review of the admission Record revealed that Resident #21 was admitted to the facility on [DATE] with diagnosis that Dysphagia and Encounter for Attention to Gastrostomy. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Item C0100 was coded 0 on the Brief Interview for Mental Status (BIMS) indicating that the resident is rarely or never understood and interview should not be conducted. Resident #23 Review of the facility policy titled Medication Administration Policy revealed, under Policy, Medications are administered by licensed nurses . as ordered by the physician and in accordance with professional standards of practice. Additionally, under Policy Explanation and Compliance Guidelines, the policy revealed, .10. Review MAR (Medication Administration Record) to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc.) with the MAR to verify resident name, medication name, form, dose, route, and time. 12. Identify expiration date. If expired, notify the nurse manager . During a medication pass observation with Licensed Practical Nurse (LPN) #4 on [DATE] at 11:17 AM, LPN #4 administered Atrovent 0.03% (percent) nasal spray, one (1) spray into each nostril. Record review of Resident #23's [DATE] Medication Administration Record (MAR) revealed an order dated [DATE] for, Atrovent nasal spray solution 0.03% (percent) (Ipratropium Bromide (Nasal), two (2) sprays in both nostrils before meals related to Vasomotor Rhinitis. An interview with LPN #4 on [DATE] at 11:50 AM confirmed she administered one spray into each nostril to Resident #23 instead of the ordered two sprays. She stated she became nervous and made a mistake. LPN #4 further stated the resident required the medication for allergies and his condition could worsen if the medication was not administered as ordered by the physician. An interview with the Director of Nursing (DON) on [DATE] at 8:50 AM revealed her expectation was for nurses to review the MAR, compare the medication with the MAR to ensure accuracy, administer the medication as ordered, and then document administration. She stated the nurses were new graduates; however, her expectation was that all medications be administered as ordered. Record review of the Resident Dashboard revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia and Parkinson's Disease. Record review of the MDS with an ARD of [DATE] revealed, under Section C, a BIMS score of 15, indicating Resident #23 was cognitively intact.

Based on observations, interviews, and facility policy reviewed, the facility failed to properly secure and store medications for two (2) of four (4) medications carts. Medication cart B and Medication cart E. Findings Include: Record review of facility policy titled, Medication Storage in the Facility, with no date, stated, Medications and biologicals are stored safely, securely and properly Observation on [DATE] at 8:40 AM during medication administration on B hall medication cart revealed a bottle of liquid vitamin with an expiration date of 06/26. Interview with Licensed Practical Nurse (LPN) #1 confirmed that the liquid vitamin was expired and was in use for a resident and stated, Pharmacy comes once a month and usually checks our med carts for expired stuff and removes it, but I guess that one got missed. LPN #1 confirmed that she should have checked the expiration date before she prepared the medication for administration. An observation on [DATE] at 11:03 AM during medication administration with LPN #2 on E hall it was observed that the nurse had drawn up three (3) resident's insulin into syringes and left two (2) of the 3 insulin filled syringes unsecured on top of the medication cart and walked down the hall to the day room to administer an insulin to a resident. Interview with LPN #2 on [DATE] at 11:04 AM confirmed that she should have stored the insulin filled syringes in the locked medication cart and that was not safe to leave medications unsecured while she was away from the medication cart. Interview with the Director of Nursing (DON) on [DATE] at 2:05 PM confirmed that all medications should be checked for expirations prior to administering and that insulin and other medications should never be left unattended and unsecured while the nurse is away from the cart.

Based on observation, resident and staff interviews, record reviews, and facility policy review, the facility failed to ensure hot meals were served at a palatable temperature for two (2) of four (4) residents reviewed for dining services. Residents #6 and #43Findings Include:Review of the facility policy titled Food Palatability Policy dated 4/26 revealed under, Purpose: To ensure all residents receive meals that are palatable, appetizing, nutritious, and served at appropriate temperatures to promote adequate nutritional intake, resident satisfaction, and quality of life. Also revealed under, Procedure: . 2. Hot foods will be served hot . 6. Dietary leadership will routinely evaluate appearance, taste, texture, temperature, and acceptability .An interview with Resident #6 during the initial tour on 7/7/26 at 12:06 PM revealed she ate her meals in her room and stated her food was cold almost every meal. Resident #43, her roommate, stated her food was cold as well but reported she never voiced her concerns to the staff because she just ate it. An observation of the lunch meal served at 12:16 PM revealed Resident #6 was served a hot dog on a bun with French fries. She stated the meal was cold. The plate was not warm to the touch, and the resident touched a French fry stating, Here, feel. The French fry was observed cold to the touch.An observation of the dining room on 7/8/26 at 12:07 PM revealed lunch trays for C and D Hall were brought to the floor in a metal rolling food cart and picked up by an aide at 12:08 PM. Resident #43 received her tray first at 12:10 PM, followed by Resident #6. The meal consisted of fried pork chop, creamed potatoes, stewed tomatoes, and a biscuit. Both residents stated their food was cold. Resident #43 stated, Mine might be lukewarm bordering on cold and the biscuit is not warm at all. At that time, immediately after Resident #6 received her meal tray, it was requested the tray temperatures be obtained. The Dietary Manager (DM) came to the resident's room and tested the food temperatures at 12:17 PM. The pork chop measured 80 degrees, the stewed tomatoes measured 90 degrees, and the mashed potatoes measured 110 degrees. Both residents stated the food temperature was not acceptable and verbalized they preferred their food to be served warm.An interview with the Dietary Manager (DM) on 7/8/26 at 12:28 PM confirmed hot foods should be served warm and palatable to the residents. She stated staff check food temperatures in the kitchen, use dome plate covers, and transport hall trays in a covered cart. She further stated the kitchen did not use plate warmers because none were available, which could allow food to lose heat after it was plated.Record review of the admission Record revealed the facility admitted Resident #6 on 10/3/18 with medical diagnoses that included Major Depressive Disorder, Schizophrenia, Unspecified, and Anxiety Disorder.Record review of the Brief Interview for Mental Status (BIMS) dated 4/10/26 revealed a summary score of 15, indicating Resident #6 was cognitively intact.Record review of the admission Record revealed the facility admitted Resident #43 on 1/18/24 with medical diagnoses that included Allergic Rhinitis and Unspecified Dementia.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/14/26 revealed under Section C a BIMS summary score of 8, indicating Resident #43 was moderately cognitively impaired.

Based on record review, staff interviews, and facility policy review, the facility failed to timely complete and transmit a discharge Minimum Data Set (MDS) assessment as required by the Centers for Medicare and Medicaid Services (CMS) guidelines for one (1) of nineteen (19) MDS reviews. Resident #1 Findings include:Review of the facility policy titled MDS Assessment, revealed It is the policy of this facility to follow the Resident Assessment Instrument (RAI) process as set forth by CMS protocol.Record review of Resident #1's MDS with an Assessment Reference Date (ARD) of 6/17/2026 revealed, under section Z0500, that the section had not been completed.An interview with the MDS Nurse on 7/09/2026 at 1:52 PM confirmed Resident #1 had discharged from the facility on 06/17/26 and went to the hospital and returned back to the facility on [DATE]. She confirmed that she had not completed the discharge assessment when the resident went out to the hospital. She explained that she was new to this position and confirmed that the assessments should be completed and submitted timely to have accurate resident information and for payment purposes.An interview with the Administrator on 7/09/26 at 1:54 PM revealed she expected the MDS assessment to be completed and submitted within the designated timeframe specified by CMS. Record review of the admission Record revealed the facility admitted Resident #1 on 12/11/2019 with medical diagnoses that included Unspecified Atrial Fibrillation.Record review of the MDS with an ARD of 6/17/2026 revealed, under Section C, a Brief Interview for Mental Status (BIMS) of 9, indicating Resident #1 was moderately cognitively impaired.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to provide the necessary care and services to meet a resident's nutritional needs by failing to implement a physician-ordered dietary intervention for one (1) of fifty-six (56) residents reviewed. Resident #76 Findings include:Review of facility policy titled Large Portions with review date 12/23, revealed, Policy: Large portions will be served when ordered by the physician or requested by the consultant dietitian, Director of Food and Nutrition Services, or resident. Resident requests will be honored .Double portions are discouraged, but if ordered, two complete trays are delivered to the resident .During an interview on 7/7/2026 at 10:30 AM, Resident #76 stated he was supposed to receive double portions with his meals but had not received them since his admission. Review of Resident #76's Order Summary Report revealed, Regular diet Regular texture, Regular liquids consistency, Double Portions Active 06/26/2026.During an interview on 7/7/2026 at 12:32 PM, Resident #76 confirmed he did not receive double portions on his lunch tray. During an observation on 7/8/2026 at 12:13 PM, Resident #76's lunch tray was observed and did not include double portions. During an interview on 7/8/2026 at 12:18 PM, the Registered Dietitian (RD) confirmed Resident #76 had a physician order for double portions and stated, Typically I tell them to give two (2) trays when they have an order for double portions. She further stated the order for double portions was requested by the resident's family upon admission because he was a big eater. Record review of the admission Record indicated Resident #76 was admitted to the facility on [DATE] with medical diagnoses that included Heart Failure.Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/2/2026, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 10, indicating Resident #76 had moderate cognitive impairment.

Based on observation, record review, interviews and facility policy review, the facility failed to provide uninterrupted enteral feedings for a resident who received nutrition through Percutaneous Endoscopic Gastrostomy (PEG) tube for one (1) of three (3) residents reviewed with PEG tubes for nutrition. Resident #21 Findings Include: Record review of the facility policy, with no date, titled Transcribing Physician Orders, stated, It is the policy of this facility to follow the attending physician's orders as written . Procedure: Orders will be followed and medications will be administered according to the prescribed physician's instruction Record review of the Medication Administration Record (MAR) revealed a physician's order dated 04/17/26, Enteral feed order two times a day for enteral feeding to run 22 hours daily related to Dysphagia. Two Cal @ (at) 50 milliliters (ml) hour (hr.) for 22 hr. Start at eight (8) PM to provide 2200 kcal (kilocalories), 92-gram protein . Observation on 07/08/2026 at 8:30 AM revealed that Resident #21's PEG feedings were not infusing and that there was a full bottle of Two Cal feeding with the tubing wrapped in paper that had not been set up and the feeding machine pump was turned off. Interview with Licensed Practical Nurse (LPN) #1 on 07/08/26 at 8:45 AM confirmed that the PEG feeding was not on, was not infusing and confirmed that she had arrived at work around 6:30 AM this morning and had not been in the resident's room until now to see that it wasn't infusing. LPN #1 confirmed that the feeding should only be off for two (2) hours and that it would have been turned off at 1800 (6:00 PM) last night and should have been turned back on at 2000 (8:00 PM) last night. Record review of the Treatment Administration Record (TAR) July 2026 revealed that on 07/07/26 it was initialed as turned off at 1800 and initialed as turned on at 2000. Interview with the Director of Nursing (DON) on 07/09/26 at 2:00 PM confirmed that LPN #1 had shared with her that the PEG feeding for Resident #21 was not infusing when she walked into the room. The DON confirmed that it should have been infusing in order to maintain eternal nutrition and because it was a physician's order that it should have been turned back on after two hours. Record review revealed that Resident #21 was admitted to the facility on [DATE] with diagnosis that Dysphagia and Encounter for Attention to Gastrostomy. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/22/26 revealed Item C0100 was coded 0 on the Brief Interview for Mental Status Score (BIMS) indicating that the resident is rarely or never understood and interview should not be conducted.

Based on observations, resident and staff interviews, record reviews, and facility policy review, the facility failed to ensure necessary nail care services were provided for residents requiring assistance for two (2) of eight (8) residents reviewed for activities of daily living (ADLs). Resident #37 and Resident #60 Findings Include: Review of facility policy titled Nail Care Policy dated 2/2026, revealed, .4. Routine nail care, to include trimming and filing, will be provided on a regular schedule identified by the facility. Nail care will be provided between scheduled occasions as the need arises . Resident #37 During observations and interviews with Resident #37 on 7/7/2026 at 12:37 PM and again on 7/9/2026 at 8:38 AM, his fingernails were observed to be approximately one and one-half (11/2) inches in length with a dark brown/black substance underneath. Resident #37 stated, They need to be cut. During an observation and interview with the Director of Nursing (DON) on 7/9/2026 at 10:05 AM, she confirmed that Resident #37's fingernails were very long and dirty with a dark black/brown substance underneath. She confirmed Resident #37 had a physician order for weekly diabetic nail care documented on the Treatment Administration Record (TAR). Record review of Resident #37's TAR for July 2026, revealed, .Diabetic nail care weekly by nurse on Thursday one time a day every Thursday. Record review of the admission Record indicated Resident #37 was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus with Hyperglycemia. Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/21/2026, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #37 was cognitively intact. Resident #60 An observation and interview with Resident #60 on 7/7/26 at 11:09 AM revealed he was diabetic and needed his toenails cut. He stated he had been asking staff for a while but could not get anyone to do it stating, They didn't seem interested in anything I had to say; Then I was told later on they would have to get podiatry, but I am still waiting. Both his big toenails were excessively long, curved and thick, measuring approximately 2 inches in length. His other toenails were long, measuring approximately one-fourth (1/4) inch with jagged outer edges. An observation and interview on 7/8/26 at 3:21 PM with Registered Nurse (RN) #1 revealed the facility has podiatry that comes to the facility monthly to cut the residents toenails. RN #1 stated she was not sure the last time the resident was seen explaining that Resident #60 goes to dialysis and he may have missed the podiatrist. She stated she was not aware of the residents' need for nail care. RN #1 confirmed his toenails were excessively long and jagged stating, I didn't know they had gotten this bad. She revealed the resident could have a skin concern and infection risk since he had diabetes. An interview with the Director of Nursing (DON) on 7/9/26 at 8:36 AM revealed that the staff should have addressed Resident #60's nailcare specifically because he was a diabetic. She acknowledged staff should have coordinated podiatry care on his offsite dialysis days confirming his risk were infection and skin concerns. Record review of the admission Record revealed the facility admitted Resident #60 on 8/19/22 with medical diagnoses that included End Stage Renal Disease and Type 2 Diabetes Mellitus with other Diabetic Kidney Complications. Record review of the BIMS dated 4/17/26 revealed a summary score of 15, indicating Resident #60 was cognitively intact.

Based onobservations, staff interviews, record reviews, and facility policy review, the facility failed to follow the standards of nursing practice for three (3) of 24 residents observed during medication and treatment care observations. Resident #15, Resident #21 and Resident #37.Findings Include: Review of facility policy titled, Standards of Nursing Practice, dated 04/26, revealed, It is the policy of this facility to follow (Proper name) Nurse Practice Act and the (Proper name) Board of Nursing Scope of Practice for all standards of nursing care and documentation . Resident #15 During a medication pass observation on 7/9/2026 at 8:37 AM with Licensed Practical Nurse (LPN) #1, she completed Resident #15's scheduled 8:00 AM medication pass; however, she did not administer the physician-ordered 4-ounce house supplement. Record review of Resident #15's Medication Administration Record (MAR) for July 2026, revealed an active physician order for House Supplement two times a day .4 ounces . During an interview on 7/9/2026 at 10:30 AM with the Director of Nursing (DON) and LPN #1, review of the MAR revealed LPN #1 documented that the house supplement had been administered, although it had not been given during the observed medication pass. When questioned about the documentation, LPN #1 asked the DON, Is that the house supplement? Record review of the admission Record indicated Resident #15 was admitted to the facility on [DATE] with medical diagnoses that included Hemiplegia, unspecified affecting right dominant side. Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/8/2026, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 9, indicating Resident #15 had moderate cognitive impairment. Resident #21 Record review of the July 2026 MAR revealed an active physician's order dated 06/03/23, Scopolamine Transdermal Patch 72 hour, apply 1 patch transdermal one time a day every 3 days for increased secretions and remove per schedule. Review of the MAR revealed that on 07/05/26 and 07/08/26 it was initialed by LPN #1 that it was removed and applied for both days. Record review of an active physician's order on the July 2026 MAR revealed an order dated 08/06/25 revealed, Juven two times a day to promote wound healing mix with water (H2O) at 0800 (8:00 AM) and 2000 (8:00 PM). An observation during medication administration on 07/08/26 at 8:24 AM with LPN #1 it was observed that the nurse did not administer Juven and did not remove nor apply the Scopolamine patch as ordered by the physician. During record review reconciliation of medications, it was observed on the record that LPN #1 had initialed that she had removed and applied the Scopolamine patch and had administered the Juven. Interview on 07/08/2026 at 9:30 AM with LPN #1 confirmed that she had initialed that she had removed and applied a Scopolamine patch and had marked it as completed on the MAR but confirmed that she had not completed either of the medication administrations. She stated, I don't have a patch to remove, she is out of the medicine. LPN #1 stated that she was out of the patch to administer when she was working on 07/02/26 and thinks she reordered it then but will have to check to make sure. LPN #1 then looks into the computer system and discovered that the scopolamine patch had not been reordered and ordered it during the interview on 07/08/26 at 9:30 AM. LPN #1 confirmed that she did not administer the Juven but had marked it as completed on the MAR and stated, I'll go give it right now. LPN #1 confirmed that it is against the standards of nursing practice to initial a medication as completed and given, when it had not been administered. Record review of a Progress Note, dated 07/05/26 at 15:25(3:25 PM), Reorder. Patch not available, signed by LPN #1 Interview on 07/09/2026 at 8:45 AM with the Infection Control (IC) nurse confirmed that it has been a concern for a while now that the nurses are not reordering medications when the residents run out and stated, I might just need to go through the carts and reorder the medications myself. Interview with the DON on 07/09/26 at 2:05 PM confirmed that the nurses knew better than to ever mark a medication as given if you don't have it to give and stated, That's falsifying documents, they know better than that. Record review of the admission Record revealed that Resident #21 was admitted to the facility on [DATE] with diagnosis that Dysphagia and Encounter for Attention to Gastrostomy. Record review of the MDS with an ARD of 05/22/26 revealed item C0100 was coded 0 on the BIMS indicating that the resident is rarely or never understood and interview should not be conducted. Resident #37 During an observation and interview with the DON on 7/9/2026 at 10:05 AM, she confirmed that Resident #37's fingernails were very long and dirty with a dark black/brown substance underneath. She confirmed Resident #37 had a physician order for weekly diabetic nail care documented on the Treatment Administration Record (TAR). Record review of the TAR, with the DON, revealed an order for Diabetic nail care weekly by nurse on Thursday. Diabetic nail care was documented as completed on 7/2/2026 by the Treatment Nurse. During an interview on 7/9/2026 at 10:26 AM, with the DON and the Treatment Nurse, the Treatment Nurse acknowledged he did not perform diabetic nail care for Resident #37 on 7/2/2026, although he documented on the TAR that the care had been completed. During an interview on 7/9/2026 10:38 AM, the Administrator confirmed nurses should not document care that has not been provided or medications/supplements that have not been administered. Record review of the admission Record indicated Resident #37 was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus with Hyperglycemia. Record review of the Minimum Data Set (MDS), with an ARD of 4/21/2026, revealed under Section C a BIMS score of 15, indicating Resident #37 was cognitively intact.

Based on observations, resident and staff interviews, record reviews, and facility policy review, the facility failed to develop a comprehensive care plan for restraint use (Resident #35) and for physician-ordered dietary interventions (Resident #76) and the facility failed to implement care plan interventions for pain management (Resident #16) and nail care (Resident #37 and #60) for five (5) of 19 care plans reviewed. Resident #16, Resident #35, Resident #37, Resident #60, Resident #76 Findings Include: Review of the facility policy titled Care Plans-Comprehensive dated 10/2016, revealed, .An individual (person centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . Resident #16 Record review of Resident #16's Care Plan Report revealed, Focus: Resident is at risk for pain .Interventions: Document type, location, and severity of pain .Give medications as ordered . On 7/08/2026 at 2:00 PM, during the Resident Council Meeting Resident #16 stated she had not received her prescribed pain medication since returning from the hospital. During a resident interview, Resident #16 stated she had requested the medication daily for one week and rated her pain as an 8 to 10. Record review of the physician orders and Medication Administration Record (MAR) revealed an active order for Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (milligrams) dated 7/2/2026. Observation of the medication cart on 7/8/2026 at 3:00 PM, revealed Hydrocodone-Acetaminophen Oral Tablet 5-325 Milligrams (MG) was not available on the medication cart for administration for Resident #16. During an interview on 7/09/2026 at 8:10 AM, the Minimum Data Set (MDS) Nurse confirmed Resident #16's pain management comprehensive care plan had not been implemented. She stated the purpose of the care plan is to communicate the resident's individualized interventions and guide staff in providing care. Record review of the admission Record revealed Resident #16 was admitted to the facility on [DATE] with a diagnosis of Heart Failure. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/21/2026 revealed, under Section C, a Brief Interview for Mental Status (BIMS) was 15, indicating Resident #16 was cognitively intact. Resident #35 Review of Resident #35's comprehensive care plan revealed it had not been developed to address the resident's use of a seat belt. Record review of Resident #35's Order Summary Report did not reveal a physician order for the use of a seat belt. On 7/07/2026 at 11:47 AM, during an observation Resident #35 was observed wearing a seat belt while seated in his wheelchair in the dining room. During an interview on 7/09/2026 at 8:11 AM, the MDS Nurse confirmed Resident #35's comprehensive care plan did not address the resident's use of the seat belt. She stated the purpose of the care plan is to communicate the resident's individualized care needs and interventions to staff. Record review of the admission Record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia. Record review of the MDS with an ARD of 6/24/2026 revealed, under Section C, a BIMS with no score, indicating Resident#35 was severely cognitively impaired. Resident #37 Record review of Resident #37's Diabetes Mellites comprehensive care plan revealed, Diabetic nail care weekly by the nurse on Thursday. On 7/7/2026 at 12:37 PM and again on 7/9/2026 at 8:38 AM during an observation and interview with Resident #37, his fingernails were observed to be approximately one and one-half (11/2) inches in length with a dark brown substance underneath. Resident #37 stated, they need to be cut. During an interview on 07/09/2026 at 11:40 AM, the MDS Nurse confirmed that Resident #37's Diabetes Mellitus comprehensive care plan was not implemented since his fingernails had not been cleaned or cut. She stated, The purpose of the care plan is to tell the staff exactly how to care for that person specifically. It should be a one-stop shop that guides their care. Record review of the admission Record indicated Resident #37 was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus with Hyperglycemia. Record review of the MDS, with an ARD of 4/21/2026, revealed under Section C a BIMS score of 15, indicating Resident #37 was cognitively intact. Resident #60Record review of Resident #60's Care Plan Report revealed under, Focus: I have diagnosis of Diabetes Mellitus. The care plan also revealed the following interventions: .Diabetic nail care weekly by nurse on Tuesday . Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails .On 7/7/26 at 11:09 AM, an observation and interview with Resident #60 revealed he was diabetic and needed his toenails cut. The resident stated he had been asking staff for a while but could not get anyone to do it, stating, They didn't seem interested in anything I had to say; Then I was told later on they would have to get podiatry, but I am still waiting. Observation revealed both great toenails were excessively long, curved, and thick, measuring approximately two (2) inches in length. The remaining toenails were long, measuring approximately one-fourth (1/4) inch, with jagged outer edges.An interview with the MDS Nurse on 7/9/26 at 11:38 AM confirmed Resident #60's care plan for nail care had not been followed. She stated the resident had a podiatry referral on his care plan; however, the podiatrist came on Fridays, and the resident attended dialysis on those days.Record review of the admission Record revealed the facility admitted Resident #60 on 8/19/22 with medical diagnoses that included End Stage Renal Disease and Type 2 Diabetes Mellitus with other diabetic kidney complications.Record review of the BIMS dated 4/17/26 revealed a summary score of 15, indicating Resident #60 was cognitively intact. Resident #76 Record review of Resident #76's comprehensive care plan revealed it had not been developed to address the physician-ordered dietary intervention of double portions. On 7/7/2026 at 10:30 AM during an interview Resident #76 stated he was supposed to get double portions with his meals, but he hasn't received that since he had been admitted . Record review of Resident #76's Order Summary Report revealed, Regular diet Regular texture, Regular liquids consistency, Double Portions Active 06/26/2026. During an interview on 07/09/2026 at 11:43 AM, the MDS Nurse confirmed that Resident #76's Dietary/Nutrition comprehensive care plan had not been developed. She stated, The purpose of the care plan is to tell the staff exactly how to care for that person specifically. Record review of the admission Record indicated Resident #76 was admitted to the facility on [DATE] with medical diagnoses that included Heart Failure. Record review of the MDS, with an ARD of 7/2/2026, revealed under Section C a BIMS score of 10, indicating Resident #76 was moderately cognitively impaired.

Based on record review, resident and staff interview, and facility policy review, the facility failed to notify the State Mental Health Authority of a resident with a significant change in status following an inpatient psychiatric admission for one (1) of four (4) Preadmission Screening and Resident Review (PASRR) reviewed. Resident #6 Findings Include:Record review of the facility policy titled Resident Assessment-Coordination with PASARR Program revealed under, Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Additionally revealed under, Policy Explanation and Compliance Guidelines: . 8. Any level II resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review. Examples include: a. A resident who demonstrates increased behavioral, psychiatric, or mood-related symptoms.Record review of Resident #6's Pre-admission Screening Application dated 10/4/18 revealed a Level II PASRR was indicated with a primary diagnosis of Schizophrenia and a secondary diagnosis of Major Depressive Disorder.An interview with Resident #6 on 7/7/26 at 1:59 PM revealed she had been transferred to an inpatient psychiatric facility twice since being admitted to the facility. The resident stated the last time she was transferred was after cutting up her roommate's shirt with scissors to make a pillowcase.Record review of Resident #6's Behavior Note dated 8/10/25 revealed the resident threatened acts of violence toward multiple residents. Additionally, a note dated 8/14/25 revealed the resident was bullying residents, making threats, and cut up another resident's shirt.Record review of the resident's inpatient psychiatric Transition Record revealed the resident was admitted on [DATE] with a diagnosis of Paranoid Schizophrenia.An interview with Social Services (SS) on 7/8/26 at 3:45 PM revealed she was responsible for submitting PASRR referrals. She confirmed the resident had schizophrenia and required an inpatient psychiatric stay due to escalating aggressive behaviors and cutting up her roommate's shirt. SS acknowledged this constituted a significant change in the resident's status. She confirmed she did not submit a status change referral to notify the state mental health authority and stated she was not aware this was a requirement.An interview with the Director of Nursing (DON) on 7/9/26 at 8:50 AM revealed she did not have knowledge related to the PASRR process. She confirmed Resident #6 experienced a significant change in status and acknowledged all PASRR requirements should have been met to ensure the resident received the necessary care in the appropriate setting.Record review of the admission Record revealed the facility admitted Resident #6 on 10/3/18 with medical diagnoses that included Major Depressive Disorder, Schizophrenia, Unspecified, and Anxiety Disorder.Record review of the Brief Interview for Mental Status (BIMS) dated 4/10/26 revealed a summary score of 15, indicating Resident #6 was cognitively intact.

Based on observation, record review, facility policy review, and staff interviews, the facility failed to ensure the residents' right to be free from physical restraints for one (1) of nineteen (19) sampled residents. Resident #35 Findings Include: Review of the facility policy titled Physical Restraints revealed, Restraints shall only be used for the safety and well-being of the residents and only after alternatives have been tried unsuccessfully. Record review of Resident #35's Order Summary Report did not reveal a physician order for the use of a seat belt and lack of quarterly assessments for restraints. Record review did not reveal a Care Plan addressing Resident #35s use of the seat belt. During an observation on 7/07/2026 at 11:47 AM, Resident #35 was observed wearing a seat belt while seated in his wheelchair in the dining room. During an observation and interview with Licensed Practical Nurse (LPN) #2 on 7/08/2026 at 11:45 AM, she stated, I have never seen him take off his seatbelt, and confirmed that the seatbelt would be a restraint. LPN #2 asked resident if he could take off his seat belt independently, Resident #35 was unable to answer the question, and he did not attempt to remove his seat belt. During an interview with the Administrator, she stated she was unaware Resident #35 was using a seat belt and confirmed that there was not a physician's order for the restraint and that there were no quarterly assessments completed. Record review of the admission Record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/24/2026 revealed, under Section C, a Brief Interview for Mental Status (BIMS) with no score, indicating Resident #35 was severely cognitively impaired and was unable to answer the questions. Section P Restraints and Alarms, was coded as 0 not used, related to restraints while in wheelchair.

Based on record review, staff interviews, and facility policy review, the facility failed to accurately code Section P of the Minimum Data Set (MDS) to reflect the resident's use of physical restraint for one (1) of nineteen (19) residents reviewed for MDS accuracy. Resident #35 Findings Include: Review of facility policy titled, MDS Assessment revealed, It is the policy of this facility to follow the Resident Assessment Instrument (RAI) process as set forth by Centers for Medicare and Medicaid Services (CMS) protocol. Record review of Resident #35's MDS with an Assessment Reference Date (ARD) of 6/24/2026 revealed Section P did not identify the resident's use of a seat belt as a physical restraint during the assessment reference period. During an interview on 7/09/2026 at 1:55 PM, the MDS Nurse confirmed Resident #35 used a seat belt during the assessment reference period and acknowledged the resident's use of the seat belt should have been coded in Section P of the MDS. Record review of the admission Record revealed Resident #35 was admitted on [DATE] with diagnoses including Unspecified Dementia. Record review of the MDS with an ARD of 6/24/2026 revealed, under Section C, a Brief Interview for Mental Status (BIMS) had no score, indicating Resident #35 was severely cognitively impaired.

Based on interviews, facility policy reviews, and record reviews, the facility failed to prevent an injury of a resident by not following the established facility policies and procedures for the use of two (2) person assistance with a full body mechanical lift for all transfers. Resident #4 had to seek medical care at the emergency room (ER) for a laceration to her head which required closure with staples. Resident #4 was one (1) of four (4) sampled residents dependent upon full body mechanical lifts for all transfers. Based on the facility's implementation of corrective actions on 11/06/24 through 11/11/24, the State Agency (SA) determined the deficiency to be Past Non-Compliance. Findings Include: Review of the facility policy titled Modified Lifting Policy for Zero Back Injury (ZBI) Program dated 1/24/22 revealed, I acknowledge that if I choose to use a lift without a second person to assist, fail to apply the sling correctly, and fail to use the correct lift specified on the residents care guide I will risk causing injury to that resident. I will be terminated from employment and my actions will be reported to appropriate state agencies as abuse. The policy was signed and dated by Certified Nursing Assistant (CNA) #1 and signed and dated 10/22/24 by the Staff Development Nurse Licensed Practical Nurse (LPN) #4. Review of the ZBI In-service Record dated 1/24/2022 signed by CNA #1 and LPN #4 dated 10/22/24 revealed: 2 (two) person assist is required both Stand Lift and Total Lift NEVER lift a resident by yourself. You must be assisted by a trained and qualified staff member (the nurse or CNA). The record review of the emergency room (ER) report dated 11/06/2024 read: Chief Complaint Patient presents with Head Injury. [AGE] year old female presents to the emergency department via (by) EMS (Emergency Management Services) from nursing home with head laceration from Hoyer lift. Interventions include local anesthesia and 6 staples. On 01/13/25 at 12:30 PM, an interview with the facility Administrator (ADM) revealed that on 11/06/24 at approximately 6:00 AM CNA #1 used the full body mechanical lift to transfer Resident #4 from her bed to the wheelchair without obtaining or requesting assistance from a second staff member. The facility policy was not followed by CNA #1 which caused a head injury to Resident #4. The ADM stated that they suspended CNA #1 immediately after the alleged event on 11/06/24 and began a facility investigation into the incident. ADM provided documentation of the investigation and provided documentation of the lift policies. The facility conducted a thorough investigation of the incident and on 11/11/24 the facility terminated CNA #1 for not following the facility policies and procedures for the use of full body mechanical lift. The ADM stated that Resident #1 was sent out to the local emergency room (ER) for treatment of a head injury and several staples were placed in the head of Resident #1 to close the wound and stop the bleeding. The facility immediately in-serviced all staff on the use of mechanical lifts with two (2) persons and an assessment and review of all residents using lifts was conducted along with a Quality Assurance (QA) meeting. Interview on 1/13/25 at 12:50 PM, with the Director of Nursing (DON) revealed that CNA #1 had not requested assistance from other staff and she used the full body mechanical lift alone which caused Resident #1 to hit her head on the door and caused a head injury to Resident #1. The DON confirmed that CNA #1 was terminated from employment on 11/11/2024 for not using two (2) persons assistance with the mechanical lift and confirmed that the CNA had been in-serviced and trained on the use the full body mechanical lifts. Interview on 1/13/25 at 2:10 PM, with the Staff Development nurse LPN #4 revealed that the staff are trained on the use of two (2) persons to assist with the full body mechanical lifts. She revealed there are no staff that do not know that the facility requires two (2) persons to assist with the mechanical lifts and confirmed that CNA #1 was inserviced on 10/22/24. An interview with DON on 1/13/25 at 3:00 PM, she confirmed that CNA #1's written statement was not consistent with the written statements and verbal statements given by the other staff that were working at the facility on 11/06/24 at 6:00 AM. DON confirmed that CNA #1 was terminated from the facility for not following the facility policy for the use of full body mechanical lifts with two (2) person assistance. An interview by telephone on 01/13/25 at 3:30 PM with LPN #5, revealed that she was working the unit on 11/06/24 along with CNA #1. LPN #5 stated that at no time did CNA #1 request for her to assist with the use of a full body mechanical lift to transfer Resident #4. She stated that CNA #1 used the full body mechanical lift with Resident #4 alone and the resident hit her head causing a laceration to the top of her scalp. LPN #5 confirmed that the facility had trained them all on the proper use of lifts and they all had to attend in-services after the incident occurred. An interview on 01/13/25 at 3:35 PM with LPN #6, revealed that CNA #1 came to her and said that Resident #4 had hit her head and was bleeding. LPN #6 went with CNA #1 to Resident #4's room and the resident was alone in the room, sitting up in a wheelchair with blood dripping down her face. LPN #6 stated that she attempted to find the source of the bleeding but because of the large amount of blood, she was unable to locate the source. She immediately called for the ambulance. LPN #6 stated that she was concerned about Resident #4 because there was so much blood coming from the cut to her head. The ambulance came quickly and took Resident #4 to the ER. LPN #6 stated that only the resident, the full body mechanical lift, and CNA #1 were in the room with Resident #4 when she arrived to assess Resident #4. LPN #6 confirmed that CNA #1 had not obtained assistance to use the full body mechanical lift with Resident #4. Surveyor attempted several times to reach CNA #1 by telephone to obtain an interview but was unsuccessful. Record review of the facility's investigation revealed a hand-written statement signed by CNA #1 that read: On October the 6th at 6:00 in the morning, (Resident #4) was to be dressed and ready. I asked the nurse for assistance, her cart was on the hall I walked up front and asked for her assistance, I proceeded to continue to assist (Resident #4) by dressing her and preparing her for transfer to dialysis. By 6:00 AM I weighed her in the bed on the lift, then nurse comes stand in the door across from her cart with her hand on her hip, looking up the hall, I move the lift around the floor to move (Resident #4) to the chair the lift pad swings back and forth and (Resident #4) swings into the side of the door, she hits her head on the corner of the back door. I proceed to put (Resident #4) in the chair then I see she is bleeding I look up the nurse has stepped away I call her, and has to go back up front to get her. I told her what happened and asked why was she bleeding she said she was a dialysis patient, and she was gone send her out. I told her as I was moving the lift she swung into the corner of the door it happened so fast. The record review of the hand written statement of CNA #1 contained the date of October 6th and the names of the nurses that were called to the room of Resident #4 were not revealed in the statement of CNA #1. The hand written statements of the other staff that were interviewed were not consistent with the hand written statement of CNA #1. The statement of CNA #1 did not name a second person to assist with the use of the full body mechanical lift. CNA #1's statement did indicate that she used the full body mechanical lift alone and an incident occurred that caused a head injury to Resident #4. Record review of the Admission Record of Resident #4 revealed that she was admitted to the facility on [DATE] with diagnosis that included Inflammatory Polyps of Colon with intestinal obstruction; End Stage Renal Disease; Type 2 Diabetes; Heart Failure; and Cognitive Communication Deficit. Record review of Resident #4's Minimum Data Set (MDS) Section C, with an Assessment Reference Date (ARD) of 09/20/24, revealed a Brief Interview for Mental Status (BIMS) score 3, which indicated that Resident #4 was severely cognitively impaired. Record review of the facility in-services after the incident and the investigation records revealed that the facility had corrected all deficiencies created by the fall of the resident from the improperly used lift. CNA #1 acted alone and had been thoroughly trained as to the procedures for using the lifts. The facility also reviewed their policies with no changes made to the policies and conducted a QA meeting on 11/06/24 as well as conducted a thorough investigation. The State Agency (SA) reviewed the Quality Assurance (QA) meeting, the lift in services that began on 11/06/24 and reviewed the documentation that the facility terminated CNA #1 on 11/11/24. The facility continued to monitor falls, accidents and monitored the lift policy throughout the next eight (8) weeks through their QA program and meetings. The deficient practice had been corrected on 11/11/24 prior to the State Agency (SA) entering the facility on 01/13/2025. The SA validated through interviews, observation, and record reviews that on 11/11/2024 the deficiency was Past Non-Compliance (PNC) and all corrections had been made.

Based on interviews, facility policy review, and record reviews, the facility failed to implement the care plan for a two (2) person assist with the use of a full body mechanical lift for all transfers of Resident #4. Resident #4 sustained a head injury and received medical treatment at the emergency room (ER) as a result of the misuse of the full body mechanical lift. Resident #4 was one (1) of four (4) sampled residents in the facility identified as dependent upon the full body mechanical lift with two (2) persons assistance for transfers. Based on the facility's implementation of corrective actions on 11/06/24 through 11/11/24, the State Agency (SA) determined the deficiency to be Past Non-Compliance. Findings include: Record review of the facility policy titled, Care Plans-Comprehensive, revised 10/2016 revealed, 2. The comprehensive care plan is based on a thorough assessment that includes . a. Incorporate identified problem areas: b. Incorporate risk factors associated with identified problems . f. Identify the professional services that are responsible for each element of care. Record review of Resident #4's care plan with a revision date of 08/24/21 titled, Focus: I require assistance with Activity of Daily Living (ADL) related to generalized muscle weakness, lack of coordination, impaired balance, abnormalities of gait and mobilities. Interventions: Transfer use total lift. Requires extensive assist times (x) two (2). The record review of the emergency room (ER) report dated 11/06/2024 read: Chief Complaint Patient presents with Head Injury. [AGE] year old female presents to the emergency department via (by) EMS (Emergency Management Services) from nursing home with head laceration from Hoyer lift. Interventions include local anesthesia and 6 staples. An interview with the facility Administrator (ADM) on 01/13/25 at 12:30 PM revealed that on 11/06/2024 at approximately 6:00 AM CNA #1 used the full body mechanical lift to transfer Resident #4 from her bed to the wheelchair without obtaining or requesting assistance from a second staff member. The facility policy nor the resident's care plan was followed by CNA #1 which caused a head laceration to Resident #4. The facility policy and procedure for using the full body mechanical lift was to utilize two staff to assist and operate the full body mechanical lift. The ADM provided documentation of the investigation and provided documentation of the lift policies. On 1/13/25 at 12:50 PM, interview with the Director of Nursing (DON) stated that Resident #4 was care planned for two (2) person assistance with mechanical lift with all transfers and confirmed that CNA #1 did not follow the care plan for Resident #4 when she transferred the resident without a second person to assist. On 1/13/25 at 2:10 PM, in an interview with the Staff Development Nurse Licensed Practical Nurse (LPN) #4 confirmed that Resident #4 was care planned for two (2) persons assistance with the use of full body mechanical lifts for all transfers. Interview with DON on 1/13/25 at 3:00 P.M. she confirmed that Resident #4 received a head injury and had to be sent to the ER for medical treatment as a result of the inappropriate use of the full body mechanical lift by CNA #1. Attempted several times to reach CNA #1 by telephone to obtain an interview but was unsuccessful. Record review of the facility's investigation revealed a hand-written statement signed by CNA #1 that read: On October the 6th at 6:00 in the morning, (Resident #4) was to be dressed and ready. I asked the nurse for assistance, her cart was on the hall I walked up front and asked for her assistance, I proceeded to continue to assist (Resident #4) by dressing her and preparing her for transfer to dialysis. By 6:00 AM I weighed her in the bed on the lift, then nurse comes stand in the door across from her cart with her hand on her hip, looking up the hall, I move the lift around the floor to move (Resident #4) to the chair the lift pad swings back and forth and (Resident #4) swings into the side of the door, she hits her head on the corner of the back door. I proceed to put (Resident #4) in the chair then I see she is bleeding I look up the nurse has stepped away I call her, and has to go back up front to get her. I told her what happened and asked why was she bleeding she said she was a dialysis patient, and she was gone send her out. I told her as I was moving the lift she swung into the corner of the door it happened so fast. Record review of the Admission Record of Resident #4 revealed the facility admitted the resident on 02/27/2024 with diagnoses that included Inflammatory Polyps of Colon with intestinal obstruction; End Stage Renal Disease; Type 2 Diabetes; Heart Failure; and Cognitive Communication Deficit. Record review of Resident #4's Minimum Data Set (MDS) Section C, with an Assessment Reference Date (ARD) of 09/20/24, revealed a Brief Interview for Mental Status (BIMS) score 3, which indicated that Resident #4 was severely cognitively impaired. Record review of the facility in-services after the incident and the investigation records revealed that the facility had acted quickly and had corrected all deficiencies created by the fall of the resident from the improperly used lift. CNA #1 acted alone and had been thoroughly trained as to the procedures for using the lifts. The facility also reviewed their policies with no changes made to the policies and conducted a QA meeting on 11/06/24 as well as conducted a thorough investigation. The State Agency (SA) reviewed the Quality Assurance (QA) meeting, the lift in services that began on 11/06/24 and reviewed the documentation that the facility terminated CNA #1 on 11/11/24. The facility continued to monitor falls, accidents and monitored the lift policy throughout the next eight (8) weeks through their QA program and meetings. The deficient practice had been corrected on 11/11/24 prior to the State Agency (SA) entering the facility on 01/13/2025. The SA validated through interviews, observation, and record reviews that on 11/11/2024 the deficiency was Past Non-Compliance (PNC) and all corrections had been made.

Based on observation, staff interview, resident representative interview, and facility policy review, the facility failed to ensure that each resident was treated with dignity as evidenced by failure to cover unclothed residents that were visible from the hallway, and failure to provide a privacy bag for a catheter for three (3) of twenty-two sampled residents. Resident #5, Resident #55 and Resident #228. Findings include: Review of the facility policy titled, Maintaining Privacy and Dignity for Residents with Foley Catheter Drainage Bags undated, revealed It is the policy of this facility to provide privacy and dignity to all residents that have a urinary drainage bag in use. The drainage bag will be maintained in a storage pouch to hide the contents and prevent embarrassment to the resident . Review of the facility policy titled Privacy/Dignity During Care with a revision date of 8/2015 revealed under, Policy: It is the policy of this facility to provide privacy and dignity to our residents while providing care. Also revealed under, Procedure: Privacy curtains, window blinds/curtains and draping of the resident will be done when providing care to ensure privacy and dignity . An observation outside Resident #5's room doorway on 6/25/2024 at 8:40 AM, revealed the room door was open, and he was sitting in a wheelchair eating breakfast dressed only in a brief. An observation and interview with Certified Nurse Aide (CNA) #4 on 6/25/2024 at 8:45 AM revealed when Resident # 5 was up in his room, he would not allow them to dress him at times. She acknowledged the resident was visible from the hall and confirmed this was a privacy concern. An observation outside Resident #5's room door on 6/25/2024 at 12:10 PM revealed, the door was open, and he was sitting in his wheelchair eating lunch dressed only in a brief. A telephone interview with Resident #5's Resident Representative (RR), on 6/25/2024 at 2:01 PM, revealed that the resident was not the kind of person to sit around without any clothes on. She revealed, if he was cognizant, he would not like the fact that he was being seen by visitors and staff with only a brief. An interview with the Administrator (ADM) on 6/26/2024 at 8:05 AM, regarding Resident #5 revealed they had tried closing his room door, but the resident would open it back up. She explained that the resident would remove his clothing and acknowledged that dignity was a concern for the resident, as he could be easily viewed by visitors and staff from the hall. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/15/2024 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 6, which indicated Resident #5 is severely cognitively impaired. Record review of the Admission Record revealed the facility admitted Resident #5 on 6/26/2019. Resident #55 An observation on 6/26/2024 at 7:55 AM and 8:05 AM, outside Resident #55's room door revealed, the door was open, and he was lying in bed with no clothing on and no bed cover, leaving him exposed and a urinal was in place between his legs. An observation and interview with CNA #5 on 6/26/2024 at 8:06 AM revealed Resident #55's door must always remain open because the resident requires close supervision. She acknowledged the resident was viewable from the hall and this was a privacy issue. An interview with the ADM on 6/26/2024 at 8:07 AM revealed Resident #55's RR made them leave the door open because she was scared that something could happen to him. The ADM stated that the resident would not keep any bed cover on and was always kicking and pulling it off. She revealed that the RR would not allow them to put clothing on him, only a hospital gown, which he always removed. She confirmed this was a dignity concern when the resident is naked and exposed to anyone in the hallway. An interview with Registered Nurse (RN) #2 on 6/26/2024 at 11:03 AM, revealed they keep the door open for Resident #55 because he coughs and spits a lot. She revealed that he fights the staff and refused to wear a gown or keep bed linen on and if he wears a brief, but he was constantly pulling his penis out. She revealed that it was the resident's preference. RN #2 acknowledged it could be seen by others as a dignity concern. A telephone interview with Resident #55's RR on 6/26/2024 at 2:49 PM, revealed she did not want him lying down there without clothes. She revealed she had asked them to leave the door open because he had fallen one time, and she wanted them to be able to check on him as they walked down the hall. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/18/2024 revealed, under section C, Resident #55's cognitive skills for daily decision-making are severely impaired. Record review of the Admission Record revealed the facility admitted Resident #55 on 11/11/2021 with medical diagnoses that included personal history of traumatic brain injury and hemiplegia. 46013 Resident #228 An observation on 06/25/24 at 11:05 AM, and 2:10 PM, revealed Resident #228 lying in bed with a urinary catheter bag and tubing hanging on the right-hand side of the bed facing the entrance room door visible from the hallway and anyone entering the room. Urine was noted in the catheter bag with no privacy covering over the urinary drainage bag. An observation on 06/26/24 at 8:20 AM, revealed Resident #228 lying in bed with a urinary catheter bag that was noted without a privacy bag, with urine visible. The urinary drainage bag was hanging on the right side of the bed facing the entrance room door and was visible to anyone entering the room and visible from the hallway. During an observation and interview, on 06/26/24 at 9:15 AM, the RN Nurse Supervisor confirmed that the resident's urinary catheter bag was uncovered and visible to anyone entering the room and visible from the hallway. She revealed that all urinary catheter bags are to be kept in a covered privacy bag and that it is a dignity issue for the resident. A record review of Resident #228's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic kidney disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/13/24, revealed Resident #228 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident has a moderate cognitive impairment.

Based on observation, staff and resident interview, record review and facility policy review the facility failed to ensure a residents call light was within reach for one (1) of 22 residents sampled. Resident #24 Findings Include Review of the facility policy titled, Call Light, Answering with no revision date revealed under, Key Procedural Points .#5. When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. An observation and interview on 06/25/24 at 8:15 AM, revealed Resident #24 was sitting on the side of the bed receiving Oxygen (O2) via (by) nasal cannula. The resident stood up and said she needed to go to the bathroom, with no shoes on and nasal cannula still attached, she attempted to take two steps and stated she needed help, but admitted she did not know where her call light was located. An observation revealed the resident's call light was out of the residents reach and behind the privacy curtain on her roommate's side of the room, lying in a chair. An interview on 6/25/24 at 3:00 PM, with Licensed Practical Nurse (LPN) #2 confirmed that Resident #24's call light should be in her reach as well as all resident's call lights. She stated that the resident can sometimes take a few steps but normally needs help. An interview and observation on 6/26/24 at 8:17 AM, with Certified Nurse Assistant (CNA) #2, upon entering the room, confirmed that the call light was not within the residents reach but needed to be. An interview on 6/26/24 at 1:30 PM, with CNA #3 confirmed that Resident #24 needed help getting up and going to the bathroom and she uses her call light sometimes. She stated her call light should always be within her reach. An interview on 6/26/24 at 3:10 PM, with the Administrator confirmed that all residents call lights need to be within their reach at all times so they can request help or assistance if needed. Review of Resident #24's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Acute Pulmonary Edema. Review of Resident #24's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/21/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 03, which indicated the resident is severely cognitively impaired and in Section GG that the resident needed partial assistance from another person to complete any activities.

Based on facility policy/procedure review, record review, and staff interview; the facility failed to provide adequate supervision for two (2) of six (6) residents reviewed as evidenced by on 11/27/15, Resident #2 and Resident #3 had a resident to resident physical altercation resulting in Resident #2 receiving a Closed Fracture of the Nasal Bone and Left Lens Dislocation and Subluxation. Findings include: Review of the facility's policy/procedure review of Preventing Resident Abuse, revised 5/2005, revealed Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: j. Assessing, care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect. Record review of the facility's incident log from 9/11/15-12/8/15 revealed that Resident #2 and Resident #3 had 3 different resident to resident incidents. Resident #2 and Resident #3 shared a room on the facility's Dementia Unit. Review of the investigation from the 11/27/15 incident between Resident #2 and Resident #3 revealed Resident #3 hit Resident #2 with the power cord to the room's air-conditioner/heater unit resulting in Resident #2's receiving a Closed Fracture of the Nasal Bone and Left Lens Dislocation and Subluxation. The facility transferred Resident #2 to the hospital and transferred Resident #3 to Geri-Psych on 11/27/15. Resident #3 has since been discharged from the facility. Review of nurses notes, dated 11/27/15, revealed Resident #2 was assessed by nurse and sent to hospital by ambulance after the resident to resident altercation with a Closed Fracture of the Nasal Bone and Left Lens Dislocation and Subluxation Review of physician's orders [REDACTED].#2 upon return to the facility from hospital revealed orders for Cephalexin 500 mg four times a day for 10 days, Pred Forte Suspension 1% one drop in left eye twice a day, and appointment with Opthalmology Clinic on 11/30/15. An interview with Certified Nurse Aide (CNA) #1 on 12/8/15 at 3:00 AM revealed that on 11/27/15, on the 11-7 shift, Resident #3 came out of her room asking to get dressed to go home. Certified Nurse Aide (CNA) #1 took Resident #3 back to her room. Upon entry into the room, CNA #1 noted Resident #2 was sitting on Resident #3's bed. It was then noted that Resident #2 was bleeding from the nose. Resident #3 said she had hit Resident #2 with a stick and pointed to the air-conditioner/heater cord. This cord had blood on it. Resident #3's gown had blood noted on it. Resident #2 was sent to the hospital and staff sat with Resident #3 the remainder of the shift. There was never any screaming or yelling from either resident during the time of the incident. Review of Resident #2's physician's orders [REDACTED]. Interview with the Director of Nursing (DON), on 12/8/15 at 6:10 AM, revealed I told staff to monitor Resident #2 and Resident #3 closer after the 1st incident. Resident #3 has not acted this way toward any other roommates. This is a new behavior for Resident #3. Resident #2 has not been in an altercation with anyone else. She wasn't the aggressor either time. DON confirmed that the facility has discharged Resident #3 to the geri psych unit and is assisting the family in finding suitable placement. The family retrieved Resident #3's personal items on 12/9/15 and apologized for the actions of the resident. Record review of Resident #2 revealed the facility admitted Resident #2 admission to the facility's Dementia Unit on 6/22/15 with the [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/21/15, revealed a Brief interview of Mental Status (BIMS) of a three (3); resident was unable to make any independent decisions. Behaviors were care-planned. Medications include: Ativan 0.5 mg twice a day (BID), Namenda 10 mg one (1) at bedtime (HS), Namenda 5 mg one (1) every day and Risperidone 0.5 mg BID. Record review of Resident #3 revealed an admission date of [DATE] with the [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 9/23/15 revealed a BIMS of 3; resident was unable to make independent decisions. Resident #3 was care-planned for behaviors. Medications include: Aricept 10 mg 1 HS, Namenda 10 mg BID, Remeron 45 mg at HS.

Based on policy/procedure review, record review and staff interview; the facility failed to revise the comprehensive care plan of two (2) of six (6) residents reviewed (Resident #2 and Resident #3) as evidenced by failure to revise interventions on the care plan when on 10/18/15, there was a resident to resident incident between Resident #2 and Resident #3. Another resident to resident incident occurred on 11/27/15 between Resident #2 and Resident #3 resulting in Resident #2 receiving a Closed [MEDICAL CONDITION] Bone and Left Lens Dislocation and Subluxation. Findings include: Review of the facility's policy/procedure for Care Plans-Comprehensive, last revised 1/13/05, revealed A comprehensive care plan shall be developed for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing and psychological needs. 4. Care Plans are revised as changes in the resident's condition dictate. Reviews are made at least quarterly. Record review revealed three (3) incidents between Resident #2 and Resident #3 on 9/24/15, 10/27/15, and again on 11/27/15. Resident #2 and Resident #3's Behavior care plan were updated with the 9/24/15 incident and were again updated with the 11/27/15 incident. Review of Resident #2's care plan and Resident #3's care plan revealed there were no revisions to the care plan related to the 10/27/15 incident to deter further resident to resident incidents. Interview with the Director of Nursing (DON) on 12/9/15 at 10:30 AM revealed, I don't know why the care plan wasn't updated after the October incident. She stated that after the October 2015 incident, there were no medication changes for either Resident #2 or Resident #3 and the two residents remained roommates. She did state the change after the October incident was that staff made hourly rounds on these two (2) residents and that during the day; they are closely monitored and spend the majority of their days in the Dementia Unit dayroom. There is not an updated care plan for the 10/18/15 incident. She said that floor nurses update the care plans on the charts after an incident. The MDS nurse will update the care plan in the computer. The RN supervisor will check the charts to make sure care plans are updated. The facility failed to provide documentation of the hourly rounds. Interview with Certified Nurse Aide #1 on 12/8/15 at 3:00 AM confirmed that hourly rounds were made on Resident #2 and Resident #3. Interview with Registered Nurse (RN) #1 on 12/9/15 at 2:20 PM revealed I think the Minimum Data Set (MDS) nurse updated care plans with falls, incidents. Interview with Minimum Data Set (MDS) nurse on 12/9/15 at 2:25 PM revealed that the nurse that completes the incident report was responsible for updating the care plans and that the MDS Nurse updates the care plans quarterly during the MDS process. Following the 11/27/15 incident, the facility sent Resident #3 to inpatient Geri Psych services and discharged the resident from the facility. Resident #2 had surgery to the left eye to reattach the lens. Record review of Resident #2 revealed admissions to the facility's Dementia Unit on 6/22/15 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/21/15 revealed a Brief interview of Mental Status (BIMS) of a three (3); resident is unable to make any independent decisions. Behaviors were care-planned. Medications included [MEDICATION NAME] 0.5 mg twice a day (BID), [MEDICATION NAME] 10 mg 1 at bedtime (HS), [MEDICATION NAME] 5 mg 1 every day and [MEDICATION NAME] 0.5 mg BID. Record review of Resident #3 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD of 9/23/15 revealed a BIMS of three (3); resident is unable to make independent decisions. Resident #3 was care-planned for behaviors. Medications included [MEDICATION NAME] 10 mg 1 HS, [MEDICATION NAME] 10 mg BID, [MEDICATION NAME] 45 mg at HS.