Every finding on record at Hurricane Health and Rehabilitation

Based on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was defined as any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, for 4 out of 25 sampled residents, blood pressure medications were administered outside of a physician's ordered parameters and one resident required medical intervention. Resident identifiers: 7, 8, 38, and 43. 1. Resident 7 was admitted to the facility on [DATE] with diagnoses which included hypertensive chronic kidney disease, type 2 diabetes, and bladder cancer. Resident 7's medical record was reviewed on 9/22/25 through 9/25/25. On 5/15/25, Lisinopril oral tablet was ordered for hypertension, with the following parameters: Hold if BP [blood pressure] is below 120/80. The Medication Administration Record (MAR) indicated that the administration time for Lisinopril was 7:00 AM. On 5/15/25, Metoprolol Succinate extended release oral tablet was ordered for hypertension, with the following parameters: Hold if BP is below 120/80. The MAR indicated that the administration time for Metoprolol was 7:00 AM. The MAR for the months of July and August 2025 indicated that resident 7 received Lisinopril and Metoprolol 17 times when no morning blood pressure (BP) readings were documented in the resident's medical record. The MAR for the months of July, August, and September 2025 indicated that resident 7 received Lisinopril and Metoprolol 20 times when it should have been held due to a BP below 120/80: On 7/6/25, BP of 115/65 On 7/13/25, BP of 100/68 On 7/15/25, BP of 109/63 On 7/20/25, BP of 104/61 On 7/24/25, BP of 100/60 On 8/4/25, BP of 101/56 On 8/9/25, BP of 105/57 On 8/11/25, BP of 102/59 On 8/15/25, BP of 106/62 On 8/16/25, BP of 115/80 On 8/21/25, BP of 85/60 On 8/23/25, BP of 100/59 On 8/24/25, BP of 91/51 On 8/28/25, BP of 106/62 On 8/31/25, BP of 105/64 On 9/6/25, BP of 115/62 On 9/7/25, BP of 101/63 On 9/13/25, BP of 101/66 On 9/19/25, BP of 93/50 On 9/21/25, BP of 106/66 On 7/25/25, a Nursing Progress note documented: CNA alerted nurse that resident was unresponsive. Nurse assessed resident. She was responsive to tactile stimuli. She was pale and groaning in pain. Vitals taken BP 84/40, P [pulse] 110, R [respirations] 22, O2 [oxygen saturation] 85@ RA [room air]. EMS [emergency medical services] called and was transferred to [hospital name redacted] for evaluation. Note: The MAR indicated that Lisinopril and Metoprolol was administered on 7/24/25 when it should have been held due to a BP below 120/80. On 8/22/25, a provider Encounter note documented: Today patient being seen regarding a hypotensive episode. Patient's blood pressure has dipped down to 82/51. She did not have a reading above 98/71 yesterday. Patient states that she has been lightheaded, and overall feeling weaker than normal. Patient states she had lost her appetite for a few days, however at this point is rebounding. Patient was eating breakfast when we were speaking. After reviewing patient's medications she is on lisinopril 20 mg [milligram] once daily for treatment of hypertension, and metoprolol 25 mg [milligram] once daily. At this point we will go ahead and hold patient's lisinopril, and metoprolol until patient's blood pressure is back above 120/80. Will also administer 500 cc [cubic centimeters] of lactated Ringer's via IV [intravenous] to aid in supporting her blood pressure. Note: The MAR indicated that both Lisinopril and Metoprolol were administered on 8/21/25 when they should have been held due to a BP below 120/80. On 9/25/25 at 11:21 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that if a resident had a Systolic Blood Pressure (SBP) below 100 she would reposition the resident and obtain a manual BP reading. If the resident's SBP remained under 100, RN 2 stated that she would contact the provider via a phone call and document the notification in the progress notes. RN 2 stated that when she administered a BP medication she verified that the resident's BP had been obtained within the last 40 minutes. RN 2 stated that the electronic charting system showed any ordered parameters associated with a BP medication; required her to acknowledge that she had seen the most recent BP; and gave the option to enter a newly obtained BP before administering BP medication. RN 2 stated that she held BP medication based on provider ordered parameters for the medication. Additionally, RN 2 stated that she would hold BP medication if the most recent SBP was below 115. RN 2 stated that the following were possible outcomes if a resident's BP was below the ordered parameters or the resident did not have BP taken before they received a BP medication: change in cognition; increased weakness and balance issues, a change in the resident's ability to safely ambulate or the resident's BP could bottom out. Resident 7's MAR was reviewed with RN 2. The MAR indicated that RN 2 administered Lisinopril and Metoprolol on 9/19/25 when resident 7 had a documented BP of 93/50. RN 2 stated that it was a documentation error because she was very careful when administering BP medications. RN 2 stated that would not have administered resident 7's BP medications with a BP of 93/50. On 9/25/25 at 2:21 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that when a resident had a low BP the nurse was expected to assess the resident for symptoms of low BP, hold medications with BP parameters, and review the resident's past BP for trends. The DON stated that the nurse was expected to notify the provider if a resident had a low BP and had symptoms or if the resident had a trend of low BPs. Resident 7's MAR was reviewed with the DON. The DON stated that resident 7's Lisinopril and Metoprolol should not have been administered if the BP was below the ordered parameters, and that the provider should have been notified of the trends in resident 7's BPs. 2. Resident 8 was admitted to the facility on [DATE] with diagnoses which included rheumatoid arthritis, type 2 diabetes, unspecified severe protein-calorie malnutrition, and essential hypertension. Resident 8's medical record was reviewed on 9/22/25 through 9/25/25. On 6/10/23, Metoprolol Succinate extended release oral tablet was ordered to be given in the morning for hypertension with the following parameters: Hold if SBP < [is less than] 120 or HR [Heart Rate] < [is less than] 60. The MAR for the months of August and September 2025 indicated that resident 8 received Metoprolol 15 times when it should have been held due to a SBP of less than 120. On 8/5/25, SBP of 101 On 8/7/25, SBP of 114 On 8/9/25, SBP of 112 On 8/12/25, SBP of 111 On 8/24/25, SBP of 113 On 8/25/25, SBP of 117 On 9/1/25, SBP of 101 On 9/4/25, SBP of 118 On 9/6/25, SBP of 106 On 9/8/25, SBP of 106 On 9/10/25, SBP of 117 On 9/11/25, SBP of 117 On 9/15/25, SBP of 108 On 9/16/25, SBP of 107 On 9/18/25, SBP of 110 3. Resident 43 was admitted to the facility on [DATE] with diagnoses which included fracture of right femur, osteoporosis, anxiety disorder, and major depressive disorder. Resident 43's medical record was reviewed on 9/22/25 through 9/25/25. On 3/6/25, Lisinopril oral tablet was ordered one time a day for hypertension with the following parameters: Hold for SBP < [less than] 120 **Hold for SBP is consistently > [greater than] 135/85. The MAR for the months of July, August, and September 2025 indicated that resident 43 received Lisinopril 10 times when it should have been held due to a SBP of less than 120: On 7/6/25, SBP of 105 On 7/12/25, SBP of 111 On 7/23/25, SBP of 108 On 8/5/25, SBP of 115 On 8/7/25, SBP of 118 On 8/17/25, SBP of 104 On 8/18/25, SBP of 106 On 8/24/25, SBP of 103 On 9/13/25, SBP of 118 On 9/16/25, SBP of 119 On 9/25/25 at 11:10 AM, an interview was conducted with RN 1. RN 1 stated that if a resident had a systolic blood pressure in the 80's or 90's she would notify the physician. RN 1 reviewed the parameters of resident 43's Lisinopril order, Hold for SBP [Systolic Blood Pressure] < [less than] 120 **Hold for SBP is consistently > [greater than] 135/85. RN 1 stated that it was confusing and she would get clarification from the physician prior to administering the medication. On 9/25/25 at 11:21 AM, an interview was conducted with RN 2. The parameters of resident 43's Lisinopril order were reviewed with RN 2, who stated that she would contact the provider to clarify what was meant by: Hold for SBP is consistently > [greater than] 135/85. On 9/25/25 at 2:21 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a nurse did not understand the parameters of an order they were expected to call nursing management or the provider for clarification. The DON reviewed the parameters of resident 43's Lisinopril order and stated that she would have called to clarify the order with the provider. 4. Resident 38 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included hypertension, congestive heart failure, diabetes mellitus type II, and hepatic failure. Resident 38's medical record was reviewed 9/22/25 through 9/25/25. A physician's order dated 2/26/25 indicated, Metoprolol Tartrate Oral Tablet 25 MG [milligrams] (Metoprolol Tartrate) Give 1 tablet by mouth two times a day for Hold for SBP <100 [less than 100], HR <60 [heart rate less than 60]. related to ESSENTIAL (PRIMARY) HYPERTENSION. The Medication Administration Record for the months of July and September 2025 indicated that resident 38 received Metoprolol two times when it should have been held due to a systolic blood pressure of less than 100: On 7/5/25, resident 38 had a BP of 99/67 and was administered Metoprolol. On 9/3/25, resident 38 had a BP of 96/61 and was administered Metoprolol. On 9/25/25 at 11:10 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she always checked the blood pressure parameters before administering blood pressure medications. RN 1 stated if the blood pressure was too low and was out of range of the parameters she would hold the blood pressure medications. On 9/25/25 at 2:21 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the nurse should have known what the blood pressure parameters were and that they should have held the metoprolol.

Based on interview and record review, the facility did not arrange services with an outside agency. Specifically, for 1 out of 25 sampled residents, residents had physician's orders to follow up with a specialist and the facility staff did not put the order in for 2 months, which delayed the resident seeing the specialist for over 3 months.Findings included: Resident 18 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included sequelae of cerebral infarction, neuromuscular dysfunction of bladder, benign prostatic hyperplasia with lower urinary tract symptoms, and muscle weakness.Resident 18's medical record was reviewed between 9/22/25 and 9/25/25.Hospital discharge documents dated 4/4/25 indicated resident 18 had a discharge diagnosis of urinary retention and acute kidney injury. Discharge Orders included, Urinary retention: According to nephrology, patient should be discharged with Foley catheter and follow-up with urology as an outpatient; and Follow-up: [Physician's name redacted], Urology; Within 1-2 weeks. Additional instructions were to call for a follow-up appointment.A physician's initial resident Encounter note dated 4/7/25 at 8:38 AM revealed, .The patient remained with an acute kidney injury and nephrology was consulted.However, he remained encephalopathy [sic] with continued worsening kidney function.The patient was followed by nephrology throughout the hospitalization.F/U [follow-up] appointments as ordered.A physician's Encounter note dated 4/13/25 at 11:00 PM revealed, .Today patient being seen regarding his catheter. Catheter has become dislodged. Nursing staff is questioning whether or not to put the catheter back in. He does have an upcoming appointment with urology. Patient has had a catheter in for quite some time at this point. Patient does have pressure wounds on his backside. I believe leaving the catheter in place would help with healing of these wounds. With [sic] will go ahead and replace the catheter today. Patient will follow up with his urologist for further evaluation regarding long-term catheter use.A physician's Encounter note dated 5/2/25 at 1:00 AM indicated, .His only complaint of pain is around the urethra, from the insertion site of the Foley catheter. He states he gets bumped and sometimes pulled and has caused some irritation.A Nursing note dated 5/4/25 at 4:13 PM revealed, Resident with UTI [urinary tract infection] symptoms.UA [urinalysis] sample obtained and sent to lab for testing. Reviewed with primary nurse [name redacted] and in physician log book. Will monitor.A Condition Follow-up note dated 5/7/25 at 8:07 AM revealed, Foul smelling urine.UA still pending.A Nursing Progress note dated 5/7/25 at 9:15 AM revealed, Called to therapy room as resident was 'seizing' per staff. Assessed resident and he was in WC [wheelchair] Diaphoretic., AAOx3 [awake, alert and oriented times 3], visibly uncomfortable.Denied pain, however 'doesn't feel right' .Called [physician] was onsite to assess. He assessed and said to call EMS [emergency medical services] and send to ER [Emergency Room] for evaluation.Resident had focal seizure in chair for about 30seconds [sic] .Hospital discharge documents dated 5/13/25 indicated, Discharge diagnosis: Severe sepsis without septic shock; catheter associated urinary tract infection; and Follow-up: [Physicians name redacted], Urology; Within 1 week. Additional instructions: Referral in [computer program].A physician Encounter note dated 5/23/25 at 1:00 AM indicated, .Chief Complaint/Nature of Presenting Problem: Confusion and paranoid behavior. Fall. Sent to emergency department.During the initial assessment, the patient wanted to know what the kitchen people knew about him. His speech was alittle [sic] garbled.He was not making a lot of sense. UA with reflex CNS [sic: C&S culture and sensitivity] was ordered. His urine is a little hazy. He has a Foley catheter to down drain. Later that day, he had a fall outside in the rocks and hit his head.He was sent to the emergency department for further workup.A Nursing note dated 5/23/25 at 11:51 AM indicated, Resident returned from ER with no significate [sic] finding. No new orders.A Nursing Progress Note dated 6/2/25 at 3:06 PM revealed, Resident sent to [facility redacted] ER via emergency transport for signs/sx [symptoms] of sepsis r/t [related to] UTI dx [diagnosis]. Resident experienced increased confusion and temperature, N/V [nausea and vomiting], unresponsiveness, inability to make self understood, shaking, jerking of movements, and chills. Sent at 1500 [3:00 PM].Note: No documentation of any urology follow up appointments could be located in the medical record. Hospital discharge documents dated 6/5/25 indicated, Discharge diagnosis: Sepsis; Bacteremia due to Klebsiella pneumoniae; Catheter-associated urinary tract infection; Acute kidney injury, POA [present on admission]; and Follow-up: [Physician's name redacted], Urology; within 1 month; and Scheduled Appointments: Wednesday, Jul. 30, 2025 2:30 PM [MDT].A physician order dated 6/6/25 indicated, Urology referral [physicians name redacted] Apt [appointment] 7/30/25.On 9/24/25 at 11:51 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1 who stated if a resident went to the hospital, when they returned, the nurse who was assigned to the room they were returning to would review the paperwork from the hospital and put new discharge orders in. LPN 1 stated the DON [Director of Nursing] or Assistant Director of Nursing [ADON] would review the paperwork to ensure that the orders were put in the resident's medical record. On 9/25/25 at 3:03 PM, an interview was conducted with the DON who stated the old system for making appointments was not putting orders in the resident's medical record. The DON stated a staff member was designated to keep track of resident appointments prior to her tenure as DON. The DON stated the ADON started a tracking system for when a resident came back with new orders for an appointment. The DON stated that transportation staff were notified, and the person making appointments would be notified, and the DON and ADON would be notified so the appointments would be scheduled in a timely manner. The DON stated resident 18's appointment was scheduled after he was seen at the hospital on 6/2/25 and his appointment was scheduled on 7/30/25. The resident was seen on 7/30/25 and physician orders to wean him from the catheter were implemented. The DON stated she did not know why resident 18 did not see the Urologist prior to 7/30/25.

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, a freezer in the outdoor storage room contained food items open to air, areas in the kitchen were not clean, food items in the reach in refrigerator were not labeled, and dead bugs were found in the outdoor dry storage room. Findings included:On 9/22/25 at 1:55 PM, an initial walk-through of the kitchen was conducted. In the outdoor storage room, a lift-top freezer contained a torn plastic bag with frozen pizza crusts that was open to air, and a large plastic bag containing what appeared to be frozen cookie dough was open to air, and appeared to have freezer burn. There was no thermometer in the freezer. In the kitchen the stove was not clean; there were crumbs, a dipping sauce packet and cheese wrapper under the stove. The ice machine was not clean with rust or water deposits above the ice. In the dry storage room, 2 bulk bins with what appeared to be flour and sugar inside, were not labeled or dated. In the dry storage room, there were also 2 large plastic containers with blue lids that were not labeled. In addition, a box of buttermilk pancake mix was not labeled with an open date, and the bag was not sealed and was open to air.On 9/25/25 at 1:17 PM, a second walk-through was conducted in the kitchen. Three dead roaches and several black bugs of different sizes were observed under the storage shelves and behind the freezer. In the kitchen, the stove was not clean, the steam table had floating food in the bottom of it and the sides had not been wiped clean, the landing under the juice machine was not clean with white powder. The cart next to the juice machine was sticky on the bottom shelf with a white powder. There were crumbs under and behind the stove. In the dry storage room the 2 large bulk storage bins containing flour and sugar were open to air, and were not labeled or dated. The buttermilk pancake mix was open to air, and the floor was not clean. The reach-in refrigerator had a bag of parmesan cheese that was not labeled or dated, and a large bowl of Jell-o salad that was not labeled.On 9/25/25 at 1:44 PM, an interview was conducted with the Dietary Manager (DM) who observed and confirmed that there were bugs in the outside storage room. The DM stated she had been the DM for 2 months and had not seen the pest control company there, but had seen several pest control boxes on the floor of the storage room so she knew a pest control company had been there. The DM stated she and the other staff members swept the storage room frequently to keep the bugs out of the storage room. The DM stated she had seen dead bugs in the storage room before. The DM stated the pizza crust and the dough were thrown into the open top freezer recently when the walk-in freezer went out and they were not properly wrapped or labeled. The DM stated they would have to be thrown away. The DM stated everything placed in a box had to be labeled with a common name, an open date and an expiration date, and if in bags, the item needed to be tied up. The DM stated the bulk bins should be labeled and covered. The DM stated the staff should be closing food items when they were finished with the food item. The DM stated she found the bag of parmesan cheese and Jell-o salad and labeled and dated them, and educated the cook who had put them there. The DM stated each staff member had cleaning duties they were responsible for each day and the cleaning duties were in a binder by the kitchen door. The DM stated she thought putting them in a more visible location would remind the staff about keeping up with them and keeping the kitchen cleaner. The DM stated the consultant Dietitian who came weekly conducted kitchen audits for cleanliness and safety on a regular basis and shared findings with her.On 9/25/25 at 2:06 PM, an interview was conducted with the Administrator (ADM) who stated a pest control company came on a monthly basis to manage pest control needs. The ADM stated for the kitchen, the bug traps were replaced every month.

Based on interview and record review, for 1 of 25 sampled residents, the facility did not ensure that residents who required dialysis received such services, consistent with professional standards of practice. Specifically, a resident receiving dialysis was not having his pre-dialysis vital signs information documented before leaving for dialysis as was required in the facilities' dialysis communication policy. Resident identifier: 30.Findings included: Resident 30 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included end stage renal disease, dependence on renal dialysis, atrial fibrillation, and muscle wasting and atrophy.On 9/23/25 at 11:48 AM, an interview was conducted with resident 30 who stated he was taken to dialysis on Mondays, Wednesdays, and Fridays by the facility transportation van at 10:00 AM.Resident 30's medical records were reviewed between 9/23/25 and 9/25/25.A review of resident 30's care plan dated 11/2/21 revealed a Focus area, Needs hemodialysis r/t [related to] renal failure (AV[arterio-venous] fistula). [Facility name redacted] on MWF [Monday, Wednesday, Friday] at 10:30 [AM]. Included in the interventions, .Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and BP [blood pressure] immediately. The goal was to have no s/sx [signs or symptoms] of complications from dialysis through the review date. Initiated 11/2/21.A review of resident 30's nursing progress notes revealed:On 9/12/25 at 5:04 PM, Patient came back from dialysis with no concerns noted and a post dry weight of 205.9 [pounds].On 9/1725 at 4:31 PM, Resident returned back to facility from dialysis and is tolerating treatment well. Pre-dialysis weight: 207.6; Post dialysis weight 205.2 [pounds].On 9/19/25 at 6:07 PM, Resident returned from dialysis. Post dialysis wt [weight] 94.1 kg [kilograms]. No new orders at this time. [Note: This is 207 pounds.]On 9/22/25 at 5:09 PM, Resident returned from dialysis. Post dialysis wt 93.6 kg. No new orders at this time. [Note: This is 205.9 pounds.]A review of resident 30's pre-and post-dialysis communication revealed that on 9/12/25, 9/17/25, 9/19/25 and 9/22/25, the resident's name and date were completed at the top of the form, however items not completed were: Cognition status, Vital signs, Fasting Blood sugar (if applicable), Recent falls or trauma (if applicable), Access site assessment, Changes in the past 24-48 hours, the nurse's signature and the date.The facility dialysis policy and procedures were reviewed. The policy titled: Dialysis (Renal), Pre-and Post-Care included the following: PolicyIt is the policy of this facility to:Assist resident in maintaining homeostasis pre-and post-renal dialysis;Assess and maintain patency of the renal dialysis access;Assess resident daily for function related to renal dialysis;Participate in ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.ProcedurePre-dialysis care:Assess resident's blood pressure (in non-fistula arm) prior to being transported to the dialysis unit.Hold any blood pressure medications and/or any other specified medications as ordered by physician.May hold medications scheduled for administration while at dialysis or during dialysis unless otherwise specified by the provider.Any staff concern about resident's condition that may influence the dialysis treatment should be addressed prior to leaving skilled facility as the resident may need to be assessed in an emergency room.Collaboration and Communication of CareThe care of the resident receiving dialysis services will reflect ongoing communication, coordination and collaboration between the nursing home and dialysis staff.Staff will immediately contact and communicate with the attending physician/practitioner, resident/resident representative, and designated dialysis staff (i.e. nephrologist, registered nurse) regarding any significant changes in the resident's status related to clinical complications or emergent situations that may impact the dialysis portion of the care plan.DocumentationDocumentation related to pre- and post-dialysis care will be placed in the clinical record and include:Resident assessments, interventions, and any provided education.Assessment of renal dialysis access site, to include presence or absence and quality of a bruit and thrill for residents with an arteriovenous fistula.Communication between facility and dialysis staff or medical provider.On 9/24/25 at 2:06 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated the night staff filled out the form the night before the resident's appointment. LPN 1 stated in the morning, the CNA obtained the resident's vital signs and the nurse took the vital signs from the sheet at the nurses station and put it on the form before the resident left the facility. LPN 1 stated after the resident returned from the dialysis appointment with the communication form, the information that was documented from the dialysis nurse was put into a progress note in the resident's medical record. LPN 1 stated resident 30 usually returned from his appointment around dinner time and had never told her that he was feeling ill after his appointment. LPN 1 stated the nurses assessed the resident's shunt each day as part of the resident's assessment. LPN 1 stated she looked at it in the morning when providing his morning medications, but did not look at it when he returned from his dialysis appointment because he had a bandage on his arm. LPN 1 stated there was not a physician's order to assess the shunt when the resident returned from dialysis which was why it was likely forgotten. LPN 1 stated it probably should be done after the bandage was removed. On 9/24/25 at 4:21 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the resident took a face sheet, a medication list and a dialysis communication form to the dialysis appointment. The DON stated the physician order said to check the shunt daily but did not indicate a time. The DON stated the resident came back with a pressure dressing after dialysis and the nurses should be looking at the port when they removed the dressing 2 hours after he returned. The DON stated blood pressures were documented on the communication form, but were not being put in the resident's progress note. The DON stated she was unaware that the communication forms were being sent to the dialysis center without being completed by the nurses.

Based on interview and observation, for 1 of 25 sampled residents, the facility did not treat residents with respect and dignity and care for each resident in a manner that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, a Certified Nursing Assistant (CNA) was observed standing next to a resident in bed while providing feeding assistance . Resident identifier: 48. Findings included:Resident 48 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included multiple sclerosis, type 2 diabetes, dysphagia, congestive heart failure, and chronic pain.An admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident 48 had a Brief Interview for Mental Status (BIMS) score of 15 indicating she was cognitively intact. The assessment also revealed that resident 48 had upper extremity impairment on one side, and was dependent on staff for eating, oral hygiene, toileting, and bathing.On 9/24/25 at 10:50 AM, an observation was made of Certified Nursing Assistant (CNA) 1 providing feeding assistance to resident 48 in her room. CNA 1 was standing next to resident 48 who was partially sitting up in her bed. On 9/24/25 at 11:09 AM, an interview was conducted with CNA 1 who stated resident 48 was unable to feed herself. CNA 1 stated she was not resident 48's CNA but she just fed her. CNA 1 stated she did not know how much assistance resident 48 needed because she was an agency CNA and was just helping out.

Based on interview and record review, it was determined for 1 of 25 sampled residents, that the facility failed to ensure that a resident who was continent of bladder on admission received services and assistance to maintain continence unless his or her clinical condition was or became such that continence was not possible to maintain; and a resident who was incontinent of bladder received appropriate treatment and services to restore continence to the extent possible. Specifically, one resident who was assessed to be continent or a good candidate for bladder retraining was not provided services. Resident identifier: 59. Findings included:On 9/23/25 at 10:37 AM, an interview was conducted with resident 59. Resident 59 stated she wore a brief and was unsure why she needed to wear one because she can tell when she needed to use the bathroom. Resident 59 stated she needed assistance from staff to go to the bathroom. Resident 59 stated she did not need to wear briefs before coming to the facility and that staff just put one [a brief] on me. Resident 59 stated that she had an episode of urinary incontinence this morning because staff did not come quick enough.Resident 59's medical record was reviewed 9/22/25 through 9/25/25.Resident 59 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included subsequent encounter for fracture of right humerus, asthma, congestive heart failure, unspecified injury of head, fibromyalgia, glaucoma, rheumatic heart disease, osteoarthritis of left ankle and foot, and irritable bowel syndrome.An admission Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 14. A BIMS score of 13 to 15 indicated cognition was intact. It further indicated resident 59 had occasional urinary incontinence and did not have a trial of a toileting program, which included scheduled toileting, prompted voiding, or bladder training.An Initial admission Record dated 8/20/25 indicated resident 59 was continent of urine, used the toilet, and did not use pads or briefs.A Daily Skilled document dated 8/22/25 indicated resident 59 was alert and oriented X (times) 3 and sundowns at night. It further indicated, sundowns at night and her memory is not that good at this time, neither is her ability to do ADLs [activities of daily living]. It further indicated, staff changes when needed. She is sometimes able to make it to the bathroom on time. It further indicated, one person assist with transfers and ADLs. uses a wheelchair and walker for ambulation.A Bowel and Bladder Evaluation dated 8/23/25 indicated resident 59 was continent or a Good Candidate for Bladder re-training.A Bowel and Bladder Evaluation dated 9/14/25 indicated resident 59 was incontinent of bladder for an unknown length of time. It further indicated resident 59 was a Possible Candidate for Bladder re-training.A Care Plan Report indicated resident 59 had bowel/bladder incontinence related to Impaired Mobility, which was initiated on 8/22/25. Interventions included, Encourage fluids during the day to promote prompted voiding responses; and Ensure there is an unobstructed path to the bathroom.On 9/24/25 at 9:26 AM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated resident 59 could use her call light to let them know when she had to use the restroom. CNA 3 stated if a resident could not use their call light, then they would offer bathroom use every couple hours.On 9/24/25 at 12:19 PM, an interview was conducted with CNA 4. CNA 4 stated resident 59 wore a brief because when she displayed sundowning cognition changes she would not always be continent. CNA 4 stated she was wearing a brief right now because it was resident 59's preference. CNA 4 stated resident 59 used the call light to get help and that she was continent during the day.On 9/24/25 at 4:36 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated resident 59 was incontinent and wore a brief. LPN 2 stated she was not sure why resident 59 was incontinent but that she was a big fall risk and struggled with her cognition.On 9/25/25 at 10:10 AM, an interview was conducted with CNA 2. CNA 2 stated a bladder program would mean a resident was put into a pull-up brief and then staff would check on the resident every 2 hours to see if they needed to go to the bathroom. CNA 2 stated she was not aware of anyone who was on a bladder program. CNA 2 was not sure if it was documented anywhere when a resident was on a bladder program, but that they just knew the residents.On 9/25/25 at 12:01 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a resident was evaluated to be a possible candidate on the Bowel and Bladder Evaluation, then that resident would need to be further evaluated and it would be on the care plan. The DON stated resident 59 had an impaired cognition, so staff should have been offering for her to attempt to go to the toilet every 2 hours. The DON stated they did not typically do the Bowel and Bladder program. The DON stated she did not think resident 59 would be able to notify staff of needing to go to the bathroom and staff should at least be offering to go to the toilet instead of being incontinent.On 9/25/25 at 2:21 PM, a follow-up interview was conducted with the DON. The DON stated resident 59 had been working with physical therapy to help her with toileting but the CNA should still be working with the resident for her bladder training even if she needed assistance to use the restroom.

Based on interview and record review, for 1 of 25 sample residents, the facility did not ensure that the monthly drug regimen recommendations by a licensed pharmacist were implemented in a timely manner. Specifically, a recommendation made by the pharmacist to separate administration of a medication and a supplement due to interaction was not acknowledged by the physician or implemented. Resident identifier: 3. Findings included:Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included ataxia, repeated falls, chronic kidney disease, encephalopathy, and memory deficit following nontraumatic subarachnoid hemorrhage. Resident 3's medical record was reviewed between 9/22/25 and 9/25/25.No documentation of the monthly pharmacy reviews were found in the progress notes. There was no documentation of the pharmacy reviews found in the resident's miscellaneous documents.The facility 2025 monthly pharmacy review binder was reviewed. In March 2025, a pharmacy recommendation for resident 3 revealed, Levothyroxine and Ferrous Sulfate 7 am orders-consider separating administration times (one an hour earlier or in the PM) Drug interaction-binding may occur. There was no acceptance of the recommendation or decline of the recommendation, and no signature indicating the physician had reviewed or acknowledged the recommendation.Resident 3's Medication Administration Records (MARs) from March 2025 through September 2025 were reviewed. Both Levothyroxine and Ferrous Sulfate were documented as administered together at 7:00 AM throughout the MARs. On 9/25/25 at 11:49 AM, an interview was conducted with the Director of Nursing (DON) who stated the pharmacist reviewed all resident medications monthly. The DON stated the pharmacist emailed his reviews to her and she gave them to the physician for review. The DON stated once the physician went over the medication reviews, they were given back to her so she could implement any medication order changes that had been approved by the provider. The DON stated the form should then be uploaded into the resident's chart. The DON stated it looked like the form for resident 3 had been completely missed.

Based on interview and record review, it was determined that for 1 of 7 sampled residents, the facility did not ensure each resident received the supervision and assistance devices necessary to prevent an accident. Specifically, Resident 3 was not properly secured when transported in a facility vehicle and the resident subsequently slid out of their wheelchair and sustained a femur fracture. Resident Identifier: 3. In response to the incident involving Resident 3, the facility identified the quality deficiency and developed a corrective action plan. At the time of the complaint survey, it was determined the facility had implemented corrective measures and met the requirements of F689. Due to the facility's corrective measures, the noncompliance was determined to be past-noncompliance. The facility's corrective action plan, which was developed and implemented by 4/23/24, included the following measures: a. On 4/22/24, the date of the incident involving Resident 3, the facility entered into an agreement with an organization to implement and provide training and new protocols to transport facility residents. The organization utilized by the facility had experience manufacturing wheelchair securement's and occupant restraint systems for transporting individuals with special needs. All staff who performed transportation services for the facility were reeducated on proper securement of residents during transport, which included training videos produced by the contracted organization. Transportation staff attested to the completion of the training by signing training records. Transportation staff were then required to complete a post-training test. b. On 4/22/24, all staff members who performed transportation services were required to read and sign the Fleet Safety Program book. c. On 4/23/24, staff members were interviewed regarding safety during transportation. Administrative staff also interviewed residents to determine if there were additional concerns about safety during transportation. d. The facility's Quality Assurance Performance Improvement (QAPI) Committee approved the updated driver safety training program and implemented the following QAPI activities: -The transportation supervisor will audit the transport of each driver daily for 2 weeks, followed by audits on 3 random days of the week for 1 week, with an audit 1 day per week for 1 week. The transportation supervisor will perform ongoing random audits. -The transportation supervisor or designee will validate transportation driver's pre and post-securement, documenting the results every week for 4 weeks then bi weekly for 2 weeks, and 3 random audits every month thereafter. -The transportation supervisor will report any trends or concerns to the QAPI committee for review for 90 days. Any discrepancies will be addressed at time of discovery. Findings Include: Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included diabetes mellitus type 2, hypotension, muscle weakness, a need for assistance with personal care, and difficulty in walking. On 4/22/24 at 4:28 PM, the facility electronically submitted a Form 358: Facility Reported Incident Initial Report (Form 358) to the Survey State Agency (SSA). The facility reported that on 4/22/24 at 1:00 PM, Resident 3 sustained injuries while being transported in a facility van by Transportation Driver (TD 1). On the Form 358, the facility documented that TD 1 explained, a car stopped right in front of him and he had to slam on his brakes. The resident [resident 3] slid out of her chair hit both of her knees and is feeling pain in both knee's (sic). The facility documented that Resident 3 was evaluated by a facility RN, emergency medical services (EMS) was called, and the resident was transported to the emergency room of a local acute care hospital. On 4/24/24, the facility electronically submitted a Form 359: Follow-up investigation report (Form 359) to the SSA. In their investigation, the facility reported that TD 1 explained that he neglected to put the lap belt on Resident 3 when transporting the resident back from an appointment. The facility documented that TD 1 further explained that he harnessed all four points of Resident 3's wheelchair, but he missed the lap belt strap. A review of resident 3's medical record was completed on 7/30/24. Facility staff completed a quarterly Minimum Data Set (MDS) assessment of Resident 3. The Assessment Reference Date was 4/3/24. As part of the MDS assessment, a facility staff member conducted a Brief Interview for Mental Status (BIMS), for which Resident 3's score was 11. Per the Centers for Medicaid Services (CMS) MDS 3.0 Resident Assessment Instrument Manual, a BIMS score of 11 represents moderately impaired cognition. Facility staff also assessed Resident 3 as requiring substantial to maximum assistance with mobility and that the resident used a wheelchair. On 4/22/24 at 12:26 PM, a facility nurse documented a Nursing Note in Resident 3's medical record. The nurse documented that Resident 3 had a fall in the transport van while returning from a doctor's appointment. The nurse documented that Resident 3 had an injury to her left knee and that the resident was sent to the emergency room . On 4/24/24 at 9:06 AM, a facility nurse documented a Nursing Note in Resident 3's medical record. The nurse documented that as Resident 3 was being transported to the facility, the resident was propelled out of the wheelchair, hitting the front seats. The nurse documented Resident 3 sustained a right leg injury and was transported to an acute care hospital. The nurse documented that an x-ray revealed Resident 3 sustained a right femur fracture. Note: Based on hospital radiology reports, Resident 3 sustained a left femur fracture. On 5/1/24 at 5:27 PM, a facility nurse documented a Nursing Note in Resident 3's medical record that the resident had readmitted to the facility. The nurse also documented Resident 3 had a large left arm bruise, two left hip sutures, one left knee suture, and that Resident 3 was to have weight bearing as tolerated. Resident 3's medical record included the resident's hospital discharge documentation that was dated 5/1/24. Per the hospital discharge documentation, upon Resident 3's presentation to the emergency room for the evaluation of the resident's left knee pain, x-ray results revealed the resident an acute left distal femoral shaft fracture. Resident 3 was initially hospitalized in the intensive care unit for close monitoring and treatment. On 7/30/24 at 11:28 PM, an interview was conducted with the Transportation Supervisor (TS). TS stated that on 4/22/24, TD1 called the facility to inform them that a resident had slid from the wheelchair during transport because TD 1 had to break hard. TS stated the incident occurred on the road just next to the facility. TS stated on 4/22/24, when the transportation van entered the parking lot, he was present along with a physical therapist, a nurse and the operations manager. TS stated when the van door was opened, it was apparent the resident had not been secured properly and the lap belt was not on. He stated Resident 3 was in notable pain and paramedics were called. On 7/30/24 at 1:48 PM, an interview was conducted with the facility's Operations Manager (OM). The OM explained that on 4/22/24, the day of incident involving Resident 3, the facility immediately updated and revised their process for ensuring transportation staff were trained and monitored. The OM stated the facility retained all prior training and included an observed daily check off for every transport to ensure the transportation driver did not forget anything before the facility van moved. The OM stated the onboarding process included new training on how to secure residents in the transportation van, as well as a post-training examination. The OM also stated that if an employee, who had been used to transport residents, had not provided transportation services within the previous 30 days, an observed check off would be required to ensure the drivers skills remained acceptable.

Based on interview and record review it was determined, for 1 of 6 sampled residents, that the facility did not ensure that residents were free from any significant medication errors. Specifically, a resident 's Clozapine medication was omitted due to unavailability from the pharmacy. Resident identifier 5. Findings included: Resident 5 was admitted to the facility on [DATE] with diagnoses which included hydrocephalus, repeated falls, schizophrenia, dysphagia, flaccid neuropathic bladder, need for assistance with personal care, and muscle weakness. Resident 5's medical records were reviewed on 3/19/2024. On 3/19/23 at 10:43 AM, an interview was conducted with resident 5. Resident 5 stated that he had missed his psychiatric medication for 3 days because it was hard to get. Resident 5 stated they had to check his blood before they could get the medication. Resident 5 stated he had not slept for the 3 days when he did not get his medication. Resident 5 stated this had happened a few times and he believed it was his fault because he did not remind staff early enough to get his medication A physician order with an initiation date of 11/25/23 documented, Clozapine 100 mg (milligrams) give 3 tablets by mouth in the evening for Schizophrenia. On 12/9/23 at 8:41 PM, the eMAR (electronic medication administration record) - medication administration note documented that the Clozapine was not administered due to medication unavailable until labs drawn. A lab result report documented that resident 5's labs had been drawn on 11/28/23. The December Medication Administration Record (MAR) documented that the Clozapine was not administered to resident 5 on the following dates: a. 12/8 b. 12/9 On 1/15/24 at 1:57 PM, a Nursing note documented, blood work results from 1/12 and 1/13 faxed to [medical doctor]. On 1/16/24 at 5:26 PM, a Nursing note documented, Phone call made to [medical doctor] to verify lab results received, CMP (complete metabolic panel) and CBC (complete blood count). She verified receipt and will be sending medications. On 1/19/24 at 11:22 PM, the eMAR - medication administration note documented that the Clozapine was not administered due to waiting for pharmacy. The January MAR documented that the Clozapine was not administered to resident 5 on the following day: c. 1/19 On 2/14/24 at 10:06 PM, a Laboratory/Radiology Note documented CMP came back normal. CBC showed low RBC (red blood cell), hemoglobin, and hematocrit and high RDW (red cell distribution width) SD (standard deviation), with the differential normal. On 2/20/24 at 10:08 PM, an eMAR medication administration note documented that there were 2 tablets left, awaiting delivery from pharm (pharmacy) of the Clozapine. On 2/21/24 at 6:55 PM, an eMAR medication administration note documented the Clozapine was out of stock. On 2/22/24 at 7:26 PM, an eMAR medication administration note documented awaiting delivery from pharm of the Clozapine. On 2/23/24 at 6:43 PM, a Laboratory/Radiology note documented Results of CMP, CBC w(with)/diff (differential) and PT(prothrombin time)/INR (international normalized ratio) results faxed to [facility name omitted] provider for refill of Clozapine. On 2/23/24 at 8:43 PM, an eMAR medication administration note documented awaiting delivery from pharm of the Clozapine. On 2/24/24 at 8:54 PM, an eMAR medication administration note documented awaiting delivery from pharm of the Clozapine. The February MAR documented Clozapine was not administered to resident 5 on the following days: d. 2/20 e. 2/21 f. 2/22 g. 2/23 h. 2/24 It should be noted that no documentation could be found that the physician was notified that the Clozapine was not administered. On 3/19/24 at 12:39 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 5 had his labs drawn and sent out to another provider in order to receive his medication. LPN 1 stated it usually only took 1 day to get the lab results back. LPN 1 stated if the order is put in the medical record then it will come up for the nurses to see and the blood will be drawn. LPN 1 stated he was unsure what to do if resident 5 ran out of medication because that specific medication was not one that the facility had a supply of. On 3/19/24 at 1:55 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility had to wait on the other facility's doctor to review the residents labs and then wait for the other facility's pharmacy to send the medication. The DON stated that the facility did not stock that medication in the house supply and only had it if it was sent down from the other facility. The DON stated the orders were put in to have the residents blood drawn every 30 days and sent to the other provider but sometimes the months had more than 30 days and it messed up the timeline. On 3/19/24 at 2:15 PM, a follow up interview was conducted with the DON. The DON stated the resident had missed doses of his Clozapine in January, February and March. The DON stated it was their job to make sure the resident had the medication he needed. A review of the facility Medication Administration policy revealed, Medications will be accurately prepared, administered, and documented per physician order.

Based on interview and observation, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, reusable ice packs were located in resident freezers, garbage cans in the kitchen were soiled, and kitchen cabinets were in disrepair. Findings include: 1. On 10/18/23 at 7:00 PM, an observation was made of the facility kitchen. The following was identified: a. There were 4 kitchen cabinets located next to the dishroom. The cabinets had been painted white, but were visibly soiled with a black grime on the outside, especially around the handles. Both the inside and outside surfaces of the cabinets were sticky to the touch. The shelves inside the cabinets were observed to be soiled with various substances. In addition, the cabinet doors were in a state of disrepair that did not allow the doors to completely cover the shelves when the doors were closed. b. There was a metal garbage can near the facility oven. The lid of the garbage can was connected to the garbage can and was open. The lid of the garbage can was observed to be entirely coated in several dried layers of debris and grime. c. There was a plastic garbage can near the facility dishroom. The garbage can had several areas of grime and sticky debris on the outside surface. 2. On 10/18/23 at approximately 7:05 PM, the refrigerator/freezer just outside the kitchen was observed to have a reusable ice pack inside. The ice pack was next to resident food. 3. On 10/18/23 at approximately 7:10 PM, the refrigerator/freezer just outside the Director of Nursing's office was observed to have a reusable ice pack inside. The ice pack was next to resident food. On 10/18/23 at approximately 7:10 PM, the Regional Nurse Consultant stated that reusable ice packs should not be in freezers with resident food. On 10/18/23 at approximately 7:05 PM, the facility Administrator stated that he was unaware that reusable ice packs should not be in freezers with resident food. The Administrator also stated that he was unaware of the condition of the kitchen cabinets next to the dishroom, but stated a complete remodel would be taking place within the next year.

Based on observation, interview, and record review, it was determined for 1 of 26 sample residents, that the facility did not ensure that the resident's environment remained free of accident hazards. Specifically, the facility did not provide adequate locks to prevent residents access to harmful chemicals. Resident identifier: 11. Findings include: Resident 11 was initially admitted on [DATE] and readmit on 1/24/22 with diagnoses which included vascular dementia with agitation, bipolar disorder, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, altered mental status, and dysphagia. Resident 11's medical record was reviewed 10/16/23 through 10/26/23. An incident progress note dated 10/10/23 at 6:38 AM, Nurse was by the laundry room when she heard someone yelling for help. When she checked inside the laundry room she found the patient sitting on the floor next to her wheelchair with a pile of socks on h ER [sic] lap. Resident stated that she did not know what had happened, but she was on the floor On 10/18/23 at 5:39 PM, an observation was made of the laundry room. The clean laundry room door was closed but unlocked, there was access to the dirty linen side of the laundry room. The dirty linen side of the laundry room had bleach, laundry detergent and laundry softener which had the potential to be accessed by residents. On 10/18/23 at 2:59 PM and interview with laundry staff (LS) was conducted. LS stated when she is not in the laundry room she will shut and lock the door. LS stated the rule is to keep the doors to the laundry room locked and closed when staff is not occupying the area. LS stated, a few weeks ago a resident was found in the laundry room. On 10/18/23 at 3:15 PM, an interview was conducted with the Plant Operation Director (POD). The POD stated that the facility was working on getting a better lock system for the laundry room to keep both the soiled and the clean laundry locked. The POD stated that the clean linen door would remained open an unlocked only if someone is in the laundry room, but if it is empty it the door should be closed and locked. On 10/18/23 at 5:45 PM, an interview was conducted with certified nursing assistant (CNA) 1. CNA 1 stated that the clean linen side of the laundry room is unlocked and the door directly leading to the soiled lined side remains locked. CNA 1 stated that the soiled lined side can be accessed through the clean linen side. CNA 1 stated that the clean lined side of the laundry room is locked during the night or if no one is close by the laundry room. CNA 1 stated that if the clean lined side is locked the key is located just next to the door on top of a black box. [Note: the key is easily accessible to the unlock the laundry room]. 47431

Based on interview and record review, the facility did not ensure that 2 of 26 sample residents had an accurate Minimum Data Set (MDS) Assessment. Resident identifiers: 29 and 34. Findings include: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses that included rheumatoid arthritis, severe protein-calorie malnutrition, diabetes mellitus, anemia, and dementia. Resident 29's medical record was reviewed on 10/16/23. Resident 29's quarterly MDS assessment completed on 6/14/23 did not include a Brief Interview for Mental Status (BIMS) score, even though the assessment indicated that the BIMS should be completed. Resident 29's annual MDS assessment completed on 9/14/23 did not include a BIMS score. 2. Resident 34 was admitted to the facility on [DATE] with diagnoses that included dementia, moderate protein calorie malnutrition, and altered mental status. Resident 34's medical record was reviewed on 10/16/23. Resident 34's initial MDS assessment completed on 5/17/23 did not include a BIMS score. Resident 34's quarterly MDS assessment completed on 7/7/23 did not include a BIMS score. On 10/18/23 at approximately 6:00 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated the that facility social worker was responsible to complete the BIMS score on the MDS. On 10/18/23 at approximately 7:30 PM, the social worker stated that she had been completing the BIMS but that the computer had not been saving her work.

Based on interview and record review it was determined, for 1 out of 26 sampled residents, that the facility did not ensure that a resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary tract infections (UTI) and to restore continence to the extent possible. Specifically, a resident with a urinary catheter had a delay in treatment for a UTI. Resident Identifier: 39 Findings include: Resident 39 was admitted to the facility on [DATE] with diagnoses that included dementia, altered mental status, acute kidney failure, stage 3 chronic kidney disease, acute respiratory failure with hypoxia, adult failure to thrive, and anxiety disorder. Resident 39's medical record was reviewed on 10/17/23. On 10/9/23 at 12:47 PM, a nurse note documented, Resident has had an increase in confusion and restlessness. His urine is also cloudy with foul odor. Received orders to collect UA [urinalysis]. UA was collected and sent. A physician order with an start date of 10/9/23 and end date of 10/12/23 documented Collect UA with C&S [culture and sensitivity] one time only for Change in condition for 3 Days. Resident 39's Medication Administration Record [MAR] and Treatment Administration Record [TAR] for the month of October documented the UA and C&S to have been completed on October 9, 2023 at 7:56 PM. On 10/17/23 at 4:24 PM, an interview was conducted with the Infection Preventionist (IP). The IP stated they were unaware a UA with C&S was collected for resident 39. The IP stated they were unable to find the results in the resident's chart and needed to look into it further. The IP stated a culture was normally obtained to make sure a resident was on the right type of antibiotic for the infection. The IP stated it usually took 3 days for a culture to result. On 10/18/23 at 6:21 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the IP had to call the hospital for the urine culture results yesterday. The DON stated the hospital was not sending the results timely. On 10/19/23 the facility provided additional documentation in the form of urine culture results. Resident 39's urine culture results were finalized on 10/11/23 at 9:01 PM and showed that resident 39 had bacterial growth from the urine . It documented the provider had reviewed the results on October 18, 2023. [Note: There was a 7 day delay in resident 39's course of treatment for their UTI.]

Based on interview and record review it was determined that the facility did not provide each resident with a safe, clean, comfortable and homelike environment. Specifically, there were walls in resident room with scratched drywall, chipped paint, a wall with drywall missing and baseboard pulling away from the wall. Findings include: 1. On 9/19/22 at 2:26 PM, an observation was made of room 16. There were large scrapes on the wall with missing paint behind the bed. The scraps were visible from the hallway. 2. On 9/19/22 at 3:00 PM, an observation was made of room 14. Room 14 had a chunk of drywall missing toward the floor outside the bathroom. The trim was pulling away from the wall. 3. On 9/21/22 at 8:30 AM, an observation was made of room 7. Room 7 had large scrapes in the drywall with missing paint behind the bed. The scrapes were visible from the hallway. 4. On 9/21/22 at 9:00 AM, an observation was made of the facility with the Administrator. The Administrator stated the facility was planning to come up with a plan to plot out phases to patch and paint the holes in rooms. The Administrator stated that the plan had not been developed. The following was observed with Administrator: a. Room 1 had scratch marks with different color paint by door. The scratches were visible from the hallway. b. Room 7 had scratches with missing paint behind his bed. The scratches were visible from the hallway. c. Room 9 had scratches on the wall that were visible from the hallway. d. Room 11 was missing paint behind the bed. e. Room 14 had a chunk out of wall and the baseboard was pulling from the wall outside the bathroom. f. Room 16 had scratches behind the bed which were visible from the hallway.

Based on observation, interview and record review it was determined, for 5 of 5 contracted staff members, that the facility did not ensure that all staff including contracted staff members were fully vaccinated for COVID-19, except for those staff who had been granted exemptions to the vaccination. Specifically, contracted staff members vaccination status were unknown. Staff member identifiers: Contracted Staff Member (CSM) 1, CSM 2, CSM 3, CSM 4 and CMS 5. Findings include: On 9/19/22 at 1:30 PM, an initial observation of the facility was conducted. There were contractor staff members observed to be working with wires and construction. There were contractors outside the dining room, in resident hallways and at the nurses station. On 9/20/22 at 8:34 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility did not have contracted employees. On 9/20/22 at approximately 9:30 AM, an observation was made of (CSM) 1. CSM 1 was observed to be placing a gown and gloves on outside room [ROOM NUMBER]. CSM 1 was interviewed. CSM 1 stated she was a hospice company's Chaplin to visit with resident 88. CSM 1 stated she visited with resident 88 about three times per month but this was her first time to visit resident 88 at the facility. On 9/21/22 at 11:50 AM, an observation was made of four contractors working on ladders with power tools and wires. The contractors were observed in resident hallways, outside the dining room and at the nurses station. The contractors were observed to be wearing a surgical mask and no eye protection. On 9/21/22 at 12:16 PM, an interview was conducted with CSM 2. CSM 2 stated he was a contractor for the fire alarm system. CSM 2 stated he had been working at the facility on 9/19/22, 9/20/22, and 9/21/22 with CSM 3, CSM 4, and CSM 5. On 9/21/22 at 7:42 PM, an interview was conducted with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP). The ADON/IP stated the company that was working on the fire system construction told her that they were unable to provide the staff members vaccination status because they would be sending different employees each day. The ADON/IP stated the company told her they would not be able to track the employees vaccination status. The ADON/IP stated that she tested the employees for COVID-19 daily before they started working in the facility. On 9/22/22 at approximately 10:00 AM, an interview was conducted with the DON. The DON stated that she did not have vaccination status for hospice personnel or for the contracted staff who were installing the new fire system.

Based on observation, interview, and record review it was determined, for 2 of 19 sampled residents, that the facility did not 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 diseases and infections. Specifically, observations were made during wound care of cross contamination during treatment application, lack of hand hygiene, and not changing soiled gloves. Additionally, observations were made of staff assisting a resident without the required Personal Protective Equipment (PPE) needed for the resident who was on contact/droplet precautions. Resident identifiers: 27 and 88. Findings included: 1. Resident 27 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/21/22 at 8:42 AM, an observation was made of resident 27's wound care provided by the wound care Physicians Assistant (PA) and Licensed Practical Nurse (LPN) 1. Upon arrival to resident 27's room the bedside table was draped with disposable pads and 4 x (by) 4 gauze pads, normal saline (NS), tongue depressors, gauze rolls, and medication cups filled with ointments were arranged on top. Resident 27 was positioned on his left lateral side. The PA and LPN 1 were at the resident's bedside with gloves already donned. The PA was observed to lift and unwrap the soiled gauze roll from the left foot, and then removed a soiled adhesive bordered foam dressing from the left foot. The left dorsal foot was observed with two wounds. The PA obtained a NS soaked gauze 4 x 4 pad from the bedside table and cleaned both wounds. The PA was observed to pick at the eschar of both wounds with his gloved index finger, removing some of the tissue. The PA then obtained a package with a sterile dermal curette from his front pocket and continued to debride both left dorsal foot wounds. The PA obtained measurements of the left dorsal foot wounds, distal wound measured 1.4 x 1.2 x 0.3 centimeters (cm) and the proximal wound measured 0.1 x 0.6 x 0.2 cm. The PA doffed his dirty gloves and washed his hands in the sink. It should be noted that the PA did not doff the dirty gloves, perform hand hygiene, and donn clean gloves after the soiled dressing was removed and prior to debridement of the wounds. LPN 1 was observed to unwrap the soiled gauze roll from resident 27's right foot. LPN 1 doffed the soiled gloves, performed hand hygiene, and donned clean gloves. The PA was observed to debride the right dorsal foot wound with a sterile scalpel. The PA obtained measurements of the right dorsal foot wounds, distal wound measured 0.7 x 0.5 cm and was intact, proximal wound measured 0.8 x 0.5 x 0.2 cm. The right ankle wound measured 0.3 x 0.6 cm and was intact. The PA was observed to clean all wounds with NS soaked gauze 4 x 4 pads. LPN 1 applied [MEDICATION(S)] with a tongue depressor to the wound bed of the right dorsal foot wounds and then using the same tongue depressor applied [MEDICATION(S)] to the right ankle wound bed. On 9/21/22 at 11:07 AM, an interview was conducted with LPN 1. LPN 1 stated that when performing wound care they should clean from the inside of the wound working outward, wiping away from the center. LPN 1 stated that after a wound was cleaned they should doff the dirty gloves, perform hand hygiene and donn clean gloves before applying the new dressing. LPN 1 stated that this would ensure that they did not cross contaminate any of the wound care from dirty to clean. LPN 1 stated that if they should touch any environmental surfaces or dirty dressings they should doff their gloves, perform hand hygiene, and donn clean gloves before continuing with the dressing change. LPN 1 stated that when she applied any creams or ointments to a wound bed she did not double dip the applicator into the creams, and that each wound should have a new applicator/tongue depressor used for treatment application. 2. Resident 88 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/19/22 at 2:01 PM, an initial tour was conducted of the facility. room [ROOM NUMBER] was observed to have a plastic container with 3 drawers and a sign that revealed Droplet-Contact precautions. The sign revealed to wear gown, gloves, surgical mask and eye protection. Resident 88 resided in room [ROOM NUMBER]. On 9/20/22 at 7:43 AM, an observation was made of an Activities staff member. The Activities staff member was observed in room [ROOM NUMBER] next to resident 88 in bed without a gown or gloves donned. The Activities staff member was observed with a surgical mask and eye protection only. Resident 88's medical record was reviewed on 9/20/22. Resident 88's physicians orders revealed Isolation Precautions: droplet. dated 9/16/22. Another physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .for covid surveillance. A list of residents COVID-19 vaccination status was provided. Resident 88 was listed as unvaccinated for COVID-19. On 9/21/22 at 12:28 PM, a sign titled contact precautions was outside room [ROOM NUMBER]. The sign revealed for staff to wear a surgical mask, gown, gloves and eye protection when entering the room. On 9/21/22 at 12:05 PM, an interview was conducted with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP). The ADON/IP stated staff were to wear goggles, an N95 mask, gown and gloves into room [ROOM NUMBER]. The ADON/IP stated there were gowns, gloves and N95 masks in drawers outside the room. The ADON/IP stated that when staff entered room [ROOM NUMBER] their surgical mask was to be changed to an N95. The ADON/IP stated all staff including activities staff should wear the gown, goggles, N95 and eye protection when entering room [ROOM NUMBER].

Based on interview and medical record review, it was determined, for 2 of 20 sample residents, that the facility did not review and revise the comprehensive care plan. Specifically, two residents who had multiple falls did not have the care plan revised and updated with interventions in an attempt to keep residents safe. Resident identifiers: 3 and 15. Findings include: 1. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/4/20 resident 3's medical record was reviewed. Resident 3's medical record revealed that resident 3 had 7 falls on 3/20/19, 7/28/19, 8/4/19, 8/8/19, 8/21/19, 8/24/19 and 2/9 20. Resident 3's medical record revealed that he had sustained injuries of a bleeding forehead on 8/4/19 and 2/9/20. Resident 3's fall care plan revealed that there were no updates to the care plan, including fall dates and interventions after each fall. 2. Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/4/20 resident 15's medical record was reviewed. Resident 15's medical record revealed that resident 15 had 5 falls on 9/16/19, 11/1/19, 1/17/20, 1/19/20, 1/21/20. Resident 3's medical record revealed that he had sustained injuries of a laceration to his right arm stump on 9/16/19. Resident 15's fall care plan revealed that there were no updates to the care plan, including fall dates and interventions after each fall. On 3/04/20 at 2:10 PM, an interview was conducted with the facility DON. The facility DON stated that facility staff had implemented interventions for each fall. The facility DON stated that facility staff had not documented the interventions that had been put in place for the residents. The facility DON stated that there were previous care plans that had interventions in place, but, that the interventions had been resolved and not carried forward to current care plans. On 3/4/20 at 2:30 PM, the facility Administrator stated that they need to do a better job with our documentation.

Based on observation, interview and medical record review, it was determined for 2 of 20 sample residents, that the facility did not ensure that the resident environment remains as free of accident hazards as is possible. Specifically, two residents who had multiple falls, did not have interventions put in place in an attempt to prevent falls. Resident identifiers: 3 and 15. Findings include: 1. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/4/20 resident 3's medical record was reviewed. Incident reports for resident 3 revealed the following: a. 3/20/19, Nursing Description: Staff was doing round(s) in room [ROOM NUMBER] and found the resident sitting on the floor. Resident Description: Resident stated he was trying to get up to go to the restroom and slipped to the floor. Immediate Action Taken: Two person assist with transfer from floor to the resident recliner. Initiated neuro checks. No bruising or redness noted. No injuries. b. 7/28/19, Nursing Description: SN (skilled nurse) was called to patients room where pt (patient) was sitting on floor. SN and CNA (Certified Nursing Assistant) assisted pt off the floor to his bed. Resident Description: Pt reports he was trying to pick up some nuts off the floor that he spilled and he fell back on to his butt. Pt said he did not hit his head. Pt denied pain. Immediate Action Taken: SN and CNA transferred pt to a safe place to rest on his bed. Head to toe assessment. Neuro's initiated. VSS (vital signs stable), MD (medical doctor), wife and DON (Director of Nursing) notified. c. 8/4/19, Nursing Description: Loud bang heard by CNA, resident found in room sitting against armoire. Blood was dripping from left side of forehead, lip sustained small cut. Staff responded to assist resident. Resident Description: Resident stated that he was having a dream he was at the rodeo and was trying to get on a horse. Recliner was positioned as if resident was trying to get off recliner. When asked if his head hurt, he responded a little. Immediate Action Taken: Vitals taken, forehead cleansed and pressure applied to stop bleeding. Small 1.5 cm (centimeter) long 0.1 cm deep superficial cut on forehead noted. Triple antibiotic ointment applied and covered w (with)/dressing. BP (blood pressure) high 160/100, PCP (primary care physician) notified. d. 8/8/19, Nursing Description: Nurse went to step out of residents room, when resident got up. Nurse heard a crash. She turned to find resident sliding down with his back to the amour (sic). Nurse stated he did not hit his head. Resident Description: Resident stated he was trying to get up, then he slipped and hit his amour (sic). Immediate Action Taken: Nurse and CNA assisted to chair. Nurse performed head to toe assessment. Scrape to back was noted. PERRLA (pupils equal round reactive to light and accommodation). Vitals (sic) signs WNL (within normal limits). Resident denied transport to (Hospital). MD, DON and wife notified. e. 8/21/19, Nursing Description: Staff were at the nurses station when a crash was heard. Staff entered into 17 to find the resident sitting in front of the open bathroom door on the floor. Resident Description: Resident stated he was trying to find the restroom and lost his balance and fell to the floor. Immediate Action Taken: Two person assist with transfer from floor to standing position. Upon assessment no injuries were noted. Initiated neuro checks. The resident was toilet(ed) and ambulated with staff back to his bed. f. 8/24/19, Nursing Description: Aide called nurse to dining room. Walked in to find resident laying on his back on the floor. Wife and laundry worker was standing there with him with several residents in the area as well. Patient Description: Resident stated he got light headed and passed out. He stated he wasn't in any pain. Immediate Action Taken: Wife stated that he stopped and looked sort of dazed and then started to go to the floor. He layed down on the floor afterwards. Checked resident for injuries, none found. Assisted resident into a wheelchair. Started neurovascular checks. Notified (Resident's physician) and DON. g. 2/9/20, Nursing Description: SN was called to patients room. Pt was on the floor and was bleeding from the Left side of his forehead. Patient Description: Pt reports that he was having a dream and next thing he knew he rolled out of his bed and hit his head on the bedside drawer. Immediate Action Taken: SN implemented a head to toe assessment. Pressure applied to hematoma on L (left) side of his forehead which was bleeding. SN with the assistance of staff transferred pt to his recliner. Traumatic wound on L side of forehead cleansed and Steri strips applied. Neuro's initiated. VSS. Pt refused to go to the hospital. 2. Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/4/20 resident 15's medical record was reviewed. Incident reports for resident 15 revealed the following: a. 9/16/19, Nursing Description: Resident found walking in room by CNA with blood running down stump on L arm. Resident was not using walker. CNA applied pressure and called for assistance from RN. RN asked resident how he started bleeding and he said it happened when he fell out of bed 10 minutes prior. Resident Description: RN asked what caused the fall and resident said he was tangled in his blanket. Resident said he did not hit his head. Resident denies pain. Immediate Action Taken: Head to toe assessment performed, no other injuries found at this time. VS and neuro checks initiated. Resident's stump cleaned small laceration found, and Band-aid applied. DON and MD notified. VS and neuros have been stable. b. 11/1/19, Nursing Description: CNA call nurse to room. Resident was laying on the floor on his left side. Resident Description: Resident stated 'I was parking my walker, I felt weak, and fell back against the wall, I slid down the wall and then rolled to my side. Immediate Action Taken: Nurse performed head to toe assessment. Redness noted on his back. Nurse and CNA assisted resident from floor to bed. Vitals and neuro signs initiated: both WNL. No other injuries noted. Resident denied hitting his head. Resident also denied transportation to (hospital) for further evaluation. MD, DON and family notified. c. 1/17/20, Nursing Description: Staff was doing rounds as he entered the room, he found the resident on the floor in front of the door. Resident Description: The resident stated he was trying to walk to his bed and he fell on the floor. Immediate Action Taken: Three person assist with transfer from floor to his bed. Initiated neuro checks. Upon assessment noted a(n) abrasion on the residents left elbow and left lumbar back. Wound on elbow was cleaned with wound cleaner and a band aid was applied. d. 1/19/20, Nursing Description: Housekeeper notified nurse that resident was on the floor. Nurse entered room to find resident face down on the floor next to his bed. Resident Description: Resident stated that he was trying to get out of bed to go to the bathroom. Immediate Action Taken: Nurse and CNA assisted resident off of floor and into bed. Nurse performed assessment. Bruising and an abrasion was noted to residents R side. Resident stated he hit his head. Vital signs were initiated and were WNL. Neuros were initiated and were WNL. Resident refused transport to (hospital) for further evaluation. Family, DON and MD notified. e. 1/21/20 Nursing Description: Nurse called to patient room by CNA. Patient was found on floor next to bed. Resident Description: Patient said he 'rolled over to get comfortable and fell off the edge of his bed.' He said his left elbow hurt. He declined Tylenol when offered. No new injuries noted. Immediate Action Taken: Patient offered and refused Tylenol. Staff frequently checked on patient for the rest of the night. Patient educated about feeling for the edge of bed before rolling. On 3/04/20 at 2:10 PM, an interview was conducted with the facility DON. The facility DON stated that facility staff had implemented interventions for each fall. The facility DON stated that facility staff had not documented the interventions that had been put in place for the residents. The facility DON stated that there were previous care plans that had interventions in place, but, that the interventions had been resolved and not carried forward to current care plans. On 3/4/20 at 2:30 PM, the facility Administrator stated that they need to do a better job with our documentation.

Based on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biological's in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, multiple medications in the medication or treatment carts were found to be expired. Findings include: 1. On [DATE] at 7:48 AM, the treatment cart in the Medicare unit was inspected. The medication cart contained twenty seven 0.18 ounces (oz) packets of Petroleum Jelly that expired on ,[DATE]. The cart also contained ten 0.18 oz packets of Petroleum Jelly that expired on ,[DATE] and fifteen packets that expired on ,[DATE]. 2. On [DATE] at 7:57 AM, the medication administration cart in the Medicare unit was inspected. The cart contained one bottle of 600 milligrams (mg) Calcium tablets that expired on ,[DATE] and bottle of 400 mg Folic Acid tablets that expired on ,[DATE]. The cart also contained 100 tablet bottle of Calcium [MEDICATION NAME]+Vitamin D 3 that expired on ,[DATE] and one 37.5 gram (gr) tube of Glucose 15 for treating low blood sugar that expired on ,[DATE]. An interview was immediately conducted with Registered Nurse (RN) 1. RN 1 stated that the medications were expired and still available for use. 3. On [DATE] at 8:12 AM, the medication storage cabinet in the Medicaid unit was inspected. The cabinet contained one bottle of 24 caplets of Laxative that expired on ,[DATE] and one bottle of Fleet Mineral Oil Enema that expired on ,[DATE] per the manufacturing date. The Fleet Enema had a pharmacy label with an expiration date of [DATE]. 4. On [DATE] at 8:20 AM, the medication administration cart in the Medicaid unit was inspected. The cart contained 1 tube of Glucose 15 that expired on ,[DATE]. On [DATE] at 8:28 AM, Registered Nurse (RN) 3 was interviewed. RN 3 stated that when comes to expiration dates on medications, she would go with whichever date comes first. RN 3 stated that she was not sure why the pharmacy had a different expiration date from the manufacturing expiration date. On [DATE] at 8:38 AM, RN 2 was interviewed. RN 2 stated that she always followed the date on the pharmacy sticker. RN 2 stated that she followed the manufacturing expiration date on over-the-counter (OTC) medications. RN 2 stated that if she had medication with different pharmacy and manufacturing dates, she would need to do some verification with the pharmacy before administering medication. RN 2 stated that she usually followed the the information on the pharmacy sticker and that she was not sure why the manufacturing and the pharmacy expiration dates were different. On [DATE] at 9:23 AM, RN 1 was interviewed. RN 1 stated that when related to expiration dates, she followed the date on the pharmacy sticker. RN 1 stated that the manufacturing expiration date and the pharmacy expiration date were supposed to be same. RN 1 was not sure why these 2 dates did not match on some of the medications in her cart. On [DATE] at 10:09 AM, the Director of Nursing (DON) was interviewed. The DON that for both, the OTC (over the counter) and pharmacy medications, they followed the manufacturing expiration date. The DON stated that he did not know that the dates on the pharmacy labels were different from the manufacturing date. The DON stated that he never questioned the pharmacy about the expiration dates. The DON stated that the dates should be the same. The DON stated that they assigned two staff members who inspected each storage room and each medication administration cart once per week. The DON stated that all of the products that were in the cart and expired should not be there. The DON stated that the treatment cart in the Medicare unit was new and he was not sure how the Petroleum Jelly found there expired in 2016 when the cart was not even ready for use just 2 months ago. The DON stated that it was possible that the pharmacy or the online supplier sent them expired products and that the staff did not check the dates assuming that the products were brand new. The DON stated that he remembered that he had an in-service with the staff about medications expiration dates but he did not have any documentation and did not remember when that in-service was. The DON stated that during the in-service he was not very specific about which date to follow. The DON stated that they did not have a specific protocol regarding the expiration dates. On [DATE] at 10:43 AM, the Administrator was interviewed. The Administrator stated that they ordered some medications through their online supplier. The Administrator stated that Petroleum Jelly had not been ordered for awhile and he was not sure how the packages from 2016 ended up being in the treatment cart.

Based on record review and interview it was determined, for 1 of 25 sampled residents, that the facility pharmacist did not report irregularities in the drug regimen review to the attending physician, the facility's medical director, and the Director of Nursing (DON). Irregularity refers to use of medication that is inconsistent with accepted standards of practice for providing pharmaceutical services and/or not supported by medical evidence. An irregularity also includes, but is not limited to, use of medications without adequate indication. Specifically, a resident had a [MEDICAL CONDITION] medication ordered by the physician without adequate indication for use. Resident identifier: 34. Findings include: Resident 34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/5/19, resident 34's medical record was reviewed. A review of the most recent resident Minimum Data Set (MDS) assessment dated [DATE], revealed that resident 34 had a [DIAGNOSES REDACTED]. The MDS indicated that resident 34 did not have a [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. According to the Nursing 2019 Drug Handbook, [MEDICATION NAME] is indicated for treatment of [REDACTED]. (Reference: Nursing 2019 Drug Handbook. (2019) Philadelphia, PA: Pages 1299-1302: Wolters Kluwer.) Additionally, according to the Nursing 2019 Drug Handbook, the Black Box Warning for [MEDICATION NAME] revealed that the Drug isn't indicated for use in elderly patients with dementia-related [MEDICAL CONDITION] because of increased risk of death from CV disease or infection. (Reference: Nursing 2019 Drug Handbook. (2019). Philadelphia, PA: Pages 38, 1299-1302: Wolters Kluwer.) The Pharmacist monthly medication review reports for (MONTH) (YEAR) through (MONTH) (YEAR) were reviewed. The Pharmacist had not identified any recommendations regarding resident 34's [MEDICATION NAME] order and diagnoses. On 2/6/19 at 9:06 AM, an interview was conducted with the DON. The DON stated that resident 34 yells at night and upsets the other residents. The DON stated that resident 34 will continually call out for staff. The DON stated that gradual dose reductions of the [MEDICATION NAME] have been tried for resident 34 but he continues to have behaviors at night. The DON stated that when the physician discontinued resident 34's [MEDICATION NAME] the behaviors at night came right back. The DON stated that resident 34's yelling was related to his [MEDICAL CONDITION] and the [MEDICATION NAME] was to help him sleep and stop calling out at night. The DON further stated that the Pharmacist had not identified a concern with the [MEDICATION NAME] order.