Every finding on record at Huebner Creek Health & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation was implemented for 2 of 3 residents (Resident #1 and Resident #2) reviewed for pharmacy services. The facility failed to ensure narcotic medications were accurately documented and reconciled on 5/29/26, 5/31/26, 6/1/26, and 6/2/26 for Resident #1 and 5/26/26, 5/28/26, 5/29/26, and 5/31/26 for Resident #2. These failures could result in the loss of residents' property, diversion of narcotics, and residents not receiving intended medication regimens. Findings included: Record review of Resident #1's admission Record dated 6/02/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included paraplegia (partial or complete paralysis of the lower extremities). Record review of Resident #1's admission MDS dated [DATE] reflected a BIMS score of 14, which indicated intact cognition. MDS revealed Resident #1 presented with occasional pain within the past 5 days. Resident pain intensity was documented as a 2 on a scale of 0 out of 10 and received pain medication regimen. Record review of Resident #1's Care Plan Report undated/ printed 6/02/2026, reflected the following:The resident has a potential for uncontrolled pain.Date Initiated: 3/27/2026 Record review of Resident #1's Order Summary Report dated 6/02/2026, reflected the following order dated 4/20/2026:oxyCODONE [sic] HCl Oral Tablet 5 MG (Oxycodone HCl)Give 1 tablet by mouth every 8 hours as needed for pain Record review of Resident #1's May 2026 Treatment Administration Record, dated 6/02/2026, for Resident #1's oxycodone 5mg tablet administration reflected the following were not documented as administered on the following dates: 5/29/2026 at 4:30 PM, 1 dose of oxycodone 5mg removed by illegible staff signature5/31/2026 at 2:00 PM, 1 dose of oxycodone 5mg removed by illegible staff signature5/31/2026 at 10:10 PM, 1 dose of oxycodone 5mg removed by illegible staff signature6/1/2026 at 9:00 PM, 1 dose of oxycodone 5 mg removed by illegible staff signature Record review of Resident #1's June 2026 Treatment Administration Record, dated 6/02/2026, for oxycodone 5mg tablet administration reflected on 6/2/2026 12:43 PM, 1 dose of oxycodone 5mg documented as administered by LVN A on the June 2026 TAR. Record review of untitled facility document dated 5/29/2026 used to track Resident #1's oxycodone 5mg tablet administration reflected the following:1. 5/29/2026 at 4:30 PM, 1 dose of oxycodone 5mg removed by illegible staff signature. 2. 5/31/2026 at 2:00 PM, 1 dose of oxycodone 5mg removed by illegible staff signature.3. 5/31/2026 at 10:10 PM, 1 dose of oxycodone 5mg removed by illegible staff signature.4. 6/1/2026 at 9:00 PM, 1 dose of oxycodone 5mg removed by illegible staff signature. 5. 6/2/2026 12:43 PM, 1 dose of oxycodone 5mg was not documented as removed on the narcotic tracking document.Further review revealed the remaining total count of tablets noted by final entry on the narcotic tracking document was entered as 7 by the entry dated 6/2/2026 at 04:00 AM. In an observation on 6/2/2026 at 3:40 PM, a blister pack identified on the pharmacy label as oxycodone 5mg tablets belonging to Resident #1 contained 6 total tablets. In an interview on 6/04/2026 at 9:55 AM, Resident #1 said she had no concerns about the administration of her pain medication. She said she had received a dose whenever she asked for it within the window of administration time, and she did not have concerns that she was receiving a medication other than what was prescribed to her. Record review of Resident #2's admission Record dated 6/03/2026 reflected an [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE]. Relevant diagnoses included chronic pain syndrome (when a person feels continuous, ongoing pain). Record review of Resident #2's admission MDS dated [DATE] reflected a BIMS score of 15, which indicated intact cognition. MDS revealed resident received pain medication regimen within the last 5 days and the resident had not presented with pain within the last 5 days. Record review of Resident #2's Care Plan Summary undated, printed 6/03/2026, reflected the following:The resident is on Pain [sic] medication Therapy [sic]Date Initiated 5/07/2026 Record review of Resident #2's Order Summary Report dated 6/03/2026 reflected the following order dated 5/14/2026:HYDROmorphone [sic] HCl Oral Tablet 2mg (Hydromorphone HCl) Give 0.5 tablet by mouth every 6 hours as needed for pain 1/2 tablet equals 1mg Record review of Resident #2's Treatment Administration Record for May 2026 dated 6/02/2026, for Resident #2's hydromorphone 2mg tablet administration reflected the following:5/26/2026: TAR reflected 2 total doses were administered on 5/26/2026 at 1:15 PM and 7:21 PM, both by LVN A. 5/28/2026: TAR reflected 2 total doses were administered on 5/28/2026 at 5:40 AM by LVN B and 6:55 PM by LVN A. 5/29/2026: TAR reflected 1 dose was administered on 5/29/2026 by LVN C at 12:02 PM. 5/31/2026: TAR reflected 1 dose of hydromorphone 2mg was administered on 5/31/2026 at by LVN D at 7:46 AM. Record review of the untitled facility document dated 5/15/2026 used to track Resident #2's hydromorphone 2mg tablet administration reflected the following:1. 5/26/2026: 3 total doses of hydromorphone 2mg tablets were removed at 3:00 AM, 9:00 PM, and 9:00 PM by illegible staff signatures. 2. 5/28/2026: 3 total doses of hydromorphone 2mg tablets were removed at 3:40 AM, 1:00 PM, and 9:00 PM by illegible staff signatures. 3. 5/29/2026: 2 total doses of hydromorphone 2mg tablets were removed at 12:00 PM and 9:00 PM by illegible staff signatures. 4. 5/31/2026: 2 total doses of hydromorphone 2mg tags were removed at 7:46 AM and 3:14 PM by illegible staff signatures. Further review revealed that the remaining total count of tablets noted by final entry on the narcotic tracking document was entered as 22 by the entry dated 6/2/2026 at 03:00 AM. In an observation on 6/02/2026 at 3:40 PM, the blister pack identified as containing Resident #2's hydromorphone 2mg tablets by the pharmacy label was observed to contain 21 tablets. In an interview on 6/04/2026 at 9:40 AM, Resident #2 said she had no concerns or issues regarding administration of her pain medication. She said she received the medication when she requested it, and the pill always looked the same. In an interview with LVN A on 6/2/2026 at 3:45 PM, she said she was responsible for many or most of the discrepancies in Resident #1 and Resident #2's narcotic records. She declined to review each discrepancy individually. She said she frequently forgot to document in the TAR when she administered pain medications, and she said she had not yet documented medications removed from the blister packs for Resident #1 and Resident #2, which was why there was a discrepancy in the count during the observation on 6/2/2026 at 3:40 PM. She said the inconsistencies for both residents were documentation only, and the medications had been administered. She denied diverting narcotic medications from the residents. She said the facility policy was to document in the TAR and on the tracking document as the medications are administered, but she often forgot. In an interview with the DON on 6/2/20276 at 3:55 PM, she the facility policy was to document narcotics both in the TAR and on the tracking document at the time the medications are administered. She said LVN A was aware of the policy and had been trained, and she was unaware LVN A had been deviating from the policy. She said the potential harm of inaccurate documentation was missing medications or residents not receiving their medications. Record review of the facility policy Medication Administration and General Guidelines dated 2025 reflected the following: .9. Except for single unit dose packet distribution systems, only the licensed or legally authorized personnel who prepare a medication may administer it. This person then records the administration on the residents [sic] MAR at the time the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ascertain that all necessary doses were administered and documented. In no case should the individual who administered the medications report off duty without first recording the administration of any medications .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure the kitchen was free from insects in the dry storage area and standing water in the walk-in refrigerator and freezer areas on 6/03/2026. This failure could lead to food contamination and illness. Findings included: In an observation of the kitchen, on 6/03/2026 at 10:54 AM, revealed the following; Two dead insects were observed in the dry storage area of the facility, underneath wire storage racks.A large, gray, plastic tub without a lid was observed in the walk-in fridge. The tub held a sealed bag of yellow food product. A moderate amount of loose, brown water was also observed in the bottom tub. In the walk-in freezer, icicles were noted to be frozen on the sprinkler head, and a thin layer of ice coated one corner of the freezer beneath the wire storage racks. In an interview on 6/03/2026 at 11:15 AM, she said the kitchen staff was responsible for sweeping underneath the storage racks in the dry storage room every evening. She attributed the brown water in the gray tub located in the walk-in refrigerator to the sprinkler head located above the wire rack. She said the sprinkler head was known to leak water into the refrigerator and cooler areas after it rained, and she said that was also why there were icicles on the sprinkler head and ice on the floor in the walk-in freezer. She said she had not notified the Maint. Dir. or Admin. of the possible leaking sprinkler heads. In an interview with the Maint. Dir. on 6/03/2026 at 11:30 AM, he said a different sprinkler head had been repaired at the facility a couple of days prior, but he was not aware there were any leaks in the kitchen. He also said the facility's contracted pest control company had been to the facility multiple times in the past month for reports of insects from residents, but they had no findings in the kitchen areas. Record review of the facility policy titled Food Storage and Supplies dated 2012 reflected the following:All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, [sic] and insects . Storeroom floors should be swept and mopped to be maintained in a sanitary manner to prevent vermin or pest infestation .

Based on observation, interview, and record review, the facility failed to ensure residents were provided a sanitary and comfortable environment for 1 of 8 residents (Resident #3) reviewed for physical environment. The facility failed to ensure Resident #3's room was free from dead insects and had hot water available through the hand sink. These failures could lead to decreased quality of life. Findings included: Record review of Resident #3's admission Record dated 6/02/2026 reflected an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included acquired absence of unspecified leg below knee (surgical procedure to remove the lower leg). Record review of Resident #3's admission MDS submitted 5/15/2026 reflected a BIMS score of 14, which indicated intact cognition. In an observation of Resident #3's room, on 6/03/2026 at 10:00 AM, revealed the following: was observed to have multiple, disposable insect traps on the floor along the perimeter of the room. One of the disposable traps was observed to contain a dead insect. Additionally, the hot water tap from the hand sink measured at 77.1 degrees Fahrenheit after continuous flow for 1 minute. The temperature of the water was 77.3 degrees Fahrenheit after 4 minutes of continuous flow, and 78 degrees Fahrenheit after 8 minutes. In an interview and observation on 6/03/2026 at 10:00 AM, Resident #3 said the sink in her room has not consistently had hot water since she arrived at the facility. She said her private caregivers are able to obtain hot water from the shower room down the hall to assist her with personal care, but it was inconvenient. She said she had reported this issue to the nursing staff. She also said she frequently sees insects crawling on the walls and ceilings at night, and an exterminator had come to spray something in her room earlier in the week, but the infestation continued. She said the disposable insect traps contained dead insects and had been in place for multiple weeks. She said knowing the traps contained dead bugs made her feel disgusted. There were no live insects observed in the resident's room, closet, or bathroom. In an interview with the Maint. Dir. on 6/03/2026 at 10:30 AM, he said he was aware the hallway where Resident #3 resided intermittently experienced hot water issues. He said he had previously made adjustments to the device that circulates hot water, and he had not been notified of any issues since then. The Maint. Dir. said he was aware of complaints from Resident #3 regarding insect infestation, and the contracted exterminator had been to the facility several times in the last month to perform inspections and treatment. He also said the disposable insect traps were placed earlier that week by the exterminator, and the facility was instructed to leave the traps in place so they could be inspected and removed by the exterminator for further treatment. He was unsure when the exterminator was due to remove the traps, but he was unaware the traps in Resident #3's room contained dead insects or that she wanted them removed. In an interview with the Admin. on 6/04/2026 at 12:20 PM, he said he was previously unaware of the hot water issue in Resident #3's room, and the facility was already working on replacing the circulator device to ensure all residents had continuous hot water on demand. He was also previously unaware of the disposable glue traps placed in Resident #3's room, and he said he would have them removed to ensure her comfort. Record review of an invoice #142195 dated 5/19/2026 reflected the following:Called the Maintenance Director, [Maint. Dir.], who said [Resident #3's room] was the only issue. He reported that resident saw a large flying roach on the wall. [Maint. Dir.] couldn't find any evidence of activity. [Resident #3's room]:Resident reported the same info to me as [Maint. Dir.]. No activity found at time of inspection. Treated bathroom with a liquid residual. Placed monitoring stations with roach bait throughout the rest of the room . A policy related to environmental concerns and homelike environment was requested from the facility, and in an interview on 6/04/2026 at 1:20 PM, the Admin. said these concerns are covered within the facility's policy regarding resident rights. Record review of the facility policy titled Resident Rights revised 11/28/2016 reflected the following:Respect and dignity- The resident has a right to be treated with respect and dignity, including: . The right to resident and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents .

Based on interview and record review, the facility failed to ensure residents had a right to confidentiality of his or her personal and medical records for one (1) of six (6) residents (Resident #1) reviewed for privacy and confidentiality. The facility failed to ensure Resident #2's medical records did not contain Resident #1's Administration Report prior to the release of Resident #2's records, dated 04/28/2026, to Resident #2's family member. This deficient practice could place residents at risk of their medical information being accessed by unauthorized individuals. The findings included: Record review of Resident #1's admission Record, dated 05/05/2026, revealed a [AGE] year-old male. He was admitted on [DATE]. Record review of Resident #1's Diagnosis Report, dated 05/05/2026, revealed diagnoses included other sequelae (a condition following a previous disease or injury) following unspecified cerebrovascular disease (a group of conditions that affect the blood flow and blood vessels in the brain), cognitive communication deficit (difficulty communicating due to injury to the brain), and cerebral infarction (a disruption in the brain's blood flow). Record review of Resident #1's Quarterly MDS Assessment, dated 04/08/2026, revealed the resident had a BIMS Score of 11, indicating he was moderately cognitively impaired. He was documented to have fluctuating inattention and disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). Record review of Resident #2's admission Record, dated 05/05/2026, revealed an [AGE] year-old female. She was initially admitted on [DATE], re-admitted on [DATE], and discharged on 03/19/2026. A family member was listed under Contacts as an Emergency Contact. During an interview on 05/05/2026 at 09:07 a.m., Resident #2's family member stated she had requested Resident #2's medical records. She stated upon receiving and reviewing Resident #2's medical records she found one document among Resident #2's records that was on another resident. Record review of a photo submitted by Resident #2's family member on 05/05/2026 at 09:41 a.m. The photo revealed how Resident #2's medical record files were listed on the USB she had received from Nursing Facility A. The files visible in the image were noted to be dated 04/28/2026 at 12:27 p.m. Record review of a photo submitted by Resident #2's family member submitted 05/05/2026 at 10:00 a.m. The photo revealed a printed copy of Resident #1's Administration Record, dated 03/11/2026. The document included Resident #2's name, date of birth , admission dates, insurance type and policy number, and care providers names. The photo submitted was one page and did not include Resident #1's social security number or diagnosis list. During an interview on 05/05/2026 at 03:56 p.m., the MR staff member stated she provided Resident #2's family member with a USB uploaded with Resident #2's medical records after obtaining approval to release the information. She stated per her standard process, she had reviewed the first 15- 17 pages of each file uploaded to the USB to confirm the documents were from Resident #2's profile in the EMR. She stated the ADMIN had notified her on 05/01/2026 that Resident #2's family member told him that another resident's information was in the released documents. She stated upon re-reviewing the released Resident #2 medical record file, on 05/05/2026, she found one document, titled under physician's orders. It was another resident's administration record. She stated she notified the administrator of her finding. She stated she did not know how the other resident's document was uploaded into Resident #2's profile. She stated she believed someone uploaded the wrong document to Resident #2's profile. She stated the error could easily happen. She stated she was unsure if Resident #1 was contacted about the error. She stated the other resident's document (Resident #2's Administration Record) contained his personal information, including his date of birth , resident representative information, and insurance information. She stated for the resident, this type of error could be considered a huge thing. She stated the information was confidential. She stated she understood Resident #2's family member was upset upon finding another resident's document. She stated she had not spoken to Resident #1 about the incident. During an interview on 05/06/2026 at 10:36 a.m., when asked how he felt about his medical and insurance information having been sent to another resident's family member, Resident #1 stated he would not like it but thought it would have been hard to get. He stated he would have been concerned about the information having been used but did not believe the information would have been released. Resident #1 stated he had not been told anything by Nursing Facility A and felt safe. During an interview on 05/06/2026 at 01:18 p.m., the DON stated she had not been notified of any resident's information having been released. She stated she did not deal with medical records. She stated the MR staff member was responsible for releasing medical records. She stated if there was an error, she was not sure who was responsible, but she assumed it would be the ADMIN. She stated the impact of a resident's medical information having been released was it was the resident's personal information and the information would be open for another person who should not have received it. During an interview on 05/06/2026 at 02:00 p.m., the ADMIN stated he was notified by Resident #2's family member that another resident's information was included in the medical records provided to her for Resident #2. He stated he asked Resident #2 to bring the USB back to be exchanged with a new USB, so the other resident's information could be removed. He stated that the MR staff member notified him today, 05/06/2026, that the other resident's document was Resident #1's Administration Record. He stated, when Resident #1 was admitted , his Administration Record was probably accidentally scanned to Resident #2's profile. He stated the impact of the document having been released was that it was a violation of personal information. He stated he was trying to give Resident #2's family member a new USB to correct the error. He stated he had not spoken with Resident #1 personally but was planning on letting him know. Record review of facility policy Resident Rights, undated, revealed: Privacy and confidentiality- The resident has the right to personal privacy and confidentiality of his or her personal and medical records. 3. The resident has a right to secure and confidential personal and medical records. a. The resident has the right to refuse the release of personal and medical records except as provided at S483.70(i)(2) or other applicable federal or state laws.

Based on observation, interview, and record review the facility failed to ensure they provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) for 3 of 3 residents (Resident #1, Resident #2, and Resident #3) who were reviewed podiatry care. The facility failed to ensure Resident #1, Resident #2, and Resident #3 received podiatry care to maintain proper toenail length during the 3/4/2026 quarterly scheduled visit. The previous visit occurred on 10/28/2025. This failure could place residents at risk of experiencing pain when wearing footwear, difficulty walking, or poor hygiene.The findings were: Review of Resident #1's face sheet, dated 3/25/26, revealed she was an 82 year female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia (decline in cognitive function), type 2 diabetes mellitus (insulin resistance and high blood sugar levels), and need for assistance with personal care. Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score was 15 of 15 reflective of no cognitive impairment and was dependent on staff for putting on/taking off footwear. Review of Resident #1's undated care plan revealed the resident has Diabetes Mellitus with the intervention, refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Review of a local podiatry group schedule, dated 3/4/26, revealed they provided podiatry services to multiple residents in the facility. Further review revealed Resident #1 was on the list but was not provided with foot care. The last date of service for Resident #2 was 10/28/2025. Review of Resident #2's face sheet, dated 3/25/26, revealed he was a [AGE] year old male who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including spinal stenosis, lumbar region with neurogenic claudication (symptoms of back pain, numbness, and weakness), type 2 diabetes mellitus (insulin resistance and high blood sugar levels), and need for assistance with personal care. Review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score was 15 of 15 reflective of no cognitive impairment and required substantial to maximum assistance with putting on/taking off footwear. Review of Resident #2's undated care plan revealed the resident has Diabetes Mellitus with the intervention, refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Review of a local podiatry group schedule, dated 3/4/26, revealed they provided podiatry services to multiple residents in the facility. Further review revealed Resident #2 was on the list but was not provided with foot care. The last date of service for Resident #2 was 10/28/2025. Review of Resident #3's face sheet, dated 3/25/26, revealed she was a [AGE] years old and admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia (decline in cognitive function), type 2 diabetes mellitus (insulin resistance and high blood sugar levels), and need for assistance with personal care. Review of Resident #3's quarterly MDS, dated [DATE], revealed a BIMS score of 7 of 15 reflective of moderate cognitive impairment and used a walker to ambulate. Review of Resident #3's undated care plan revealed the resident has Diabetes Mellitus with the intervention, refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Review of a local podiatry group schedule, dated 3/4/26, revealed they provided podiatry services to multiple residents in the facility. Further review revealed Resident #3 was on the list but was not provided with foot care. The last date of service for Resident #2 was 10/28/2025. Observation and interview on 3/26/26 at 3:00 PM with Resident #1 revealed he needed help with cutting my toenails. I can't do it. I asked the SW what happened because they used to come every 3 months but haven't had it done lately. Resident #1 stated that 5 months ago was the last time their nails were cut. Resident #1 stated, The nurses don't cut my nails because I have diabetes. The podiatrist has to do it. The resident allowed the investigator to see the length of her toenails which were observed to be up to 1/4 inch beyond the flesh of the toes with some nails curving toward the skin. Interview on 3/26/26 at 10:45 AM Resident #2 stated, We have a podiatrist that cuts toenails. Haven't seen her in quite a while. She's good at what she does. Observation and interview on 3/26/26 at 11:25 AM Resident #3 said she asked them (staff) about getting their toenails cut and they (staff) said as soon as the man comes. Resident #3 stated that their toenails were cut last year. Resident #3 stated, It hurts to wear shoes and it's embarrassing. Resident #3's toenails were observed to be 1/2 to 1 inch beyond the flesh of the toe. Interview with a family member revealed the hospital had noticed the resident needed their nails cut and the social worker had stated that Resident #3 was on the list during the last podiatry visit, but they left before they saw Resident #3. Resident #3 said that she would like to get their toenails cut as soon as possible. Interview on 3/26/26 at 11:44 AM with the ADON revealed Resident #3 was up at the front with the SW early this week, Monday or Tuesday, and the SW stated the podiatrist would come in a month or an outside facility visit could be arranged. The ADON stated that Resident #3 said that she would wait. The ADON stated that Resident #3's toenails were in need of attention but we have to respect the residents wishes if they want to wait. She stated that long toenails can be a fall hazard and could cause pain.Interview on 3/27/26 at 3:55 PM with the DON stated the Social Worker stated that there were some residents that did not receive foot care and that this puts them at risk for injury or infections. They could have a hang nail. They can't wear shoes or a nail could break.Interview on 3/26/26 at 4:52 PM the SW stated, the current podiatry company came in on March 4, 2026, but stated that the list was too long and they were not able to see everyone. The SW stated she had to call them (podiatry company) to provide a list of who they saw. The contracted podiatry company stated they could not come again any earlier than April 20, 2026. The facility's parent company uses a contracted podiatry company for all facilities. I spoke to Resident #3 yesterday and I asked her if she wanted me to make an appointment outside the facility. She stated no, she would wait for the company to return. She knew that the next visit would be on the 20th. She was OK with waiting. She was last seen on 10/28/2026. Nurses and CNAs can cut fingernails. Nurses attend to residents with diabetes. Only the podiatrist cares for toenails. The SW stated, Resident #1, Resident #2, and Resident #3 had insurance which allowed 4-6 podiatry visits per year.Review of a facility policy, Nail Care, undated, revealed Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle are and is usually done during the bath. Nails can become thinner and more brittle in the elderly and thicker if peripheral circulation is impaired. Nails are also important in assessment, as changes occur with certain medical conditions, such as clubbing with chronic obstructive pulmonary disease or cardiac disease. Color changes with circulatory or lymphatic impairment and certain drug therapy is common. Ingrown toenails are also common in the elderly. Fungal infections of the toenails, dry, brittle ridges and thickening of the nails all occur in the elderly with some frequency. NAIL CARE, ESPECIALLY TRIMMING, IS PERFORMED BY A PODIATRIST IN THOSE WITH DIABETES AND PERIPHERAL VASCULAR DISEASE.GoalsNail care will be performed regularly and safely.The resident will free from abnormal nail conditionsThe resident will be free from infection.

Based on observation, interview, and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 2 of 2 residents (Residents #1 and #2) reviewed for medical records. 1. The facility failed to ensure Resident #1's ADL-Bathing record recorded a bath or refusal for 2/28/2026, 3/5/2026, 3/7/2026, 3/10/2026, 3/12/2026, 3/14/2026, 3/17/2026, and 3/24/2026 as noted on the electronic medical record. 2. The facility failed to ensure Resident #2's ADL-Bathing record recorded a bath or refusal for 2/28/2026, 3/5/2026, 3/7/2026, 3/10/2026, 3/12/2026, 3/14/2026, 3/17/2026, and 3/24/2026 as noted on the electronic medical record. These failures could place residents at risk of not receiving necessary care and services to ensure a resident's abilities in ADLs did not deteriorate, promoted proper hygiene, and a dignified existence.Findings include: Review of Resident #1's face sheet, dated 3/25/26, revealed she was an 82 female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia (decline in cognitive function), type 2 diabetes mellitus (insulin resistance and high blood sugar levels), and need for assistance with personal care. Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score was 15 of 15 reflective of no cognitive impairment and was dependent on staff for shower/bathe self. Record review of Resident #1's 30-day Task record for ADL-Bathing reflected a preference of bathing on Tuesdays, Thursdays, and Saturdays. Based on an admission date of 1/1/2026, Resident #1 did not have a bath entry or refusal recorded on the electronic medical record for 2/28/2026, 3/5/2026, 3/7/2026, 3/10/2026, 3/12/2026, 3/14/2026, 3/17/2026, and 3/24/2026. During an observation and interview on 3/26/2026 at 3:00 PM, Resident #1 was sitting alone in the dining hall. Their clothes were clean with a groomed appearance. She stated, she was able to take showers on her scheduled days but sometimes they ask me at 9 AM to 10 AM and it's too early so I may refuse the shower. She revealed it was better after dinner. Review of Resident #2's face sheet, dated 3/25/26, revealed he was a [AGE] years old male who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including spinal stenosis, lumbar region with neurogenic claudication (symptoms of back pain, numbness, and weakness), type 2 diabetes mellitus (insulin resistance and high blood sugar levels), and need for assistance with personal care. Review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score was 15 of 15 reflective of no cognitive impairment and required substantial to maximum assistance from staff for shower/bathe self. Record review of Resident #2's 30-day Task record for ADL-Bathing reflected a preference of bathing on Tuesdays, Thursdays, and Saturdays. Based on a readmission date of 8/9/2025, Resident #2 did not have bath entries or refusals recorded on the electronic medical record for 2/28/2026, 3/5/2026, 3/7/2026, 3/10/2026, 3/12/2026, 3/14/2026, 3/17/2026, and 3/24/2026. During an observation and interview on 3/26/2026 at 10:45 AM, Resident #2 was observed in their room with clean clothes and a groomed appearance. He stated I have to have help with showers. During an interview on 3/27/26 at 3:03 PM, CNA A revealed that showers were required to be documented in the POC. She said for me, when we are really busy, I don't chart. I always offer residents a shower. She revealed reasons for not marking a shower or refusal on the EMR was due to being busy and hectic when I have to provide care for 30+ residents. During an interview on 3/27/26 at 2:48 PM, CNA B stated that shower documentation was in the system. We can hit the tub icon and document PRN or scheduled shower. I have to fill it out. She revealed that the resident (Resident #2) probably refused the scheduled shower. During an interview on 3/27/26 at 5:55 PM, the DON revealed that showers were required to be documented. She stated that the process for shower refusals was the CNA asks and alerts the nurse if refused, the nurse will walk in with the CNA to offer, if still no, they try again later and document as a refusal if not wanted. Record Review of a facility policy, Nail Care, undated, revealed: Documentation Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident and or soft resident file. It may include observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility, and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge). Documentation also occurs in the clinical software Point Click Care (PCC). Goal 1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.2. The facility will ensure that information is comprehensive and timely and properly signed.

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 3 residents (Resident #1), reviewed for a call light system. The facility failed to ensure Resident #1 could reach or trigger the call light installed near her bed when she fell on 3/11/26. This failure could place residents at risk of not receiving timely care and nursing interventions; and could result in falls, injuries, a diminished quality of life, and incontinent episodes.The findings include: Record review of Resident #1s face sheet, dated 3/13/26, reflected an 80 -year-old female who was readmitted to the facility on [DATE]. Resident #1 had diagnoses which included sepsis (toxic response to an infection), unspecified organism (at admissions), diabetes (high blood sugar), dementia (decline in mental ability) , hypertension (blood force against an artery is high), and cognitive deficits. The RP was listed as: a Guardian. Record review of Resident #1's significant change MDS, dated [DATE], reflected a BIMS score of 02, indicative of severe impairment in cognition. The resident was incontinent of bowel and had a Foley catheter. Resident #1 was dependent on transfer and mobility. The resident was impaired on upper and lower range of motion. Record review of Resident #1's fall assessment, dated 3/11/26 at 9:30 PM, by LVN A, reflected: history of falls; disoriented, neurological checks done and x-ray results were negative. The fall assessment also reflected that the resident had an unwitnessed fall on 3/11/26 at 9:30 PM, in her room; resident fell to the left side of the bed near the wall; sustained some scratches to the right side of the face. Record review of Resident #1s fall risk score, dated 3/11/26, reflected a score 11 (High). Record review of Resident #1 's x-ray of skull, cervical spine, and right humerus (long bone in the upper arm), dated 3/12/26, reflected no fractures. Record review of Resident #1's, undated, care plan reflected a goal of fall prevention with interventions that included: low bed, call light in reach, clutter free room, call hospice, monitor for risk of falls, and appropriate footwear. After resident experienced a fall on 3/11/26 new interventions included: scoop mattress, floor mats both side of bed, and wedges/bolsters to the bed. Record review of Resident #1's court order, dated 12/19/2025, reflected a temporary Guardian who was assigned to the resident. Observation and interview on 3/13/26 at 4:01 PM, revealed Resident #1 was in bed with a doll present. The door was closed. Floor mats were on both sides of the bed, scooped pressure release mattress with bolsters on both sides present. Observation further revealed small abrasion to right side of face. The call light was a pressure call bulb light; but the resident could not activate due to upper body impairment. The resident spoke in a faint voice. The resident was alert and oriented to herself. The call light was in reach; tied to the left side of the resident's night gown near the left arm. The resident's arms were crossed away from the call light. The resident stated she fell to her right side but did not know the details. Resident #1 said, I fell Tuesday [actual fall was Wednesday] .no pain and do not know why. Resident stated she would ask for help to prevent future falls, but she could not reach or push the call light.Observation on 3/15/26 at 9:30 AM of Resident #1's room revealed the door was open. Resident #1's room was located 3 rooms away from the nurse station which would make it difficult for staff to hear the resident's faint voice in the event the resident fell and was unable to use the assigned call light. During an interview on 3/13/26 at 4:32 PM, the Rehab Director stated in the past the resident had a regular call light and was using it effectively and then changed to a pressure call light. The Rehab Director stated the resident declined in the ability to use the regular call light. The Rehab Director stated the resident was weak and preferred to stay in bed. The Rehab Director stated she was not aware the resident was unable to use the squeeze pad requiring palm or pressure dexterity. The Rehab Director stated to her knowledge the facility had not tried or trained the resident in the use of pressure pad neck range of motion or another adoptive device. During an observation and interview on 3/13/26 at 4:45 PM with the Rehab Director, revealed Resident #1 was unable to locate the bulb call light and when the bulb call light was placed on the resident's right hand, by the Rehab Director, the resident was unable to trigger the call light. The resident only smiled when told to find the call light. When instructed by the Rehab Director to trigger the call light the resident was unable, on command, to initiate and follow through on the call light. The Rehab Director stated the facility needed to explore other options such as an adaptive call light because the resident had declined cognitively. The Rehab Director had no explanation for the facility for not exploring another adaptive call light. The Rehab Director stated the resident could experience a fall in the future because the resident could wiggle in her bed. The Rehab Director stated for the resident's safety the facility could explore another adoptive device or re-train the resident on the use of pressure release call lights. During an interview on 3/15/26 at 9:01 AM, the ADON stated the timeline of Resident #1's fall on 3/11/26 was:Nurse Note dated 3/11/26 at 9:20 PM authored by LVN A stated resident was given a Tylenol-codeine pain pill; nothing mentioned about the call light.Nurse Note dated 3/11/26 at 9:30 PM authored by LVN A revealed: the nurse entered the room to administer Resident #1's night medications and found resident on floor next to the bed and wall (left side of bed and left side of location of catheter). The bed was in a low position and call light in reach but call light was off. Head to toe assessment was done; no injuries noted. Vitals within normal limits. Resident was assisted by Hoyer back to her bed. Medications were administered. The resident was unable to provide clear explanation for the fall. MD, hospice, and guardian were notified. Neurological checks were started.3/12/26 at 8:12 AM order by hospice for multiple x-rays (cervical spine, right arm and skull). [ADON attempt to show the fall was without major injury]3/12/27 at 9:40 AM x-rays were all negative. Neurological checks continued.The ADON stated the preventative measure prior to the fall included low bed, wedges on bed and every 2-hour rounding for repositioning. After the fall, the ADON stated new preventative measures included: scoop mattress and floor mats on both sides of bed. The ADON stated he was not aware the resident could not trigger the call light. During an interview on 3/15/26 at 9:53 AM, LVN A stated the same information found in her progress note, dated 3/11/26. LVN A stated Resident #1 could not trigger her call light and needed to move her hand to trigger. LVN A stated on the date and time of the fall the resident did not trigger the call light. LVN A stated the roommate did not have the capacity to call for help for the resident and it was coincidental she found the resident when making rounds to administer the night medications. LVN A stated at the time of the fall there were floor mats and the mattress had wedges and was scooped. LVN A stated the resident was provided no explanation for the fall. LVN A stated the resident was able to wiggle out of the bed at the time of fall on 3/11/26. LVN A stated the new intervention included frequent rounds. LVN A stated Resident #1 could benefit for safety reasons with a roommate who was alert and oriented. LVN A added Resident #1 could be moved to a room closer to the nurse station so nurses could see the resident more frequently. During an interview on 3/15/26 at 10:16 AM, LVN B stated she was aware the resident fell on 3/11/26 at night. LVN B stated preventative measures included: 1-2 hours rounding, floor mats in place, and assessments. LVN B stated the resident could still wiggle in her bed which was intermittent. LVN B stated the resident was able to trigger the call light and there was no need for further accommodations. During an interview on 3/15/26 at 10:29 AM, CNA C stated she had been working with Resident #1 for about one year. CNA C stated she heard about the resident's fall on 3/11/26; fall out of bed. CNA C stated the resident moved in her bed and could wiggle. CNA C stated fall preventative measures in place now included floor mats, wedges, scoop mattresses, and more frequent rounding. CNA C stated Resident #1 cannot push the call light with her hand. During an interview on 3/15/26 at 10:39 PM, the DON stated preventative measures in place prior to the residents fall on 3/11/26 at night included: increase in rounds, bed in lowest position, and call light in reach. After the fall, new measures included floor mats, scoop mattresses, and wedge to the bed and more frequent rounds. The DON stated the resident was re-educated on the use of the bulb light. The DON stated depending on the day and time, the resident could trigger the call light and at other times could not activate the call light. The DON stated the resident's door should have been opened unless care was being given. The DON stated the facility would investigate other accommodations for the times the resident could not trigger the call light. During an interview on 3/15/26 at 12:30 PM, the Administrator stated after the fall on 3/11/26, new preventive measures put in place included floor mats, scoop mattress and increased monitoring. The Administrator stated the facility was doing the right thing to prevent falls and would explore other measures to increase safety. Observation and interview on 3/15/26 at 12:40 PM, the Administrator and the state surveyor made a visit to Resident #1's room. The resident was alert and oriented to person. The resident was being fed her noon meal by a CNA. The Administrator directed the resident to locate the call light, and the resident was unable to find the call light situated near her bed. The resident stated she was fine and smiled. The resident showed signs of discomfort and frustration when she was unable to locate the call light; and the interview was ended by the state surveyor. Record review of the facility's, undated, Fall Policy read: .Preventing falls requires an interdisciplinary program that focuses on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident and family.Environmental.Position call bells within reach.Respond timely to call bells. Record review of the facility's, undated, Resident Rights policy, read: .The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Record review of facility's policies reflected the facility had no policy on the call light system.

Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. The facility failed to maintain the holding temperature for cream of corn at 135 F or above. The facility failed to maintain the cold temperature for the cold smore parfait at 41 F or below.The facility failed to sanitize the thermometer before taking food temperatures. These failures could place residents at risk for food borne illness.The findings included: During an observation on 3/10/2026 at 11:09 a.m., [NAME] J sanitized the thermometer then wiped it with a paper towel and proceeded to take the temperature of the mashed potatoes. During an observation on 3/10/2026 at 11:15 a.m., [NAME] J took the temperature of the cream of corn which reached 106 degrees Fahrenheit. During an observation on 3/10/2026 at 11:20 a.m., [NAME] J sanitized the thermometer then wiped it with a paper towel and proceeded to take the temperature of the corn. During an observation on 3/10/2026 at 11:26 a.m., [NAME] J took the temperature of the smore parfait which reached 46.8 degrees Fahrenheit. During an interview on 3/10/2026 at 11:33 a.m., [NAME] J stated the holding temperature for hot items should be 130 degrees or above and for cold items 40 and below. [NAME] J stated the holding temperatures are important because if they are not reached it can cause bacteria and make residents sick. [NAME] J stated she sanitizes the thermometer before taking each food item's temperature in order to not contaminate anything. [NAME] J stated she didn't think there was a lot of risk when wiping the thermometer with a paper towel before taking food temperatures because it's food to food. During an interview on 3/10/2026 at 11:49 a.m., the DM stated the holding temperature for hot items should be over 140 and for cold items it should be 40 and below. The DM stated if these temperatures are not reached the food could start growing bacteria. The DM stated the thermometer should be sanitized between each food item because it is the proper thing to do. The DM stated sanitizing is important because if the thermometer touches anything it could pick up something. Record review of the facility's policy Daily Food Temperature Control, dated 2012, stated: 1.There is a thermometer available for use in the department to test the temperature of foods which is sanitized between each food testing.4. All hot foods shall be cooked and held for service at temperatures of 140 degrees F or above.6. Cold foods shall be less than 41 degrees F.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 32 residents (Resident #6, Resident #8, and Resident #100) reviewed for infection control: 1. The facility failed to ensure LVN I cleaned the insulin pen for Resident #6 prior to administration and perform proper hand hygiene. 2. The facility failed to ensure LVN I cleaned the insulin pen for Resident #8 prior to administration and perform proper hand hygiene. 3. The facility failed to ensure Resident #100's indwelling urinary catheter bag was not touching the floor. These failures could place residents at-risk for infection due to improper care practices.The findings included: 1. Record review of Resident #6's admission record, dated 3/11/26, revealed an [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses of dementia (a progressive neurological disorder that affects memory, thinking, behavior, and the ability to perform daily activities), type 2 diabetes mellitus (a chronic metabolic disorder characterized by high blood glucose levels due to insulin resistance and/or decreased insulin production), and end stage renal disease (ESRD, the final stage of chronic kidney disease in which the kidneys no longer function adequately to meet the body's needs and typically requires dialysis or kidney transplantation). Record review of Resident #6's admission MDS assessment, dated 12/11/25, revealed Resident #6's cognition was moderately impaired for daily decision making. The MDS also revealed the resident received insulin. Record review of Resident #6's care plan, last revised 12/30/25, stated the resident had diabetes mellitus with interventions to administer diabetes medications as ordered by doctor. Record review of Resident #6's physician orders, dated 3/11/26, revealed an order for:-Insulin Lispro 100 unit/mL inject as per sliding scale, subcutaneous four times a day, with a start date of 12/4/25, and no end date. During an observation on 3/10/26 at 7:28 a.m. LVN I planned to administer 6 units of insulin lispro to Resident #6. LVN I did not sanitize the insulin pens rubber stopper, placed a needle cap on the pen, and dialed the pen to 6 units. LVN I then cleaned the residents left arm with an alcohol pad, injected him with the insulin, and never primed the insulin pen. 2. Record review of Resident #8's admission Record, dated 3/11/25, revealed an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of type 2 diabetes mellitus without complications and presence of insulin pump. Record review of Resident #8's quarterly MDS assessment, dated 2/23/26, revealed Resident #8's cognition was severely impaired for daily decision making. The MDS also revealed the resident received insulin. Record review of Resident #8's care plan, last revised 10/22/25, stated the resident had diabetes mellitus with interventions to administer diabetes medications as ordered by doctor. Record review of Resident #8's physician orders, dated 3/11/26, revealed an order for:-Insulin Lispro 100 unit/mL inject as per sliding scale, subcutaneous before meals, with a start date of 7/7/25, and no end date. During an observation on 3/10/26 at 7:16 a.m. LVN I went to the resident restroom to wash his hands before obtaining her blood glucose. LVN I quickly rinsed his hands under the water and used his bare hand, touched the sink handle, and turned off the water. LVN I dried his hands with paper towels. While still in the bathroom LVN I put on his gloves. LVN I then exited the bathroom and touched the door with his gloved hands. LVN I obtained the blood glucose and returned to his nurse cart. LVN I then planned to administer 5 units of insulin lispro to Resident #8. LVN I prepared the insulin injection at his cart and did not sanitize the insulin pens rubber stopper, placed a needle cap on the pen, and dialed the pen to 5 units. LVN I then cleaned the residents lower left abdominal area with an alcohol pad and injected her with the insulin. During an interview on 3/10/26 at 7:44 a.m. LVN I stated he should clean resident's insulin pens the same way he would clean an insulin vial because it could be dirty. During an interview on 3/10/26 at 3:46 p.m. the DON stated staff was expected to clean the insulin pen rubber stopper for infection control. The DON stated not cleaning the pen with alcohol prior to placing the needle cap could place the resident at risk of infection. The DON stated LVN I's handwash technique broke infection control procedures and placed the resident at risk of infection. 3. Record review of Resident #100's face sheet dated 03/09/2026 revealed Resident #100 was a [AGE] year-old male and was most recently admitted to the facility on [DATE], with an original admit date of 06/06/2025. Resident #100's diagnoses included: neuromuscular dysfunction of bladder (a loss of bladder control caused by nerve damage from illnesses), colostomy status (a surgically created opening in the abdomen that allows stool to leave the body through the colon into an external pouch), paraplegia unspecified (a condition in which a person has loss of movement and often loss of sensation in the lower half of the body usually affecting both legs and sometimes the lower trunk), and urinary tract infection, site not specified (an infection somewhere in the urinary system). Record review of Resident #100's Quarterly MDS assessment, dated 01/16/2026, revealed Resident #100 had a BIMS score of 15, indicating the resident's cognition was intact. Record review of Resident #100's Physician Orders, dated 01/23/26 revealed the following: -Ensure foley bag is in privacy bag while in bed or wheelchair every shift -Ensure the catheter strap is in place and secure -Empty the urinary drainage bag each shift Record review of Resident #100's comprehensive care plan revealed a care area, initiated 08/05/25, that stated the resident had an indwelling catheter for wound healing and a diagnosis of neuromuscular dysfunction of the bladder. The interventions included: The resident has an 18 Fr 30 ml indwelling foley catheter. Position catheter bag and tubing below the level of the bladder and in a privacy bag, and check tubing for kinks and maintain the drainage bag off the floor. Observation on 03/08/26 at 9:30 am revealed Resident #100 was in bed, and the urinary catheter bag was not in a privacy bag and was resting directly on the floor next to the bed. During an interview on 03/11/2026 at 9:39 am, CNA F who had worked at the facility for approximately one month and was responsible for Resident #100's care that day, stated urinary catheter drainage bags should be secured to the side of the bed and placed in a privacy bag and should not be placed on the floor. During an interview on 03/11/26 at 11:09 am, LVN G, who had worked at the facility for approximately seven months, stated urinary catheter drainage bags should be secured to the side of the bed, placed in a privacy bag, and should not be placed on the floor. LVN G further stated placement of the drainage bag on the floor could present an infection control concern. During an interview on 03/11/26 at 11:30 am, the DON stated the urinary catheter drainage bags should be secured to the side of the bed and maintained off the floor and placed in a privacy bag when the resident is in bed or a wheelchair. The DON stated that having the catheter bag on the floor placed the resident at risk for infection. Record review of the facility's Pharmacy Policy & Procedure Manual titled Insulin Pen Use, revised 4/1/15, stated, Always attach a new needle before each use.always use a new sterile needle for each injection. This helps prevent contamination and potential needle blocks.Wipe the rubber seal with alcohol.Always remove the needle after each injection and store the pen without a needle attached. This helps prevent: Contamination and/or infection.Dispose of the needle safely. Used needles should be placed in sharps containers (such as red biohazard containers). Record review of the facility's Infection Control Policy & Procedure Manual, Fundamentals of Infection Control Precautions, stated Hand hygiene continues to be the primary means of preventing the transmission of infection.Before and after direct resident contact.Before and after performing any invasive procedure (e.g., fingerstick blood sampling.After contact with a resident's mucous membranes and body fluids or excretions. Recommended techniques for washing hands with soap and water include wetting hands first with clean, running warm water. rubbing hands together vigorously for at least 20 seconds covering all surfaces of the hands and fingers; then rinsing hands with water and drying thoroughly with a new disposable towel.Gloves are worn. to provide protective barrier and prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin.Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves.Any resident care equipment/article that is visibly contaminated with blood or body fluids will immediately be cleaned with an approved disinfectant.Used sharps are never recapped and always placed in puncture-resistant containers. Record review of the facility's Nursing Policy and Procedure Manual titled Catheter Care, stated When the resident is ambulatory the bag must be held lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Keep tubing off floor and minimize friction or movement at insertion site.Be sure the catheter tubing and drainage bag are kept off the floor.Keep drainage bag below level of bladder when cleaning the urethral area.

Based on observation, interview, and record review, the facility failed to provide necessary services to maintain good grooming, personal hygiene for residents who were unable to carry out activities of daily living for 2 of 8 Residents (Resident #45 and Resident #80) reviewed for quality of life. 1. The facility failed to ensure Resident #45 received scheduled showers on 3/3/26 and 3/7/26. 2. The facility failed to ensure Resident #80 received scheduled showers on 3/3/26, 3/5/26, and 3/10/26. This deficient practice could affect any resident and contribute to feelings of poor self-esteem and hopelessness.The findings included:1. Record review of Resident #45's admission record, dated 3/11/26, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side (paralysis or weakness on one side of the body resulting from a stroke), seizures(sudden, uncontrolled electrical disturbances in the brain that can cause changes in behavior, movements, or consciousness), and acquired absence of left leg above the knee. Record review of Resident #45's quarterly MDS assessment, dated 11/24/25, revealed the resident's cognition was intact for daily decision-making skills. The MDS indicated the resident needed partial/moderate assistance to shower/bathe self and substantial/maximal assistance for tub/shower transfers. Record review of Resident #45's care plan, revised 3/4/26, revealed the resident had ADL self-care performance deficit related to hemiplegia to right dominate side required 1 person assisted with ADL care. Interventions included bathing requires 1 staff for assistance, bed mobility requires 1 staff for assistance, dressing requires 1 staff for assistance, and she preferred not to have male aides for incontinent care or showers. Record review of Resident #45's task record for February 2026, revealed her last shower was received on Thursday February 26th, 2026. Record review of Resident #45's task record for March 2026, revealed she received showers on Tuesdays, Thursdays, and Saturdays. It showed she received a shower on Thursday 3/5/26 and was signed off by staff as given. The shower task record contained an area for PRN bathing, and all March 2026 dates were blank for this area. During an observation and interview on 3/8/26 at 4:03 p.m., Resident #45 was in bed and her hair appeared slightly oily. She stated it was a hard question to answer if she had been receiving her showers because staff were not showering her. She stated she had not received a shower over the weekend on Saturday 3/7/26 because no one was available to give her one. She stated she thought she last showered on 3/3/26 or 3/5/26 but was unsure. She stated her next shower was scheduled for Tuesday 3/10/26. She stated she preferred bed baths because the shower chair was uncomfortable and the water temperature fluctuated in the showers. 2. Record review of Resident #80's admission record, dated 3/11/26, revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute on chronic systolic (congestive) heart failure (a condition in which the heart's left ventricle is weakened and unable to pump blood effectively, resulting in reduced cardiac output and fluid buildup in the lungs and body that occurs as a sudden worsening of an existing heart failure condition), unsteadiness on feet, and pain. Record review of Resident #80's quarterly MDS, dated [DATE], revealed the resident's cognition was intact for daily decision-making skills. The MDS indicated the resident needed substantial/maximal assistance for transfers. Record review of Resident #80's care plan, initiated 6/27/25, revealed the resident had an ADL self-care performance deficit with interventions that she required 2 staff for transfers, provide resident with sponge bath with full bath or shower could not be tolerated, and resident required x1 staff participation with bathing. Record review of Resident #80's task record for March 2026, revealed she received showers on Tuesdays, Thursdays, and Saturdays during the 2 p.m.-10 p.m. shift. The record showed her only shower was on Saturday 3/7/26. The shower task record contained an area for PRN bathing, and all March 2026 dates were blank for this area. Record review of the daily staff schedule for 3/10/26 revealed during the 2p.m. to 10 p.m. shift CNA C was assigned to the 100 and 800 hallways where Resident #80 resided. During an interview on 3/8/26 at 8:54 a.m. Resident #80 was in bed. She stated she was supposed to receive a bath on Saturday 3/7/26 but had not. She stated she would get a bath when there was enough staff. She stated her next bath was due on Tuesday 3/10/26. During a follow up interview on 3/11/26 at 4:25 p.m., Resident #80 stated she missed her shower on 3/10/26 because there was not enough staff. She stated around noon that day she finally received a shower after almost 8 days without a shower. She stated it felt so good to shower. She stated the day prior, CNA C stated he could not shower her because they were short staffed. During an interview attempt on 3/11/26 at 4:40 p.m., CNA C did not answer or respond to a request for an interview. During an interview on 3/11/26 at 1:49 p.m. CNA D stated showers for residents were a big mess and no nursing staff was handling the concerns aides had about organizing showers. CNA D stated they were supposed to shower residents during the 2-10 shifts and they do not always. CNA D stated if showers were missed, staff had no method to track who still needed showers. CNA D stated it was unorganized. CNA D stated, in the past, they had certain tasks assigned on certain days, for example cutting residents nails on Sundays. CNA D stated she had brought these concerns up to management including the Administrator. CNA D stated on the morning shift, they had staff assigned to bathing residents. However, she was assigned to weights for residents instead. During an interview on 3/11/26 at 2:25 p.m., RN E stated he was assigned to a few hallways which included the hallway Resident #45 resided on. RN E stated Resident #45 was not known to refuse baths. RN E stated Resident #45 had not brought the concern to him that she missed any showers or baths. RN E stated as far as he knew, aides used shower sheets to document residents' showers and would let the nurse know if a resident refused. RN E stated they relied on the aide to notify them if a resident missed a shower. RN E stated showers were important for residents, and staff needed to ensure residents were receiving their scheduled showers. During an interview on 3/11/26 at 3:00 p.m., the DON stated they had no staff shortages for nurse aides. The DON stated they had received complaints about residents not receiving showers, but none recently. The DON stated that, during morning meetings, they reviewed clinical reports, and if it was documented that someone had not receive a shower, they discussed the reasons why. The DON stated management also conducted morning rounds with residents they were assigned to and asked about showers. The DON stated residents were able to voice concerns about not receiving showers. The DON stated staff were expected to document showers in the medical record; however, some staff were known not to document. The DON stated it had not been brought to her attention that residents were not receiving showers and that it was not due to a lack of staff. The DON stated that if residents were missing showers, staff would not be taking good care of them. The DON stated it could cause residents to have skin issues if not showered regularly and would place them at risk for infections. The DON stated, however, that wound care nurses completed weekly skin audits for residents. During an interview on 3/11/26 at 4:47 p.m., the Administrator stated he had not received any complaints from residents or staff about residents missing showers. He stated they did have call ins, and they offer bonuses for other staff to pick up shifts, but there were no shortages that would affect staff's abilities to shower residents. The Administrator stated if a resident went 8 days without a shower, they would be able to tell because they would smell and have white stuff in their hair. The Administrator stated they completed room rounds and received no complaints about showers in the month of March. Record review of the facility's policy titled Bath, Tub/Shower,, with no revision date noted, revealed the following: Bathing by tub bath or shower is done to remove soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation.The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level.The resident will experience improved comfort and cleanliness by bathing.The resident will maintain intact skin integrity.The resident will be free from soil, odor, dryness, and pruritus following bathing.The resident will receive assistance with bathing according to their resident centered plan of care.

Based on observation, interview, and record review, the facility failed to within 14 days after a facility completes a resident's assessment to transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 1 resident (Resident #89) reviewed for MDS transmission. Resident #89's discharge MDS assessment was not transmitted within 14 days of completion. This deficient practice placed residents at risk of not having assessments completed and submitted in a timely manner as required. The findings were: Review Resident #89 face sheet, dated 03/11/2026, revealed and admission date of 09/25/2026 with diagnoses which included: acute kidney failure, unspecified, urinary tract infection, site not specified, essential (primary) hypertension (high blood pressure), type 2 diabetes mellitus with diabetic chronic kidney disease, and hypo-osmolality and hyponatremia. Review of Resident #89's Discharge MDS Assessment, dated 10/11/2025, revealed the assessment had not been transmitted to CMS. During an interview and observation on 03/11/2026 at 1:35 p.m. the MDS Case Manager stated the completion and transmission of MDS assessments was the responsibility of herself and another Case Manager who was currently on vacation. The MDS Case Manager reviewed Resident #89's MDS Assessment and stated it had been completed; however, she was not the MDS Case Manager who had completed it and was not sure why it was not transmitted. During an interview and observation on 03/11/2026 at 1:35 p.m. the Regional Reimbursement Nurse stated the other MDS Case Manager who was on vacation had done the admission Assessment and transmitted, and the 5-day MDS Assessment and since Resident #89 was managed care the MDS Case Manager marked for the 5-day MDS Assessment not to be sent, and it was not transmitted. The Regional Reimbursement Nurse further stated she believed what probably happened while reviewing Resident #89's Discharge MDS Assessment was that there was a place which said do not send to CMS and it had been marked when the 5-day MDS Assessment had been completed due to Resident #89 was managed care and when the Discharge MDS Assessment was completed it was not unmarked so it would be sent to CMS. The Regional Reimbursement Nurse further stated the Discharge MDS Assessment should have been transmitted to CMS. The Regional Reimbursement Nurse stated they had 14 days to transmit the MDS Assessment from the day it was signed as completed by the RN. The Regional Reimbursement Nurse stated the Discharge MDS Assessment was the way to let CMS know the resident was no longer in the facility and it let them know the care measures of a resident. The Regional Reimbursement Nurse stated she did not feel there would be any potential harm by not transmitting the Discharge MDS Assessment and that it did not affect the billing, it was more of a tracking form. During an interview on 03/11/2026 at 3:00 p.m. the Director of Nursing stated the MDS nurse (MDS Case Manager) was responsible for the completion and transmission of the MDS Assessments. During an interview on 03/11/2026 4:24 p.m. the Administrator stated the Regional Reimbursement Nurse told him they did not have a policy regarding MDS Transmissions they followed the CMS RAI manual. Record review of the CMS RAI Version MDS 3.0 Manual dated October 2025 revealed in part, Chapter 5: Submission and Correction of the MDS Assessments 5.2 Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their Stated-specific instrument.Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements.-Assessment Transmission: Comprehensive assessment must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date.

Based on observations, interviews, and record review, the facility failed to respect the residents' right to confidentiality in his or her personal and medical records for 1 (Resident #99) of 16 residents. The facility failed to ensure RN A did not walk away from a computer without concealing Resident #99 private health information on the computer screen. This failure could place residents at risk of resident-identifiable information being accessed by the public, identity theft, or embarrassment. Findings included: Record review of Resident #99's admission record, dated 3/11/26, revealed a [AGE] year-old female resident originally admitted on [DATE], and readmitted on [DATE] with diagnoses including aphasia following cerebral infarction (a communication disorder caused by brain damage from a stroke that affects the ability to speak or understand language), cerebral palsy (a group of disorders affecting movement, muscle tone, and posture caused by damage to the developing brain), bipolar disorder (a mental health disorder characterized by alternating episodes of depression and mania or elevated mood), seizures (sudden, uncontrolled electrical disturbances in the brain that can cause changes in behavior, movements, or consciousness), unspecified intellectual disabilities (limitations in intellectual functioning and adaptive behaviors affecting learning, reasoning, and daily functioning), and hemiplegia and hemiparesis following cerebral infarction (paralysis or weakness on one side of the body resulting from a stroke). Record review of Resident #99's quarterly MDS assessment revealed the resident's cognition was severely impaired for daily decision making. Record review of Resident #99's care plan, last revised 3/21/24, revealed the resident had a behavior problems of yelling out loud and being difficult to redirect at times, related to recent history of CVA (cerebrovascular accident - a stroke caused by interruption of blood flow to the brain, resulting in brain cell damage and possible loss of neurological function such as movement, speech, or cognition). Interventions included intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, and divert attention or remove from situation and take her to alternate location as needed. During an observation on 3/10/26 at 9:31 a.m., RN A was administering medications to Resident #99 by the nursing station. RN A dropped the top to a liquid medication. RN A walked away from the medication cart to go clean the top that had fallen on the floor. RN A left the medication cart unlocked and the computer screen up and open to the resident's information. Resident #99's name, date of birth , physician, location, code status, allergies, and a list of medications were displayed as well as her most recent vitals, including her weight were visible. Four other residents were nearby in the common area. During an interview on 3/10/26 at 9:33 a.m., ADON B stated RN A could not walk away with her screen displaying patient information. ADON B asked RN A to minimize her screen if she walked away. During an interview on 3/10/26 at 9:35 a.m., RN A stated it was not ok to leave residents' information displayed on the computer screen because anyone could see or steal the resident's private information. During an interview on 3/10/26 at 3:50 p.m. the DON stated she had begun to in-service staff over HIPPA rights. The DON stated staff was not supposed to leave patient information displayed on the computer screen, because others could see it. Record review of the facility's undated policy titled Resident Rights reflected under the section Privacy and Confidentiality.the resident has a right to personal privacy and confidentiality of his or her personal and medical records.personal privacy includes accommodation, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, and that the facility must respect the resident's rights to personal privacy, including the right to privacy in oral, written, and electronic communications.the residents have the right to secure and confidential personal and medical records and the right to refuse the release of personal and medical records except as permitted by law.

Based on observations, interviews and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 trash disposals areas that were reviewed for disposal of garbage. The facility failed to ensure trash was not left outside of the trash disposal container. This failure could place residents at risk for rodent infestation.The findings include: During an observation on 3/8/2026 at 10:05 a.m., 1 bag of trash was leaning against the trash disposal container that was located outside the facility in a gated area. During an interview on 3/8/2026 at 10:08 a.m., the DM stated the trash area falls under her and that it should look clean, nothing on the floor and the doors closed. The DM stated the purpose of that is to prevent rodents and for infection control. Record review of the facility's policy Waste Control and Disposal, dated 2012, stated:3.Trash must be securely tied in leak-proof plastic bags and removed from the department to the outdoor trash receptacle.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 4 nurses' medication carts (600 hall nursing medication cart) reviewed for storage of drugs. The facility failed to ensure the 600-hall nursing medication cart was locked. This deficient practice could place residents at risk of medication misuse and diversion.The findings were: Record review of Resident #99's admission record, dated 3/11/26, revealed a [AGE] year-old female resident originally admitted on [DATE], and readmitted on [DATE] with diagnoses including aphasia following cerebral infarction (a communication disorder caused by brain damage from a stroke that affects the ability to speak or understand language), cerebral palsy (a group of disorders affecting movement, muscle tone, and posture caused by damage to the developing brain), bipolar disorder (a mental health disorder characterized by alternating episodes of depression and mania or elevated mood), seizures (sudden, uncontrolled electrical disturbances in the brain that can cause changes in behavior, movements, or consciousness), unspecified intellectual disabilities (limitations in intellectual functioning and adaptive behaviors affecting learning, reasoning, and daily functioning), and hemiplegia and hemiparesis following cerebral infarction (paralysis or weakness on one side of the body resulting from a stroke). Record review of Resident #99's quarterly MDS assessment revealed the resident's cognition was severely impaired for daily decision making. Record review of Resident #99's care plan, last revised 3/21/24, revealed the resident had a behavior problem of yelling out loud, difficult to redirect at times, related to recent history of CVA (cerebrovascular accident - a stroke caused by interruption of blood flow to the brain, resulting in brain cell damage and possible loss of neurological function such as movement, speech, or cognition). Interventions included intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention or remove from situation and take her to alternate location as needed. During an observation on 3/10/26 at 9:31 a.m. RN A was administering medications to Resident #99 by the nursing station. RN A dropped the top to a liquid medication. RN A walked away from the medication cart to go clean the top that had fallen on the floor. RN A left the medication cart unlocked. Resident #99 was right next to the cart and other unknown residents were nearby in a common area. During an interview on 3/10/26 at 9:35 a.m. RN A stated it was not ok to leave the medication cart unlocked and she did not realize she had left it unlocked. RN A stated anyone could access the cart if it was unlocked and grab something from it. During an interview on 3/10/26 at 3:50 p.m. the DON stated she had begun to in-service staff over keeping medication carts locked. The DON stated staff were not supposed to leave medication carts unlocked because anyone could get into the cart and they have some residents who needed supervision. Record review of the facility's policy titled Medication Storage in the Facility, version date 3-2025, revealed guidance regarding securing medications. The policy states, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier.The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

Based on observation, interview, and record review the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 5.88% based on 2 out of 34 opportunities, which involved 2 of 6 Residents (Resident #6 and Resident #8) reviewed for medication administration, in that: 1. The facility failed to ensure LVN I primed the insulin pen for Resident #6 prior to administration. 2. The facility failed to ensure LVN I primed the insulin pen for Resident #8 prior to administration. These failures could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions.The findings included: 1. Record review of Resident #6's admission record, dated 3/11/26, revealed an [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses of dementia (a progressive neurological disorder that affects memory, thinking, behavior, and the ability to perform daily activities), type 2 diabetes mellitus (a chronic metabolic disorder characterized by high blood glucose levels due to insulin resistance and/or decreased insulin production), and end stage renal disease (ESRD, the final stage of chronic kidney disease in which the kidneys no longer function adequately to meet the body's needs and typically requires dialysis or kidney transplantation). Record review of Resident #6's admission MDS assessment, dated 12/11/25, revealed Resident #6's cognition was moderately impaired for daily decision making. The MDS also revealed the resident received insulin. Record review of Resident #6's care plan, last revised 12/30/25, stated the resident had diabetes mellitus with interventions to administer diabetes medications as ordered by doctor. Record review of Resident #6's physician orders, dated 3/11/26, revealed an order for:-Insulin Lispro 100 unit/mL inject as per sliding scale, subcutaneous four times a day, with a start date of 12/4/25, and no end date. During an observation on 3/10/26 at 7:28 a.m. LVN I planned to administer 6 units of insulin lispro to Resident #6. LVN I did not sanitize the insulin pens rubber stopper, placed a needle cap on the pen, and dialed the pen to 6 units. LVN I then cleaned the residents left arm with an alcohol pad, injected him with the insulin, and never primed the insulin pen. 2. Record review of Resident #8's admission Record, dated 3/11/25, revealed an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of type 2 diabetes mellitus without complications and presence of insulin pump. Record review of Resident #8's quarterly MDS assessment, dated 2/23/26, revealed Resident #8's cognition was severely impaired for daily decision making. The MDS also revealed the resident received insulin. Record review of Resident #8's care plan, last revised 10/22/25, stated the resident had diabetes mellitus with interventions to administer diabetes medications as ordered by doctor. Record review of Resident #8's physician orders, dated 3/11/26, revealed an order for:-Insulin Lispro 100 unit/mL inject as per sliding scale, subcutaneous before meals, with a start date of 7/7/25, and no end date. During an observation on 3/10/26 at 7:16 a.m. LVN I planned to administer 5 units of insulin lispro to Resident #8. LVN I did not sanitize the insulin pens rubber stopper, placed a needle cap on the pen, and dialed the pen to 5 units. LVN I then cleaned the residents lower left abdominal area with an alcohol pad, injected her with the insulin, and never primed the insulin pen. During an interview on 3/10/26 at 7:44 a.m. LVN I stated he should prime the insulin pen to push air out. He stated he forgot to prime the insulin pens and thought it should be primed by turning the dial to 5-10 units. LVN I stated if you did not prime the insulin pen there could be air instead of the insulin the resident should be getting. During an interview on 3/10/26 at 3:46 p.m. the DON stated staff were expected to prime insulin pens prior to administration to ensure they get all the air bubbles out and are providing the accurate amount of units to the patients. Record review of the facility's Pharmacy Policy & Procedure Manual titled Insulin Pen Use, revised 4/1/15, revealed instructions for proper insulin pen preparation prior to administration. The policy states, Always perform the safety test before each injection. The policy further states performing the safety test ensures an accurate dose by ensuring that pen and needle work properly.removing air bubbles. The procedure for the safety test instructs staff to select a dose of 2 units by turning the dosage selector.hold the pen with the needle pointing upwards.tap the insulin reservoir so that any air bubbles rise up towards the needle.press the injection button all the way in. Check if insulin comes out of the needle tip.You may have to perform the safety test several times before insulin is seen.

Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #6) reviewed for quality of care: The facility did not maintain communication, coordination, or collaboration with the dialysis facility for Resident #6. This failure could affect residents who received dialysis treatments and place them at risk of complications and not receiving proper care and treatment to meet their needs. The findings included:Record review of Resident #6's admission record, dated 3/11/26, revealed an [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses of dementia (a progressive neurological disorder that affects memory, thinking, behavior, and the ability to perform daily activities), type 2 diabetes mellitus (a chronic metabolic disorder characterized by high blood glucose levels due to insulin resistance and/or decreased insulin production), and end stage renal disease (ESRD, the final stage of chronic kidney disease in which the kidneys no longer function adequately to meet the body's needs and typically requires dialysis or kidney transplantation). Record review of Resident #6's admission MDS assessment, dated 12/11/25, revealed Resident #6's cognition was moderately impaired for daily decision making. The MDS also revealed the resident received dialysis. Record review of Resident #6's care plan, revised 3/10/26, revealed the resident needed dialysis related to renal failure with interventions of to not draw blood or take blood pressure in arm with graft, to monitor access site, and obtain vitals and eight per protocol, and to report significant changes in pulse, respirations, and blood pressure immediately. This care area was added after the survey start date of 3/8/26.Record review of Resident #6's physician orders, dated 3/11/26, revealed an order for:-Dialysis every Monday, Wednesday, and Friday, with a chair time of 10:30 a.m., and pick up at 9:30 a.m. one time a day every Monday, Wednesday, and Friday, with an order date of 1/26/26, and no end date.-Assess dialysis device to right arm for positive bruit (an abnormal whooshing sound heard over a vascular access with a stethoscope indicating blood flow) and thrill (a palpable vibration felt over the vascular access site indicating blood flow through the fistula or graft) every shift, with a start date of 12/9/25, and no end date.-Check shunt (a surgically created vascular access, such as an arteriovenous fistula or graft, used for hemodialysis) to right arm for signs and symptoms of infection, bleeding, bruising, pulsation (a rhythmic throbbing or expansion of the blood vessel at the access site caused by blood flow) or aneurysm (an abnormal bulging or ballooning of the blood vessel wall that can weaken the access site).-NO needle sticks, blood pressure, or blood draw in right arm, with a start date of 12/9/25, and no end date. Record review of Resident #6's dialysis communication forms revealed the resident had a total of 2 dialysis communication forms, dated 2/23/26 and 3/2/26. The forms only contained an area for the dialysis center to fill out before and after weights, medications given at the center, shunt condition, and dialysis nurses' signature. No information was communicated from the nursing facility to the dialysis center on the form. Vitals were written at the top of the forms, and it was unclear if they were taken at the nursing facility or the dialysis center. No dialysis communications forms were provided for 1/26/26, 1/28/26, 1/30/26, 2/2/26, 2/4/26, 2/6/26, 2/9/26, 2/11/26, 2/13/26, 2/16/26, 2/18/26, 2/20/26, 2/25/26, 2/27/26, 3/4/26, 3/6/26, 3/9/26. Record review of Resident #6's progress notes with date range of 1/9/26-3/12/26 revealed nursing notes in reference to his return from dialysis on:-2/2/26 returns from dialysis via w/c with no distress. vs 121/73-68-18-97. (blood pressure, respirations, pulse, temperature). O2@96% RA (Room Air) dialysis shunt dressing intact, by LVN H.-2/9/26 returns from dialysis via w/c with no distress. vs 124/72-72-18-97.1. O2@96% RA dialysis shunt dressing intact, by LVN H.-2/11/26 returns from dialysis stable with no complaints. vs 114/71-79-18-97.2. O2@97% RA dialysis shunt dressing intact, by LVN H.-2/13/26 returns from dialysis stable with no complaints. vs 123/73-18-81-97.1. O2@97% RA (oxygen saturation measured while breathing room air). Dialysis shunt dressing intact by LVN H. No progress notes were found for: 1/26/26, 1/28/26, 1/30/26, 2/4/26, 2/6/26, 2/16/26, 2/18/26, 2/20/26, 2/23/26, 2/25/26, 2/27/26, 3/2/26, 3/4/26, 3/6/26, 3/9/26. Record review of Resident 6's weights, dated 3/11/26, revealed:-12/3/25: 167.3 pounds-12/10/25: 171.0 pounds-12/17/25: 174.1 pounds-12/24/25: 172.0 pounds-2/12/26: 171.3 pounds-1/2/26: 169.6 pounds-3/4/26: 175.2 pounds During an interview on 3/9/26 at 10:38 a.m., Resident #6 stated he went to dialysis a few days a week. He stated they made sure he had breakfast before he went. He stated he was unsure if facility staff assessed him when he returned from dialysis. During an interview on 3/11/26 at 11:36 a.m. ADON B stated the facility would send communication forms with the resident to dialysis, however, he would return without them. He stated they would call the dialysis center, and they would tell the facility they would send them, but they never did. He stated the form they used to send to dialysis did not have any information such as vitals obtained at the nursing facility before they sent him to the center. He stated nursing staff should be putting a progress note in when the resident returned from dialysis. During an interview on 3/11/26 at 3:23 p.m., the DON stated the facility would send a binder with the resident to the dialysis center. The DON stated the binder contained an admission record with the resident's information and a list of his current medications. The DON stated they also sent dialysis communication forms in the binder. The DON stated after reviewing the two communication forms, they had staff not using the correct communication form. The DON stated the form should contain an area for vitals the facility took prior to sending him to dialysis or any other information they need to communicate to the dialysis center. The DON stated staff were expected to document the resident's vitals, including blood pressure, bruit, and thrill in the computer. The DON stated staff should call the dialysis center if the resident returns without a communication form. The DON stated it was possible some of the forms were backlogged in the medical records office waiting to be scanned in, but that did not help anyone if they were not accessible. The DON stated not having communication forms or assessments upon return would make it difficult to assess changes in condition. Record review of the facility's policy titled Dialysis, revised November 2013, revealed the following: The facility will monitor departures and returns from the dialysis center.The facility will document the resident's vital signs, general appearance, orientation, and additional baseline data as needed.The resident's clinical record will be documented with this information.The date and time that the resident leaves the facility will be recorded by the nurse.The date and time of the resident's return to the facility will be recorded by the nurse.The site will be assessed for bleeding, bruising, lack of pulsations, and aneurysm every shift.The nurse will palpate the access from the distal anastomosis to the proximal anastomosis.A thrill, the feeling of turbulent blood flow, should be felt along the course of the vessel.A bruit, the rushing sound of turbulent blood flow, should be heard along the course of the vessel or shunt.Conduct this procedure every shift.Record the results of the examination.Report nonfunctioning accesses to the dialysis center immediately.Report any drainage, redness or swelling around the insertion site to the dialysis center as soon as possible.

Based on observations, interviews, and record review, the facility failed to ensure residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 1 residents (Resident #64) reviewed for quality of care. The facility failed to ensure Resident #64's sterile water was dated on the oxygen concentrator. This failure could place residents at risk for infection. The findings include: Record review of Resident #64's face sheet, dated 3/9/2026, revealed a [AGE] year-old male readmitted to the facility on [DATE], with an original admission date of 5/30/2023, with a primary diagnosis of spinal stenosis, lumbar region with neurogenic claudication (narrowing of spinal canal compresses nerves causing leg pain, numbness, or weakness). Record review of Resident #64's MDS assessment, dated 2/13/2026, revealed the resident's BIMS score was 15 out of 15 which indicated the resident's cognition was intact. Record review of Resident #64's order summary dated 3/9/2026 revealed the following order: May use oxygen at 2-4 liters per minute with a nasal canula to keep saturation greater than 93%, as needed for shortness of breath, feeling faint with a start date 2/11/2026 and end date 3/10/2026. During an observation on 3/8/2026 at 2:27 p.m., Resident #64's oxygen concentrator had a sterile water container attached to it with no date. During an observation on 3/9/2026 at 8:46 a.m., Resident #64's oxygen concentrator had a sterile water container attached to it with no date. During an interview on 3/9/2026 at 9:55 a.m., Resident #64 stated that he used the oxygen concentrator every night, and staff never date the sterile water container. During an interview on 3/10/2026 at 4:40 p.m., LVN K stated there were no CNAs on the hall at that time, and the ADON was acting as the CNA. LVN K stated residents who used oxygen concentrators with sterile water containers must have the sterile water dated to signify when it was put on the oxygen concentrator. LVN K stated the purpose of it was to show how long the sterile water has been on there, and if there was no date, they would not know when to change it out. LVN K stated the nurse was responsible for dating the sterile water. During an interview on 3/10/2026 at 4:51 p.m., the ADON stated that sterile water packs on oxygen concentrators should have the date they were put on there. The ADON stated the purpose of that was to know when it was last changed and to maintain infection control. The ADON stated that nurses were responsible for dating the sterile water. During an interview on 3/10/2026 at 4:57 p.m., the DON stated that sterile water should have been dated which signified the day it was changed out. When asked the risk if the sterile water was not dated, the DON stated they would have to look it up. The DON stated the nurse that replaced the sterile water should have dated it. Record review of the facility's undated policy entitled Oxygen Administration, did not apply to the citation.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #6) reviewed for care plans: The facility failed to ensure Resident #6's comprehensive care plan included he received dialysis services outside the facility. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services.The findings included: Record review of Resident #6's admission record, dated 3/11/26, revealed an [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses of dementia (a progressive neurological disorder that affects memory, thinking, behavior, and the ability to perform daily activities), type 2 diabetes mellitus (a chronic metabolic disorder characterized by high blood glucose levels due to insulin resistance and/or decreased insulin production), and end stage renal disease (ESRD, the final stage of chronic kidney disease in which the kidneys no longer function adequately to meet the body's needs and typically requires dialysis or kidney transplantation). Record review of Resident #6's admission MDS assessment, dated 12/11/25, revealed Resident #6's cognition was moderately impaired for daily decision making. The MDS also revealed the resident received dialysis while a resident. Record review of Resident #6's care plan, last revised 3/10/26, reflected the resident needed dialysis related to renal failure with interventions of to not draw blood or take blood pressure in arm with graft, to monitor access site, and obtain vitals and eight per protocol, and to report significant changes in pulse, respirations, and blood pressure immediately. This care area was added after the survey start date of 3/8/26. Record review of Resident #6's physician orders, dated 3/11/26, revealed an order for:-Dialysis every Monday, Wednesday, and Friday with a chair time of 10:30 a.m. and pick up at 9:30 a.m., one time a day every Monday, Wednesday, and Friday. During an interview on 3/11/26 at 3:28 p.m., the MDS Case Manager stated they performed audits that week and found that Resident #6 was missing dialysis from his care plan and she added it on 3/10/26. The MDS Case Manager stated the resident was admitted to the facility on dialysis services and it should have been in his care plan before 3/10/26. The MDS Case Manager stated it should have been added so nurses and aides would receive alerts of tasks they needed to complete for his dialysis, and what his care needs were. Record review of the facility's policy titled Comprehensive Care Planning, no date, stated The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.The comprehensive care plan will describe the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented.When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 2 of 2 residents (Resident #1 and Resident #2) reviewed for infection control. The facility failed to ensure LPN A cleaned the blood pressure cuff between Resident #1 and Resident #2 on 02/13/2026. These deficient practices could place residents at-risk for infections.The findings included: During an observation on 02/13/2026 at 07:40 a.m., LPN A was observed taking Resident #1's blood pressure prior to administering medications to the resident. LPN A returned to her medication cart and placed the blood pressure cuff on the cart. LPN A did not sanitize the blood pressure cuff. LPN A then administered Resident #1 his medications. At 07:58 a.m., LPN A then went and took Resident #2's blood pressure with the same cuff. LPN A again returned to her medication cart and placed the blood pressure on top of her cart. LPN A again did not sanitize the blood pressure cuff. During an interview on 02/13/2026 at 10:32 a.m., LPN A revealed she forgot to wipe the blood pressure cuff between residents because she was nervous and just forgot. She revealed she was aware that the failure to wipe the blood pressure cuff with the disinfectant wipes between residents was an infection control concern and stated nursing staff received frequent trainings on hand hygiene and infection control. Record review of Resident #1's admission Record, dated 02/13/2026, reflected a [AGE] year-old male. He was admitted on [DATE]. Record review of Resident #1's Medical Diagnosis tab, dated 02/13/2026, reflected diagnoses included metabolic encephalopathy (occurs when the brain's normal functioning is disrupted due to chemical or metabolic imbalances in the body), essential (primary) hypertension (a condition where the force of blood against the artery walls is consistently too high), and paroxysmal atrial fibrillation (an irregular heart rhythm that can cause fatigue, heart palpitations, shortness of breath, and dizziness). Record review of Resident #1's admission MDS Assessment, dated 12/15/2025, reflected the resident had a BIMS score of 14, which indicated he was cognitively intact. He had an active diagnosis of hypertension but no infections in the last seven (7) days of the assessment. He had not received any antibiotic (a medication prescribed to treat bacterial infections) medications during the last seven (7) days or since admission/entry. During an interview on 02/13/2026 at 11:40 a.m., Resident #1 revealed the staff checked his blood pressure daily. He revealed he had no concerns regarding his medication administration by the staff. Record review of Resident #2's admission Record, dated 02/13/2026, reflected an [AGE] year-old male. He was admitted on [DATE]. Record review of Resident #2's Medical Diagnosis tab, dated 02/13/2026, reflected diagnoses included anemia (a condition characterized by a deficiency of healthy red blood cells leading to insufficient oxygen delivery to the body's tissues), atherosclerotic heart disease (a condition characterized by the buildup of fats, cholesterol, and other substances in the artery walls leading to narrowed arteries and reduced blood flow), and essential (primary) hypertension. Record review of Resident #2's Significant Change MDS Assessment, dated 01/19/2026, reflected the resident had a BIMS score of 12, which indicated he was moderately cognitively impaired. He had an active diagnosis of hypertension but no infections in the last seven (7) days of the assessment. He had not received any antibiotic medications during the last seven (7) days or since admission/entry. During an interview on 02/13/2026 at 11:48 a.m., Resident #2 revealed no complaints or concerns regarding his medication administration or care by the staff. During an interview on 02/13/2026 at 04:51 p.m., the ADON revealed he provided staff training on infection control and during the training he discussed the need to wipe the blood pressure cuff between residents with disinfectant wipes. He revealed the impact of failing to disinfect the blood pressure cuff between residents was that it could cause the spread of infection. During an interview on 02/13/2026 at 05:34 p.m., the DON revealed her expectation was for staff to disinfect the blood pressure cuff with disinfectant wipes between every resident. She revealed the reason for disinfecting the blood pressure cuff between residents was to prevent the spread of any type of infections. She stated there was a possibility a resident might have been exposed to something by a facility guest and not decontaminating the blood pressure cuff after use might risk exposure to another resident. During an interview on 02/13/2026 at 05:59 p.m., the ADMIN revealed his expectation was for staff to use the disinfectant wipes to sanitize the blood pressure cuffs. He revealed the impact of not sanitizing the blood pressure cuff was that it was an infection control concern with the potential of the cuff carrying and transmitting germs to another resident. Record review of facility policy Infection Control Plan: Overview, dated 2019, reflected: Infection ControlThe facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.IntentThe intent of this policy is to assure that the facility develops, implements, and maintains an Infection Prevention and Control Program in order to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. The program will: - Perform surveillance and investigation to prevent, to the extent possible, the onset and the spread of infection; - Prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions;.

Based on observation and interview, the facility failed to post on a daily basis information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 20 of 20 days (01/23/2026 - 02/12/2026) reviewed for posting of required information. The facility failed to post the required current nurse staffing and census information from 01/23/2026 to 02/12/2026. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census. The findings included: During an observation on 02/12/2026 at 09:23 a.m., 10:30 a.m., and at 12:49 p.m., a document labeled Friday - 01/23/26 E-Daily [facility name], dated 01/23/2026, was posted on a wall of the front lobby. The document included the following information: current census and the scheduled number and hours worked of registered nurses, licensed practical nurses, and certified nurse aides for the day, evening, and nocturnal shifts. During an interview on 02/13/2026 at 04:51 p.m., the ADON revealed he was responsible for posting the daily census and nurse staffing posting. He stated he had just not put them out but had the postings prepared in a book. He stated he just forgot to post them. He revealed he had never observed a resident or guest looking for the posting but some of the residents' families would ask staff directly who was providing care for their family member that day. During an interview on 02/13/2026 at 05:27 p.m., the ADON revealed the facility did not have a policy on the posting of the daily census and nursing staffing. During an interview on 02/13/2026 at 05:34 p.m., the DON revealed her expectation was for the daily census and nurse staffing posting to be posted daily. She revealed the ADON was responsible for the task of posting the daily census and nurse staffing and was unsure why the document was not posted for 02/12/2026. During an interview on 02/13/2026 at 05:59 p.m., the ADMIN revealed his expectation was for the daily census and nurse staffing posting to be posted daily. He revealed he did not know how the lack of posting the document could impact residents or facility guests, but that it was a requirement to be posted. He stated he knew that some families were aware of their ability to review the nurse staffing binder which was located at the nursing station and was accessible to facility guests. He stated the nurse staffing binder included information such as who was scheduled to work and the nursing staff assignments, where staff were assigned to be working and which residents they would be providing care to.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 10 residents (Resident #1) reviewed for medications at the bedside. The facility failed to monitor residents for medications at the bedside when on 02/24/2024 Resident #1 was assessed by RN A as lethargic and difficult to arouse with a Tylenol bottle at the bedside. RN A called 911 and EMS transported Resident #1 to the emergency room for evaluation and treatment. Resident #1 was assessed at with a 12,000mg Tylenol overdose (the harm threshold is 4,000mg over 24-hours) and was treated with an antidote, stabilized, and discharged back to the facility 02/26/2024 without assessing other residents for safety nor educating staff with an in-service for the incident. An IJ was identified on 12/12/2024. The IJ template was provided to the facility on [DATE] at 03:50 PM. While the IJ was removed on 12/13/2024, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure could place residents who needed safety monitoring for medications at the bedside, at risk for harm by neglect to include serious injury, or death. The findings included: A record review of Resident #1's admission record dated 12/11/2024 revealed an admitted [DATE] with diagnoses which included Alzheimer's disease (cause of dementia, causes brain cells to die over time and the brain to shrink), depression, and encephalopathy (A medical term used to describe a disease that affects brain structure or function. It causes altered mental state and confusion). A record review of Resident #1's Quarterly MDS assessment dated [DATE], revealed Resident #1 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 13 out of a possible 15 which indicated no cognitive impairment. further review revealed Resident #1 was assessed as independent - Resident completes the activity by themselves with no assistance from a helper. For the daily task of eating, The ability to use suitable utensils to bring food and / or liquid to the mouth and swallow food and / or liquid once the meal is placed before the resident. A record review of Resident #1's physician orders dated 02/24/2024 revealed the physician prescribed Tylenol 325mg, give 2 tablets by mouth every 6 hours as needed for pain DNE (do not exceed) 3,000mg of APAP (Tylenol) per day. A record review of Resident #1's care plan dated 12/11/2024 revealed Resident #1 had, Suicidal ideation. Returned from hospital on 02/26/2024 after taking OTC Tylenol provided by family. Resident stated he swallowed the entire contents of the bottle. Sent to ER. staff to monitor Resident Q15 minutes. A record review of Resident #1's hospital stay summary dated 02/26/2024 revealed, . (Resident Representative and Family) present at bedside. Note that they had spent the day shopping and spending time with patient. Imagine that he felt more depressed after they brought him back to nursing home (first time they had visited in 3 weeks). Plan: as per initial consult note dated 02/25/2024. Agree with continuation of 1:1 given severity of recent suicide attempt. (Resident #1) is a [AGE] year-old male with PMH HTN, HLD, CAD with h/o stent placement x2, seizure disorder with prior unspecified brain surgery x 3. Hx of prior stroke of L posterior occipital, parietal, and temporal lobe, dementia / Alzheimer's disease, and severely hard of hearing who presented to the ED via EMS on 02/24/2024 for a chief complaint of acute acetaminophen (Tylenol) toxic ingestion. patient is currently a Resident of (the facility) since October 2023 after an admission for heat stroke. Per (Resident representative) patient is unable to take care of himself. (Resident representative) visits (Resident #1) as often including taking him out of the facility for meals and shopping as often as he can but reports that the patient frequently is unable to remember that he was visited. Last visit was 2 days ago (02/22/2024) and patient stated to (Resident representative) that he was lonely. Somehow the patient obtained a bottle of acetaminophen (Tylenol) and ingested 24 capsules of 500mg (12,000 mg) at approximately 1300 (1 PM) on 02/24/2024 before staff were able to halt the process. A record review of Resident #1's nursing progress notes revealed, Type: Nursing Progress Note Effective Date: 2/24/2024 19:10:00 (07:10 PM) Department: Nursing Position: Registered Nurse Created By: (RN A) Created Date: 2/24/2024 19:10:24 Note Text: on 2/24/2024 @ 1600 (4 PM) Resident (#1) noted, lethargic and difficult to arouse. Is A/O X 1 to self only, noted empty bottle of Tylenol extra strength on nightstand. Notified MD, DON, and Administrator, call made to (Resident representative). New orders: Transfer to ER for Eval & Tx. Emergency response made to 911, arrived @ 1700 (5 PM). Resident left facility 1708 (05:08 PM). During an interview on 12/11/2024 at 10:59 AM the previous DON stated she was the DON for the facility in February 2024. The DON stated she remembered Resident #1 as a friendly outgoing fell ow who routinely was out of bed and participating in meals and activities. The DON stated she recalled Resident #1 was assessed with a Tylenol overdose incident sometime in late February 2024. The previous DON stated she recalled Resident #1 was treated at the hospital and returned to the facility. The previous DON stated although she did not have direct recollection from February 2024, she and the administrator would review all hospital transfers and admissions and was confident she and the previous administrator had reviewed Resident #1's hospital discharge and admission. the previous DON stated she did not recall if she had provided an in-service for the staff specific to Resident #1's suicide attempt. The previous DON stated she could not recall if the facility had assessed peer residents for safety to include reviews for medications at the bedsides. During an interview on 12/11/2024 at 02:56 PM RN A stated he was the RN for Resident #1 from December 2023 to April 2024 and usually worked Monday through Friday from 06:00 AM to 02:00 PM and Resident #1 was usually in a good mood and up out of bed and had meals in the dining room. RN A stated on 02/24/2024 Resident #1 stayed in bed and refused breakfast and lunch as well as his medications. RN A stated he had documented at 4pm that around 3pm resident was found lethargic and hard to arouse, I found a bottle of empty Tylenol and called 911, I continued to provide support with positioning and assisted Resident #1 with 911. I documented and reported to (the MD), and the (Residents' Representative). RN A stated he did not assess peer residents for safety with a sweep for medications at the bedside, nor did he witness other staff assess other residents for safety. RN A stated he recalled the DON was notified of Resident #1's suicide attempt and 911 transfer to the hospital. RN A stated he had no knowledge of how Resident #1 came to possess the Tylenol bottle. RN A stated he had not received an in-service specific to medications at the bedside after resident #1's suicide attempt. During a joint interview on 12/10/2024 at 4:00 PM the Administrator and the DON stated they were not the leadership for the facility in February 2024. The Administrator and the DON stated they began their service in April 2024 . The Administrator and the DON stated they had minimal knowledge of Resident #1's suicide attempt on 02/24/2024 and were not aware if the previous Administrator nor the previous DON had provided an in-service to the staff specific to medications at the bedside and or provided a safety assessment of peer residents for medications at the bedside. The Administrator and the DON stated after Resident #1's suicide attempt the staff should have been in-serviced and peer residents should have been assessed for safety. The Administrator and the DON stated they would research the incident and provide documentation to support the facility's actions surrounding Resident #1's suicide attempt. On 12/11/2024 the administrator and the DON provided in-service records for the date of 02/27/2024 titled Documentation for Change of Condition, Completing Incident Report. No further documentation was provided for evidence of Resident assessments for safety regarding medications at the bedside nor in-services for medications at the bedside. A record review of the facility's in-service was titled, Documentation for Change of Condition, Completing Incident Report dated 02/27/2024 revealed the previous DON provided the in-service to 26 employees. A record review of the facility's undated policy titled Nursing Home List of Items Not Allowed in Residents Room revealed, Medications: (includes all Prescription and Over-the-Counter drugs, except emergency items like nitroglycerin, which must be ordered by the doctor through the Nursing Home.) and in certain situations where the resident is allowed to self-administer as per care plan. NOTE: A good rule of thumb has been established by the Food and Drug Administration whereby any products labeled Keep out of reach of children or carries any type of caution label is merchandise that contains ingredients which are harmful if taken without supervision or used in a way not designated. Many of our residents, due to mental impairments or poor eyesight might inadvertently drink or eat some of the above items causing irreparable harm. A record review of the Tylenol manufactures website TYLENOL(R) Easy to Swallow Caplets for Fast Pain Relief | TYLENOL(R) accessed 12/16/2024 revealed, Warnings: Liver warning: This product contains acetaminophen. Severe liver damage may occur if you take more than 4,000 mg of acetaminophen in 24 hours. Keep out of reach of children. Overdose warning: In case of overdose, get medical help or contact a Poison Control Center right away. (1-800-222-1222) Quick medical attention is critical for adults as well as for children even if you do not notice any signs or symptoms. The Administrator was notified on 12/12/24 at 03:50 PM, an IJ situation had been identified due to the above failures. The IJ template was given to the administrator on 12/12/24 at 03:50, PM and a POR was requested. The POR was accepted on 12/12/2024 at 08:01 PM and indicated the following: (the Facility) 12/12/2024 Plan of Removal Problem: IJ F689 Free of Accidents/Hazards/Supervision/Devices called on 12/12/24. Interventions: Facility staff searched through all items in residents' rooms to check for any items not allowed on 12/12/2024. All items identified as not allowed in residents rooms were removed from their rooms on 12/12/2024. On 12/12/2024, in-service initiated for all staff if you see medications at bedside or any other items not allowed in resident rooms, they should notify charge nurse, DON, and Administrator. Administrative staff will keep a log of any medications found at bedside. This log will include the residents name, date, what item was found, and action taken and that resident will be assessed to ensure they are free from harm by the item not allowed in the room. RP will be contacted to discuss facility policy for Items not Allowed in Rooms. On 12/12/2024, the Regional Compliance Nurse In-serviced the DON and administrator on resident overdoses. If a resident overdoses they should search that residents to look for additional items that residents can harm themselves with and remove any items identified. On 12/12/2024, Regional Compliance Nurse in-serviced DON and Administrator to search all other residents' rooms to ensure they don't have any items not allowed in their room / items that they harm themselves with when an incident of an overdose occurs. On 12/12/2024, Regional Compliance Nurse in-serviced DON and Administrator to add incidents that are accidents, hazards, and/or require supervision occur in the facility that they should add to the monthly QAPI Committee meeting for review. On 12/12/2024 nursing staff in-serviced to ask residents that return from being out on pass if they returned with any items that are not allowed in resident's rooms and if they do identify, they will not let resident take to his/her room and notify the DON and/or administrator. Resident out on pass log will be reviewed 5 x a week by DON and/or designee, and DON / designee will confirm the confirm with the nurse that the residents were screen when they returned from out on pass. On 12/12/2024, Facility to provide education/notification in form of an email to all RPs of residents with a list of the items not allowed in residents rooms. E-mails will be sent with a read receipt to ensure they have been reviewed. An audit list will be kept to verify that all current residents RP's read the email. A physical copy of the items not allowed in residents rooms will be mailed out to resident RP's on 12/13/2024. For all future residents, list will be provided upon admission as part of the admission packet. On 12/12/2024, education/in-service to be provided to all staff to reiterate the policy of items not allowed in residents rooms, by phone, COVR (scheduling portal/message board) and in person. Staff will not be able to return to work until education has been provided. In-service will be completed by 12/12/24. Signature or acknowledgement of this in-service will be confirmed by an audit list. On 12/12/2024 Facility will provide a copy of list of items not allowed to residents and keep a signed copy. Resident that are alert but unable to physically sign will be confirmed by two witnesses. On 12/12/2024, a sign was placed at the front door of the facility with the items not allowed in residents rooms. On 12/12/2024 all residents assessed to ensure that no residents voiced any suicidal Ideations On 12/12/2024 MD was notified of IJ F689 Free of Accidents/Hazards/Supervision/Devices On 12/12/2024 Facility to provide care for affected resident as per plan of care. Monitoring: Facility staff will conduct champion rounds 5x a week indefinitely in every resident room and look for items not allowed in residents. They will remove items not allowed if they identify any. Monitoring will start 12/12/2024. Regional Administrator and Regional Compliance Nurse will monitor during weekly visits and ask DON and Administrator what items are not allowed in residents room and what to do if any are identified. Monitoring will start 12/12/2024 and will continue x 8 weeks. Administrator / DON will monitor 5 residents' rooms daily, 5 days a week to ensure residents do not have any items not allowed in room. Regional Administrator and Regional Compliance Nurse will check 5 rooms each once a week to ensure that staff are conducting their champion rounds 5 x week and look for items not allowed in residents rooms. Monitoring will start 12/12/2024 and will continue x 8 weeks. Plan of Removal Verification Facility staff searched through all items in residents' rooms to check for any items not allowed on 12/12/2024. All items identified as not allowed in residents rooms were removed from their rooms on 12/12/2024. o During facility observation on 12/13/24 at 11:00 a.m., observed multiple bagged items in Administrator's office that staff identified as unauthorized items, removed from room, and bagged individually. Interview with the Administrator on 12/13/24 at 1:24 p.m. revealed that responsible parties have already been contacted, and they were picking up unauthorized items. o During facility observation on 12/13/24 at 12:15 p.m., observed Hospitality Aide / Receptionist B greeted a visitor arriving at the facility and provided him with the list of unauthorized items. o During facility observation on 12/13/2024 at 12:45 p.m. Hospitality Aide B monitored a bag a visitor entered the facility with and told the visitor to ensure the resident was safe to have the shakes in the bag. o During facility observation on 12/13/24 at 1:28 p.m., surveyor observed Hospitality aide / Receptionist B on phone with family member explaining the list of unauthorized items. On 12/12/2024, in-service initiated for all staff if you see medications at bedside or any other items not allowed in resident rooms, they should notify charge nurse, DON, and Administrator. Administrative staff will keep a log of any medications found at bedside. This log will include the residents name, date, what item was found, and action taken and that resident will be assessed to ensure they are free from harm by the item not allowed in the room. RP will be contacted to discuss facility policy for Items not Allowed in Rooms. During facility observation of in-service log on 12/13/24 at 1:38 p.m., observed in-service log (on-going) for all staff. In-service reflected medications at bedside or any other items not allowed in resident rooms, notification of charge nurse, DON, and Administrator. On 12/12/2024, the Regional Compliance Nurse In-serviced the DON and administrator on resident overdoses. If a resident overdoses they should search that residents to look for additional items that residents can harm themselves with and remove any items identified. o During facility observation on 12/13/24 at 1:38 p.m., observed in-service given by Regional Compliance Nurse completed 12/12/24 to DON & Administrator. In-service reflected resident overdoses, searching residents' rooms and removing items. In-service was signed by DON and Administrator. On 12/12/2024, Regional Compliance Nurse in-serviced DON and Administrator to search all other residents' rooms to ensure they don't have any items not allowed in their room / items that they harm themselves with when an incident of an overdose occurs. o During facility observation on 12/13/24 at 11:00 a.m., observed multiple bagged items in Administrator's office that staff identified as unauthorized items, removed from room, and bagged individually. Interview with the Administrator on 12/13/24 at 1:24 p.m. revealed that responsible parties have already been contacted, and they were picking up unauthorized items. o Interview with ADON C [shift M-F, days, on-call] on 12/13/24 at 11:11 a.m. revealed she received an in- service from the DON, and she has also been providing the in-service to staff members regarding personal items that residents may not have in their rooms. ADON C stated she has been handing out the lists to staff members and explaining purpose of list and items on the list. She stated she assisted in room check and removing unauthorized items from the rooms, explaining to residents, and calling family members. o Interview with ADON D [M-F, on-call] on 12/13/24 at 12:12 p.m. revealed that she received in-service from DON and has also been giving in-service to facility staff regarding items not allowed in residents' rooms. She stated she assisted in identifying and removing unauthorized items from residents' rooms and educating residents and family members. She stated she will continue to educate staff, residents, and visitors about unauthorized items. She stated she was aware at times that residents could request self-administer medications and if this occurred, she would review with DON to complete self-administration assessments as needed. On 12/12/2024, Regional Compliance Nurse in-serviced DON and Administrator to add incidents that were accidents, hazards, and/or require supervision occur in the facility that they should add to the monthly QAPI Committee meeting for review. o Record review of the POR binder revealed that Regional Compliance Nurse had completed the in-service on 12/12/24 with DON and Administrator to add incidents that are accidents, hazards, and/or require supervision to the QAPI Committee meeting for review. On 12/12/2024 nursing staff in-serviced to ask residents that return from being out on pass if they returned with any items that were not allowed in resident's rooms and if they do identify, they will not let resident take to his/her room and notify the DON and/or administrator. Resident out on pass log will be reviewed 5 x a week by DON and/or designee, and DON / designee will confirm the confirm with the nurse that the residents were screen when they returned from out on pass. o A record review of the facility's Out on Pass Log revealed residents will be screened upon return to the facility. On 12/12/2024, Facility to provide education/notification in form of an email to all RP's of residents with a list of the items not allowed in residents rooms. E-mails will be sent with a read receipt to ensure they have been reviewed. An audit list will be kept to verify that all current residents RP's read the email. A physical copy of the items not allowed in residents rooms will be mailed out to resident RP's on 12/13/2024. For all future residents, list will be provided upon admission as part of the admission packet. o Interview with Admissions Coordinator/Marketing G [1st shift, M-F and varying weekends] on 12/13/24 at 8:14 a.m. revealed that he received in-service from Administrator regarding items residents may not have in their rooms. He stated he has a copy of the list and has incorporated the list with the Admission Packet to provide to new admissions/family members. He stated since his office in in the front of the facility, he will watch out for residents and visitors coming in with shopping bags and remind them of the unauthorized list of items. o Interview with BOM on 12/13/24 at 2:45 p.m. revealed that BOM sent email notification to family members who have provided email on 12/12/24 at 5:35 p.m. Email included delivered and read notification. o Interview with BOM on 12/13/24 at 2:45 p.m. revealed the responsible parties who have not provided an email were mailed a letter explaining the List of Items not allowed in facility. BOM stated letters were mailed on 12/13/24. On 12/12/2024, education/in-service to be provided to all staff to reiterate the policy of items not allowed in residents rooms, by phone, COVR (scheduling portal/message board) and in person. Staff will not be able to return to work until education has been provided. In-service will be completed by 12/12/24. Signature or acknowledgement of this in-service will be confirmed by an audit list. o Total staff 117. Review of POR binder revealed 114 out of 117 staff members have been contacted. Nurses: 11 out of 27 nurses interviewed with sample from all three shifts. CNA/MA 7 out of 25 nurse aides interviewed. 16 non-nursing / non-direct care staff interview. o Interview with MA E on 12/13/24 at 8:10 a.m. [1st shift, M-F] revealed that she received in-service from DON regarding items that residents may not have in their rooms. She stated she was provided a list of items to follow. She stated if she found unauthorized items, she would notify the charge nurse or her DON to let them know. o Interview with CNA F on 12/13/24 at 8:12 a.m. [1st shift, M-F] revealed that she received in-service from DON regarding items that residents may not have in their rooms. She stated she was provided a list of items to follow. She stated if she found unauthorized items, she would notify the charge nurse or her DON to let them know. o Interview with Admissions Coordinator/Marketing G [1st shift, M-F and varying weekends] on 12/13/24 at 8:14 a.m. revealed that he received in-service from Administrator regarding items residents may not have in their rooms. He stated he has a copy of the list and has incorporated the list with the Admission Packet to provide to new admissions/family members. He stated since his office in in the front of the facility, he will watch out for residents and visitors coming in with shopping bags and remind them of the unauthorized list of items. o Interview with LVN H [PRN Nurse, varying shifts] on 12/13/24 at 8:18 a.m. revealed that she received in- service from DON regarding items that residents may not have in their rooms. She stated she was provided a list of items to follow. She stated if she found unauthorized items, she would inform residents and remove them from the room for safekeeping and notify family members to pick them up. She stated she would notify DON of unauthorized items. o Interview with Housekeeper I on 12/13/24 [1st shift, rotating schedule] at 8:32 a.m. revealed that she received in-service from DON regarding items that residents may not have in their rooms. She stated she was provided a list of items to follow and look for. She stated she would notify her supervisor or the Administrator if she identified unauthorized items. o Interview with Hospitality Aide/Receptionist B [1st Shift M-F] on 12/13/24 at 10:15 a.m. revealed that she received in-service from Administrator about items residents may not have in their rooms. She stated she was provided a copy for herself and has copies available at the receptionist deck to hand out to residents and/or family members. She stated she would watch for residents returning from pass or visitors entering the facility with items and provide them with a list of authorized items and remind them that they need to follow the posted guidelines. She stated she was comfortable asking residents and visitors to follow guidelines. o Interview with RN J, Charge Nurse [1st Shift M-F] on 12/13/24 at 10:40 a.m. revealed that she received in-service on items residents may not have in their rooms and has been provided a list of items to keep for reference. She stated that if she identifies unauthorized items or is told by her aides or other staff members about unauthorized items, she will speak to resident and/or R/P and remove them from the room. She would educate residents and/or R/P and notify DON or Administrator at time of occurrence. o Interview with PT K [1st Shift M-F] on 12/13/24 at 10:48 a.m. revealed that he has received in-service from DON regarding items residents may not have in their rooms. He stated he was given a personal copy of the list. He stated that if he noticed any items in the rooms, he would remove them and notify the DON or Administrator as well as let the resident know why they were not safe to keep in the room. o Interview with COTA L [1st shift M-F] on 12/13/24 at 11:00 a.m. revealed that she received in-service regarding unauthorized items that residents may not have in their rooms. She stated she had a copy of the list of items and if she notices items, she will let the resident know why they cannot have it/them and remove the item(s). She stated she would let the charge nurse know. o Interview with PT M [1st shift M-F] on 12/13/24 at 11:03 a.m. revealed that she received in-service from DON on items not allowed to be in resident's rooms. She stated she would remove unauthorized items and let the resident know why she had to take the items. She stated she would notify the Charge Nurse or DON of found items and give the item to them for safekeeping. o Interview with the SW [1st shift M-F] on 12/13/24 at 11:05 a.m. revealed that she received in-service from DON regarding personal items that residents may not keep in their rooms. She stated she will remove unauthorized items from the room, educate residents and/or family members/visitors as well as keep an eye out for people coming in facility with shopping bags. She stated she will continue to educate. o Interview with the BOM [1st shift M-F] on 12/13/24 at 11:07 a.m. revealed that she received in-service from DON on items that residents may not keep in their rooms. She stated she had a list of the items and if she were to see residents with unauthorized items, she would notify the DON or Administrator. o Interview with LVN/MDS N Coordinator [1st shift M-F] on 12/13/24 at 11:09 a.m. revealed that she received in-service from DON on unauthorized items. She stated she had the list of items and was aware of what to look for in the residents' rooms. She stated she will remove identified items and notify Charge Nurse and DON of identified items. o Interview with ADON C [1st shift M-F and on-call] on 12/13/24 at 11:11 a.m. revealed she received in- service from DON and has also been providing the in-service to staff members regarding personal items that residents may not have in their rooms. She stated she had been handing out the lists to staff members and explaining purpose of list and items on the list. She stated she assisted in room checks and removing unauthorized items from the rooms, explaining to residents, and calling family members. o Interview with LVN O (PRN shifts) on 12/13/24 at 11:22 a.m. revealed she received in-service from DON on items residents are not allowed to keep in their rooms. She stated she would remove identified items, explain to resident and/or family why they cannot have these items and let the DON know. She stated as charge nurse, she would assist her aides with removing items and education. o Interview with CNA P [1st shift, M-F and PRN] on 12/13/24 at 11:32 a.m. revealed that she received in- service from DON about items not allowed to be in residents' rooms. She stated that she would let her resident know that she would have to remove unauthorized items and notify Charge Nurse and/or DON. o Interview with Medical Records / Central Supply Q [1st shift M-F] on 12/13/24 at 11:34 a.m. revealed that she received in-service from DON on items that residents may not have in their rooms. She stated she was in residents' rooms almost daily for stocking supplies and was aware of being on the lookout for unauthorized items. She stated she would remove the items, let the resident know why he/she cannot have the items and notify the Charge Nurse and/or DON. o Interview with the Activity Director [1st shift / some evenings, M-F] on 12/13/24 at 11:36 a.m. revealed that she received in-service from DON regarding items residents may not have in their rooms. The Activity Director stated she did a lot of resident shopping and followed this list prior to in-service. The Activity Director stated she would review it with the resident council and keep a copy of the list for reference. o Interview with CNA R [1st shift & prn, M-F] on 12/13/24 at 11:36 a.m. revealed she received in-service on authorized and unauthorized items that residents may have in their room. She stated she had been a nurse aide for more than [AGE] years and was very aware of these items. She stated she would let her resident know why he/she cannot have the items and remove items from room and let the Charge Nurse know. o Interview with Laundry Staff S [1st shift wknd] on 12/13/24 at 11:42 a.m. revealed that she received in- service by DON about unauthorized items in resident's rooms. She stated she would let the charge nurse, or the DON know if she saw items in the room. o Interview with Laundry Staff T [1st shift wknds] on 12/13/24 at 11:42 a.m. revealed that she received in- service by DON about unauthorized items in resident's rooms. She stated she would let the charge nurse, or the DON know if she saw items in the room. o Interview with SLP U [1st shift M-F] on 12/13/24 at 11:45 a.m. revealed that she received the in-service on unauthorized items and feels comfortable removing the items, letting Charge Nurse and DON know and educating resident on the list of unauthorized items. She stated she had daily contact with residents regarding food items / non-compliance and items that they may / may not keep in their rooms. o Interview with Housekeeper V [1st shift, M-F] on 12/13/24 at 11:47 a.m. revealed that she received in- service from DON. She reviewed provided list and stated that she had been taught to let the Charge Nurse, DON or her supervisor know if a resident has these items. She stated she was not comfortable removing items hersel [TRUNCATED]

Based on interviews and record reviews, the facility failed to ensure nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents needs safely for 1 (Resident #10) of 10 residents reviewed for nursing services in that: 1. Facility failed to obtain wound care orders for Resident #10 when he was admitted to facility on 1/14/2021, post- surgical removal of left toes. 2. Assessment of Resident #10's wound appearance was not documented from 1/14/21 to 1/16/21. 3. LVN F provided wound care to Resident #10 without provider orders. 4. LVN F did not communicate to the charge nurse taking care of Resident #10 wound care done. 5. LVN G did not call physician to obtain wound care orders for Resident #10 on admission. This failure could place residents at risk for infection, resulting in unnecessary pain, further surgical interventions, and/or death. The findings were: Record review of face sheet dated 2/2/2021, indicated Resident #10 was admitted on [DATE] revealed [DIAGNOSES REDACTED]. Record review of Resident #10's MDS-Medicare 5 day- dated 1/16/2021 revealed a BIMS score of 15, which indicated an intact cognitive response. Further review revealed Resident #10 had in Section G, functional status walks in room did not occur, required staff to provide care 100% of the time. Locomotion on unit or in room requiring 2 persons physical assist. Dressing requiring one-person physical assist. Balancing during transitions and walking not steady only able to stabilize with staff assistance, moving from seated position to standing position. No walking occurring. Functional limitation in range of motion impairment on one side to lower extremity. Wheelchair for mobility device. Lower body dressing, Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Section I Active Diagnoses: [REDACTED]. Section J, Health conditions, other major orthopedic surgery. Section M, Skin conditions, surgical wound Record review of Resident #10's care plan dated 1/15/2021 revealed 1. Resident has a surgical site to: none documented. 2. The resident has a pressure ulcer or potential for pressure ulcer development: Interventions: Ensure heels are floated with the use of pillows, Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Record review of Resident #10's Order Summary report dated for admission 1/14/2021-indicated no orders for wound care to left post surgical lower extremity. Record review of Resident #10 hospital progress note dated 1/14/2021 revealed page 2 of 2, section Diagnosis, Assessment, and Plan: cleared by Vascular surgery for [REDACTED]. Discharge instructions in section Wound/Dressing care: Keep wound clean and dry. Review of hospital records indicated amputation was due to his [MEDICAL CONDITION] and no vascularization to his lower extremity. No indication of wound infection. Unable to speak with surgeon. Record review of facility Skilled Nursing Notes dated 1/15/2021 section B. pg 1 Lt-Foot Heel Ulcer documented for skilled care. pg 3 of 4, dressing to foot. Further review of the Skilled Nursing Note revealed it was written by the LVN I. Record review of facility initial skin assessment dated [DATE], Section A.e: Surgical incision checked yes, ee: note Left foot TMA(trans metatarsal amputation). Record review of Resident #10's TAR (Treatment Administration Record) no entry for wound care. Record review of facility New Admission Report Sheet dated 1/14/2021 at 5:00 p.m. by LVN G, revealed notes with [DIAGNOSES REDACTED]. Eschar right toe-dressed with [MEDICATION NAME]. Off-loading boots. Record review of Resident #10's POC Response History for Certified Nurse Aide documentation dated 1/15/2021-1/16/2021-check mark to section {None of the above observed} for skin assess, scratched, red areas, discoloration, skin tear, open areas. In an interview on 2/3/2021 at 2:03 p.m. LVN G stated he works 2 pm to 10 pm Monday-Friday, he then confirmed there were no orders for wound care for Resident #10's admission date of [DATE] through 1/16/2021. LVN G stated he was not aware of Resident #10 having a wound or bandage to his left foot on admission and he did not call the physician to obtain orders. He stated he does a head to toe assessment on residents when admitted . He stated, whatever I charted was what the resident had at the time of admission. When asked did he see the [DIAGNOSES REDACTED]. When asked did you see a wound dressing on his left foot? He stated, I do not remember, and whatever I charted was what I saw. Investigator showed LVN G New Admission Report Sheet dated 1/14/2021 at 5:00 p.m. by LVN G, revealed notes with [DIAGNOSES REDACTED]. Eschar right toe-dressed with [MEDICATION NAME]. Off-loading boots, he stated yes that was his report sheet and he wrote the information on it. When asked why he did not look at the residents feet, he stated he could not remember , we are very busy and cannot always do all of our tasks. If there is no treatment nurse, we have to find time to do the treatments or wound care and it is hard. In an interview on 2/4/2021 at 2:15 p.m. LVN F stated that he recalled on 1/15/2021 in the evening hours (he did not remember what time) he was walking by Resident #10's room and an aide (he could not remember who) asked him to look at Resident #10's foot dressing. He stated that he noted his left foot dressing was coming off and he decided to change it. He went to the wound care cart that was close by and obtained the same type of dressing that was on Resident #10. He stated he saw the surgical wound had staples and sutures and there was a small amount of red blood on the dressing. He stated he cleaned it and wrapped it back up. He confirmed that there were no orders for wound care for Resident #1's admission date of [DATE] through 1/16/2021. He further confirmed that he did not tell the charge nurse that he had done this, nor did he document it. He revealed, the process should have been to check the resident's chart for a wound care order and to communicate with the resident's primary nurse about finding the wound dressing on the resident. In an interview on 2/4/2021 at 2:30 p.m. ADON B confirmed there were no orders for wound care for Resident #10's admission date of [DATE] through 1/16/2021. ADON B stated she was not aware of Resident #10 having a wound to his left foot. ADON B stated that she was not sure which CNA was working on the evening of 1/15/2021 with Resident #10. In an interview on 2/4/2021 at 3:00 PM CNA R stated, I do not recall the resident's previous admission before he had to have left leg amputation. CNA R stated he works the 2 pm to 10 pm shift on the hall where resident # 10's room was. CNA R stated that he only remembers when Resident #10 was here for his second admission. And he did not recall seeing a wound dressing on his left foot. He further revealed that he always reports to the nurses if a resident has a bruise or skin condition , so they can treat it. In an interview on 2/4/2021 at 3:00 p.m. with DON confirmed there were no orders for wound care for Resident #10's admission date of [DATE] through 1/16/2021. DON stated she was not aware of Resident #10 having a wound to his left foot or wound care ordered for it. Further interview with DON revealed she has the expectation that all nurses will do a full body skin assessment of newly admitted residents and that it will be documented in the resident's electronic medical record under skin assessments. She stated that inservicing will immediately occur to include education for both nurses and nurse aides on skin assessing. Record review of the facility's policy titled Skin Assessments with revision date of 8/15/2016 revealed: It is the policy of the facility to establish a method whereby nursing can assess a resident's skin integrity to allow appropriate intervention be initiated in a timely manner. Procedure: 1. All new admits and residents returning from a hospital stay will have a head to toe skin assessment completed. If the facility Treatment Nurse/designee is available, he/she should complete the assessment within four hours of the resident's arrival at the facility. If the Treatment Nurse/designee isn't available, then the charge nurse should complete the assessment within four hours of the resident's arrival at the facility. The charge nurse will then notify the Treatment Nurse/designee of any skin problems noted, complete the appropriate attachments/assessments. The DON or designee, along with the Treatment Nurse/designee and other team members will review for the follow-up assessment and recommendations. Any alterations in skin integrity will be treated according to physician orders. Notify DON and responsible family member.