Every finding on record at Innisfree Health and Rehab, LLC

Number of residents sampled: Number of residents cited: Based on observation, record review, interviews and facility policy review, the facility failed to ensure frozen food boxes had a received date, an opened date, and that frozen food was sealed to prevent freezer burn, preserving flavor, texture and nutrients. This failed practice had the potential to affect all 87 residents who received meals from the kitchen. The findings include: During an observation and concurrent interview on 07/20/2026 at 12:22 PM, the following were observed:-One opened box of cheese, beef, and bean burritos without an opened or received date. The Dietary Consultant inspected all sides, top and bottom of the box and confirmed there were no opened or received dates.-One opened box of frozen biscuit dough with a received date of 07/14/2026, had no opened date. The box was opened and the plastic bag inside the box was tied in a knot in the middle with two opened areas with frozen biscuit dough exposed to the freezer. The Dietary Consultant confirmed the biscuit dough was not sealed or covered. -One opened box of frozen whole grain hamburger buns without an opened date. The Dietary Consultant pointed out three packages of buns with an open date of 07/20/2026 resting on the shelf, out of the box, and stated the bread came out of the opened frozen box of bread.-One opened box of frozen sausage patties with a received date of 07/14/2026, had no opened date. The Dietary Consultant looked for dates on all six sides of the boxes and stated, I cannot find an open date. During an interview on 07/22/2026 at 9:41 AM, the Dietary Manager (DM) stated, all boxes that are opened in the freezer should have an open date on the box to determine when the food could no longer be served. The DM stated the box of frozen hamburger buns should have had a date on them as well as the three packages of hamburger buns resting on the shelf. DM revealed when dietary staff opens a frozen box of food the open date should be written on the box. During an interview on 07/22/2026 at 10:10 AM, the Prep [NAME] revealed none of the residents had feeding tubes, and all 87 residents eat from the kitchen. Review of a facility policy dated 11/25/2019 and titled Storage Periods, Use by Guideline, revealed food will be stored properly and used within the appropriate time period to ensure safe and quality food is served.

Number of residents sampled: Number of residents cited: Based on record review and interviews, the facility failed to notify an emergency contact of an unstageable pressure ulcer in a timely manner for one (Resident #88) of two residents reviewed. The findings including: Review of Resident #88's admission Record revealed the facility admitted Resident #88 on 04/01/2025 with an original admission date of 09/26/2024.The admission Record revealed Resident #88 had diagnoses that included unstageable pressure ulcer with an onset date of 05/23/2025 and admitting diagnoses of diverticulitis with perforation, and ischemic cardiomyopathy dated 04/01/2025. Review of admission Minimum Data Set (MDS) with an Assessment Reference Date of 04/07/2025, revealed Resident #88 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS revealed Resident #88 had no active diagnoses of pressure ulcers on admission. The MDS also revealed Resident #88 was dependent on staff for toileting and ambulating 10 feet, required maximum assistance for sitting to standing, chair to bed, and bed to chair transfers. Review of Progress Notes dated 04/14/2025 at 12:41 PM, revealed Resident #88 was very confused, and a Care Plan meeting was held with the resident's family member. The Progress Note also revealed that Resident #88 had skilled services, new ostomy and a wound vac. Review of a Nursing Weekly Skin Audit dated 04/22/2025, revealed an ostomy to left upper quadrant [LUQ], wound vac mid chest to pelvis, and a stage 2 pressure ulcer to coccyx. Intervention put in place were pressure reduction mattress, skin protectant, moisturizer and treatment orders written. The Skin Audit was signed by Licensed Practical Nurse (LPN) #9. Review of Progress Notes from 04/29/2025 at 9:18 AM, revealed [named] person from [named] General Surgery clinic called revealing that Resident #88's family member had advised the surgeon that resident had not been cognitively the same since undergoing a sigmoidectomy with ostomy placement and was leaning in the wheelchair since admission. Doctor, Physician Assistant and nurse were consulted. Review of Progress Notes on 04/30/2025 at 4:39 PM, revealed Resident #88's family member was concerned with Resident #88's sleepiness and leaning in chair. The Progress Note revealed the Physician Assistant stopped Resident #88's opioid medication and would re-evaluate. Review of Advanced Practice Registered Nurse (APRN) #2's notes dated 05/06/2025, revealed the unstageable pressure ulcer to coccyx was first discovered and documented on 4/23/2025 in the facility's electronic records, and left and right medial and lateral buttocks skin shearing was discovered on 05/06/2025. Review of a Physician Progress Note dated 05/12/2025, revealed Resident #88's family member was called due to worsening of coccyx pressure ulcer with tunneling and concern for osteomyelitis. The family member revealed Resident #88 would require extra medication for a Magnetic Resonance Imaging and the family member stated they would meet Resident #88 at the hospital to assist with the scan. Review of [named] Hospital Records dated 05/14/2025, revealed Resident #88 was lethargic, and Resident #88's family member revealed to hospital staff they were told about a week ago that Resident #88 had a sacral pressure ulcer. During an interview on 07/22/2026 at 1:39 PM, LPN #9 stated Resident #88 had a new colostomy, and abdominal surgical wound with a wound vac on admission. LPN #9 looked through Resident #88's electronic record and stated, [Resident #88's] pressure ulcer started on 05/06/2026. LPN #9 stated she talked to the wound care nurse about Resident #88's pressure ulcers but did not recall talking to Resident #88's family. During an interview on 07/22/2026 at 3:23 PM, Registered Nurse/Wound Care Consultant stated Resident #88 was in very poor health, had a wound vac on their abdomen and developed pressure ulcers. Wound Care Consultant stated, I remember them (family) being very involved in [Resident #88's] care but the Wound Care Consultant did not remember speaking with the resident's family member. During an interview on 07/23/2026 at 2:10 PM, the Director of Nursing (DON) reviewed shower sheets from April 2025-May 2025 and revealed Resident #88 had a shower on 04/22/2025 and there was no documentation of a pressure ulcer. The DON revealed the Nursing Weekly Skin Audit, dated 04/22/2025, revealed Resident #88 had a stage II on the coccyx. When asked was Resident #88's family notified of the pressure ulcer, the DON confirmed there was no documentation indicating the family was notified that pressure ulcers had been discovered on 04/22/2025. DON stated, they think [family member] may have been informed at the bedside. During an interview on 07/23/2026 at 3:34 PM, the Administrator stated if a new pressure ulcer was found on a resident the family should be contacted right away so they can be involved in the plan of care. This Surveyor attempted to interview the family member of Resident #88 who declined the interview. Review of a facility policy titled Change of Condition or status, revised on 11/22/2016, revealed the resident's legal representative or responsible party will be notified promptly of a change of condition. A significant change in a resident's physical health would be a major decline that will not normally resolve itself without intervention of staff or disease related clinical interventions. Deterioration in health in either a life-threatening condition or resident has clinical complication. The DON or charge nurse or designee will record changes in a resident's medical condition in the electronic record, nurse action or interventions and will include physician and responsible party contacts. Physicians' notification will include time and response. Abnormal findings should be reported to the charge nurse, and date and time the condition was identified, assessment, emergency care, notification of physician and of legal representative, and signature and title of person performing procedure should be documented.

Number of residents sampled: Number of residents cited: Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure a resident was free from physical and verbal abuse for one (Resident #37) of four residents reviewed. The findings include: A review of Resident #37's admission Record indicated the facility admitted Resident #37 on 02/27/2024, with diagnoses that included vascular dementia with other behavioral disturbance, cognitive communication deficit, nontraumatic intracerebral hemorrhage, depression, macular degeneration and legal blindness. A review of the annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/04/2026, revealed Resident #37 had a Staff Assessment for Mental Status (SAMS) score of 3 which indicated Resident #37 had severe cognitive impairment. The MDS also revealed Resident #37 was dependent on staff for all self-care and mobility activities. A review of Resident #37's Care Plan, initiated on 03/23/2024, revealed a focus that the resident had the potential to be verbally aggressive related to dementia. Interventions included, when the resident becomes agitated: intervene before agitation escalates, guide away from source of distress, engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. A review of an Order Summary Report revealed Resident #37 had laboratory orders with a start date of 06/04/2025, for blood tests that included, complete blood count (CBC) and comprehensive metabolic panel (CMP) every six months in April and October; and Lipids and Vitamin D level yearly in April. A review of a Reportable for verbal abuse dated 04/15/2025, alleged a Phlebotomist used a curse word toward Resident #37, stating [the resident] needed to keep their [expletive] arm still. A review of a Reportable for Physical abuse dated 04/15/2026 revealed the Phlebotomist called CNA #4 to Resident #37's room to assist with a lab draw. CNA #4 allegedly sat on Resident #37's shoulder area in an attempt to keep the resident still for the lab draw. During a phone interview on 07/23/2026 at 11:17 AM, CNA #4 reported that on 04/15/2025 the Phlebotomist asked for her assistance with Resident #37's lab draw because the resident did not like that stuff. CNA #4 indicated Resident #37 had dementia and that she tried to talk to Resident #37 calmly. She reported she did not physically restrain the resident, and she did not abuse the resident. CNA #4 reported she had attended in-services about abuse at the facility. A review of the facility's electronic education records indicated the Phlebotomist completed competencies for Neglect, Abuse and Theft on 05/24/2024 with a score of 100. The review revealed CNA #4 completed competencies for Neglect, Abuse and Theft on 08/01/2024 with a score of 100. During a phone interview on 07/23/2026 at 11:58 AM, CNA #5 reported she was in Resident #37's room to ask a question while the Phlebotomist was preparing for a lab draw from Resident #37. She reported the resident was not cognitive, was being combative and the Phlebotomist was telling the resident to keep your [expletive] arm still. CNA #5 reported the resident was not being still and the Phlebotomist called CNA #4 to the room for more assistance. CNA #5 reported that CNA #4 put her hip on the resident's shoulder and upper chest area, as if sitting on the resident, to keep the resident still. CNA #5 reported that CNA #4 then reached across the resident to also hold the right arm still. CNA #5 reported that the Phlebotomist attempted to obtain the lab sample without success, the Phlebotomist and CNA #4 left the resident's room. During an interview on 07/23/2026 at 2:54 PM, the Director of Nursing (DON) reported at the time of the incident in April 2025, Resident #37 was not cognizant and was not able to tell staff about the incident. She reported that staff should not hold a resident down during a lab draw due to that being a restraint and abuse. She reported that staff should not curse nor use a harsh tone with a resident during a lab draw due to possible emotional abuse and added that cursing or using a harsh tone was disrespectful. She indicated if a resident was being combative or refusing a lab draw, the staff should reapproach the resident later or change the staff attempting the task. During an interview on 07/23/2026 at 3:38 PM, the Administrator reported Resident #37 was not cognizant and was not able to tell her what took place during the lab draw in April 2025. The Administrator reported staff should never use physical strength to hold a resident with dementia during a lab draw. She indicated this would be a form of abuse. She indicated staff should never use curse words toward a resident and added this also would be a form of abuse. She reported a staff in-service was conducted on 04/15/2026 and that staff were in-serviced on the abuse and neglect policy emphasis on verbal abuse. She indicated if a resident was being combative or refusing a lab draw the staff should get a nurse, redirect or reapproach the resident. The Administrator reported that the Phlebotomist and CNA #4 were suspended immediately upon the notification of the allegation, pending investigation. She reported neither the Phlebotomist nor CNA #4 were brought back to work at the facility because she felt it was in the best interest of the facility after the investigation was completed. During an interview on 07/23/2026 at 2:27 PM, the Advanced Practice Registered Nurse (APRN) indicated if a resident was refusing or being combative during lab draws the staff should back off and give the resident time to calm down and relax. She reported staff should not use physical strength to hold a resident during a lab draw. She indicated using physical strength to hold a resident during a lab draw could cause potential injury. She reported that staff should not use curse words toward a resident nor use a harsh tone with the resident. She added that the residents deserve respect. During an interview on 07/23/2026 at 1:10 PM, the Medical Director (MD) indicated it was not acceptable for staff to ask other staff to sit on a resident to keep the resident still or to hold a resident down for lab draws, nor for staff to use curse words toward a resident. MD reported it was dangerous for a resident to be held down due to possible brittle bones. He indicated if a resident was refusing lab draws it should be discussed with the resident or their representative. A review of CNA #4's employee file revealed CNA #4 signed acknowledgement form – abuse investigation and reporting policy on 10/31/2023. A review of the facility's electronic competencies for CNA #4 revealed she passed courses neglect, abuse and theft and residents rights with a score of 100 on 08/01/2024. A review of Phlebotomist employee file revealed Phlebotomist signed acknowledgement form – abuse investigation and reporting policy on 09/07/2022. A review of the facility's electronic competencies for phlebotomist revealed she passed courses neglect, abuse and theft and residents rights with a score of 100 on 05/24/2024. A review of a facility policy titled, Abuse, neglect, misappropriation and exploitation investigation and reporting policy, revised 11/20/17, revealed the policy and procedures for investigation and reporting of alleged violations that included abuse. The policy indicated the facility will endeavor to protect residents from maltreatment, and the facility recognizes residents have a right to be free from physical and verbal abuse. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical harm, pain or mental anguish. Verbal abuse was defined as any intentional act that a reasonable person would believe subjects an endangered person or an impaired person, regardless of age, ability to comprehend, or disability, to ridicule or psychological injury in a manner likely to provoke fear or alarm. A review of revised facility policy dated 11/22/16 titled, Resident Rights, revealed residents have rights which included be given the opportunity to refuse treatment and be free from physical abuse. The facility re-educated all staff on 04/15/2025 on the topic of abuse and neglect policy with emphasis on verbal abuse. In addition, CNA #4 and the Phlebotomist were suspended during facility investigation and then terminated following the incident involving Resident #37. These actions were performed before the survey team entered the facility, verified by document review and staff interview resulting in this finding being cited at past non-compliance.

Number of residents sampled: Number of residents cited: Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #78) of three residents reviewed. The findings include: A review of Resident #78's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included unspecified displaced fracture of second cervical vertebra, subsequent encounter for fracture with routine healing, neuralgia, neuritis, and depression. A review of Resident 78's admission Minimum Data Set (MDS) with an Assessment Reference Date of 04/08/2026, revealed Resident #78 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS revealed Resident #78 had a functional limitation in range of motion for their upper extremity, with an identified impairment on one side. The MDS also revealed the resident had no therapies in the last 7 days. A review of Resident #78's Care Plan revealed the resident had an Activity of Daily Living (ADL) self-care deficit related to impaired balance and limited mobility. Interventions initiated on 04/23/2026 included sling to left upper extremity (LUE) as tolerated and Physical Therapy (PT)/Occupational Therapy (OT) evaluation and treatment as per Medical Doctor (MD) orders. A review of Resident #78's Order Summary revealed an order dated 03/31/2026 for occupational therapy to eval and treat as indicated one time only for 5 days and a separate order dated 03/31/2026 for physical therapy to eval and treat as indicated one time only for 5 days. A review of a facility document titled SNF [Skilled Nursing Facility] Initial Visit dated 04/07/2026 completed by the Advanced Practice Registered Nurse (APRN), revealed Resident #78 was admitted to the facility for therapy and that Resident #78 had limited mobility to left shoulder. APRN noted [resident] is able to move left forearm, guarding present, limited mobility left shoulder. The resident reported pain to the left clavicle area to left elbow area. Evaluation of 04/07/2026 left shoulder x-ray impression noted no acute fracture, healing proximal humeral fracture noted. Physical Examination included extremities -No BLE edema, LUE limited mobility. A review of Resident #78's Progress Note dated 04/09/2026 by Licensed Practical Nurse (LPN) #8, revealed the resident returned from an orthopedic clinic appointment. Remains non-weight bearing (NWB) to LUE, beginning April 16, wean out of sling. Begin PT/OT. A review of Resident #78's Progress Note dated 05/11/2026 by LPN #8, revealed the resident returned from an orthopedic clinic appointment with orders received for PT/OT, and requested billing office to check payor source. A review of Resident #78's Progress Note dated 05/12/2026 by Advanced Practice Registered Nurse (APRN), revealed nursing staff reported the resident had an orthopedic appointment yesterday and that ortho ordered PT/OT for Resident #78's left shoulder. A review of Resident #78's Progress Note dated 05/18/2026 by the APRN, revealed the resident was expressing concern for left shoulder not being healed and unsure when [resident] will be getting therapy due to financial barrier. A review of Resident #78's Progress Note dated 05/19/2026 by the APRN, revealed the resident was frustrated because [resident's] arm and shoulder haven't gotten any better since [resident] admitted to [facility]. A review of Resident #78's Progress Note dated 07/06/2026 by LPN #8, revealed the resident went to an orthopedic follow up clinic appointment and returned with orders for PT and OT, business office made aware. During an interview on 07/20/2026 at 3:49 PM, Resident #78 indicated they came to the facility for therapy. They indicated they tried to do their own range of motion (ROM) to the left arm but had not received any therapy since being at the facility. During an interview on 07/22/2026 at 11:51 AM, the Director of Therapy/Occupational Therapist (OT) indicated she had not worked with Resident # 78. She reported Resident #78 had not been on any of the therapy services. OT reported she was not able to start therapy with a resident until authorization of insurance was obtained, but she was not aware the resident needed therapy. OT reported Resident #78 had not had a physical therapy (PT) nor an occupational therapy (OT) evaluation. She reported that the resident had not had restorative therapy since a resident could only have restorative therapy after a PT or OT evaluation had been completed. During an interview on 07/22/2026 at 12:08 PM, Medical Records stated it was her responsibility to scan order documents, enter those documents into the electronic health record (EHR) and file the documents in the resident's soft chart. She reported that the floor nurse who received the order was responsible for follow up on the orders they received. During an interview on 07/22/2026 at 12:16 PM, Consultant #6 stated that the nurse who received the order should have given the order to the Director of Nursing (DON) and the DON should have taken the order to the Business Office Manager (BOM). She stated that the BOM should check the resident's benefits, and the order should have been given to therapy. She verified until therapy receives authorization, therapy would not know to start therapy. Consultant #6 suggested the order could have been mentioned in morning meeting. She checked the morning meeting notes and stated, there is nothing in there about therapy. During an interview on 07/22/2026 at 3:11 PM, the DON stated that when an order was received from a doctor's appointment the transport person would send a text to the Administrator, DON, BOM and the nurses on the hall of that resident. She reported the paper copy of the order was given to medical records. She indicated the medical records ensured the Administrator and the DON were aware of the new order. She reported once therapy received authorization the evaluation should be completed in less than a week. She reported nurses should follow doctor's orders. The DON indicated it was important for a resident to receive timely implementation of a doctor's order to ensure continuation of care for the resident. During an interview on 07/22/2026 at 2:31 PM, the Administrator indicated when an order was received from an out of facility doctor's visit, the charge nurse would take the order to medical records or leave the order in the medical record's box and communicate with the BOM to ensure there was a payor source. She reported the morning meeting was a time for new orders to be verbalized. She indicated no minutes were recorded for Resident #78 having new therapy orders and she did not recall any verbal mention of the new order for PT or OT. The Administrator indicated after the BOM verified whether the payor source for Resident #78 would or would not have paid for therapy, the BOM would have informed the Administrator that a PT/OT evaluation was needed for the resident. The Administrator, the Director of Therapy, and OT would have received the authorization, and an evaluation would have been set up. The Administrator indicated it was important for a resident to receive timely implementation of a doctor's order for therapy so that care was not delayed.

Number of residents sampled: Number of residents cited: Based on observation, record review and interview the facility failed to appropriately monitor and supervise a resident with severe cognitive impairment to prevent elopement for one (Resident #91) of one residents reviewed. The findings include: Review of an admission Record indicated Resident # 91 was admitted by the facility on 12/12/2025 with diagnoses that included dementia, diabetes and benign prostatic hyperplasia. Review of an admission Minimum Data Set (MDS) with an Assessment Reference date of 12/18/2026, revealed Resident #91 had a Brief Interview for Mental Status score of 3, which indicated the resident had severe cognitive impairment. The MDS also revealed Resident #91 had no wandering behaviors, that Resident #91 had a Urinary Tract Infection (UTI) in the last 30 days and was not on antibiotics at the time. Review of Resident #91's Care Plan initiated on 12/24/2025, revealed the resident was an elopement risk/wanderer related to dementia. Interventions included offer a distraction to Resident #91 when wandering, offer toileting assistance, snack, conversation or television. Review of a facility Day/Night assignment sheet dated 12/19/2026 at 6:00 PM, revealed the following staff were scheduled to work with a census of 81:-9 CNA's-1 Lead CNA-3 LPN-2 MA-C's Review of Witness Statement dated 12/19/2025 by Certified Nursing Assistant (CNA) #3, revealed CNA #3 clocked out around 6:10 PM, and told Resident #91 to have a good day, then got in her car that was parked facing away from the building, without a view of the 300 Hall exit. Review of CNA #3's Timecard dated 12/19/2026, confirmed she clocked out at 6:10 PM. During an interview on 07/21/2026 at 11:30 AM, the Administrator revealed that on 12/19/2025 at 6:30 PM, [after CNA #3 exited the building], Resident #91 used a foot to hold open the 300 Hall exit door, rolled down the wheelchair accessible sidewalk in their wheelchair and turned over. During an interview on 07/21/2026 at 1:47 PM, CNA #1 stated that on 12/19/2025 he became concerned when Resident #91 was not sitting outside their room near the 300 Hall exit and he started looking for Resident #91. CNA #1 stated he had witnessed Resident #91 trying to elope from the facility soon after admission but could not remember who this had been reported to. During an interview on 07/21/2026 at 2:18 PM, Medication Administration Certified (MA-C) #2 they were assisting CNA #1 in the search for Resident #91, looking in the bathrooms and then went outside. MA-C #2 stated, from the corner of my left eye I noticed Resident #91's wheelchair laying on its side in the dark about 30 foot away from 300 Hall exit. MA-C #2 stated Resident #91 had a knot on the back of the head, and a scrape on one of their hands. During an interview on 07/22/2026 at 8:47 AM, Licensed Practical Nurse (LPN) #7 stated on 12/19/2025 she noticed Resident #91 had changed sitting locations and she was keeping an eye on Resident #91 but had not seen any exit seeking behaviors. LPN #7 stated, I would have alerted all the staff for more eyes on [Resident #91] and made [Resident #91] 1:1 if they were exit seeking. During an interview on 07/23/2026 at 2:27 PM, the Director of Nursing (DON) stated she was not in the facility when Resident #91 eloped. The DON revealed Resident #91 got out of the building when CNA #3 was leaving, and the door was not closed before she got to her car and drove off. The DON stated, Resident #91 caught the door with their foot. The DON confirmed Resident #91 had a skin tear and knot on their head. The DON stated they could not remember the temperature outside but did not remember the weather being very cold at the time. The DON stated, I thought Resident #91 was wearing a shirt and sweatpants. The DON stated, When [Resident #91] came out of the 300 Hall exit doors they tipped over right at the ramp. The DON stated, when staff thinks a resident is missing, they immediately look for the resident, check the surroundings and make sure nobody is outside. Then we call the Medical Director [MD], police, family, administrator/DON, and then report the incident. During a follow-up interview on 07/22/2026 at 2:00 PM, CNA #1 stated Resident #91 was wearing jeans, a short-sleeved shirt, and shoes when the resident had exited the facility, and it was not cold outside at the time. Review of a facility Weekly Exit Door Inspections monthly report from 12/3/2025-1/21/2026, revealed the 300 Hall doors were documented as functioning properly. Review of a facility document titled, Q15 Minute Safety Checks, dated from 12/26/2025 until 12/30/2026 at 13:15 PM revealed the resident was monitored [after the incident] until Resident #91 was transferred to a memory care unit. Review of CNA #3's employee file indicated the handbook acknowledgement including abuse investigation and reporting was signed on 04/24/2025. Review of a facility in-service on Abuse and neglect policy with emphasis in elopement, dated 12/19/2025, revealed 114 staff signatures, including CNA #3. Review of a facility in-service on Be aware of your surroundings and ensure the door lock has engaged after entering or exiting the facility dated 12/19/2025, revealed 114 signatures that included CNA #3 Review of a facility in-service on elopement risk, dated 12/24/2025, revealed it was signed by CNA #3. Review of a facility policy titled Elopement and Wandering, revised 11/22/2017 revealed residents are assessed on a quarterly basis for elopement and wandering. Security system should always be on, any suspicion that a resident has left the facility should be reported to the charge nurse or Director of Nursing [DON], obtain staff assistance in the immediate vicinity and make a thorough search of the facility and grounds. If not located call appropriate code, notify police, physician and notify state within 1 hour after it has been discovered resident has been missing from the facility for 3 hours then complete the wandering/elopement risk information sheet. On return examine residents for injuries and notify physician with findings, responsible party and state agency. Staff shall be in-serviced annually and on hire, and employees should know their responsibility regarding door alarms, reporting wandering behaviors and elopement. Review of facility in-service documentation, interviews with staff, relocation of the resident to a secure area, and review of facility documents that revealed no further incidents occurred following December 2025 resulted in this finding being classified as past non-compliance.

Number of residents sampled: Number of residents cited: Based on interviews and record review the facility failed to ensure a resident did not receive unnecessary medications for one (Resident #78) of five residents reviewed. The findings include: A review of Resident #78's admission Record revealed the facility admitted Resident #78 on 04/01/2026 with diagnoses which included unspecified displaced fracture of second cervical vertebra and encounter for other specified prophylactic measures. A review of a facility document titled Skilled Nursing Facility (SNF) Initial Visit dated 04/07/2026, revealed that the Advanced Practice Registered Nurse (APRN) documented New orders from [MD]: Once current supply of lovenox is exhausted, change to xarelto 10 mg PO daily until ambulating greater than 150 feet. A review of Resident # 78's Order Summary revealed an order dated 04/07/2026 for an anticoagulant to be administered one tablet by mouth one time a day related to encounter for other specified prophylactic measures, discontinue when ambulating more than 150 feet. A review of Resident # 78's Active Orders revealed an order dated 04/07/2026 and started 04/08/2026 for an anticoagulant medication with instructions to give one tablet by mouth one time a day related to encounter for other specified prophylactic measures discontinue when ambulating more than 150 feet. A review of Resident #78's Medication/Treatment Administration Record for April, May, June, and July 2026 revealed the resident received the anticoagulant medication daily from 04/08/2026 through 07/23/2026. A review of Resident 78's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/2026, revealed that Resident # 78 required moderate assistance to walk 150 feet. High-risk medications the resident received included an anticoagulant. A review of Resident 78's quarterly MDS with an ARD of 07/09/2026, revealed that Resident #78 could walk 150 feet independently. High-risk medications the resident received included an anticoagulant. During an interview on 07/23/2026 at 2:54 PM, the Director of Nursing (DON) indicated Resident #78 ambulated without assistive devices. She reported the resident had an active order for an anticoagulant medication. She verified the ambulation status for the resident was that the resident was able to walk more than 150 feet per the resident's MDS with an ARD of 07/09/2026. The DON reported the anticoagulant should have been discontinued. She reported it was important for a resident not to take unnecessary medications due to the possibility of side effects. She reported the expectation of nurses was to follow doctor's orders and clarify those orders if needed. During an interview on 07/23/2026 at 2:27 PM, the APRN verified that Resident #78 had an active order for an anticoagulant medication. The APRN indicated that Resident #78 was able to walk 150 feet and did not require a cane, walker, or wheelchair. She reported per the instructions on the order for the anticoagulant, the order should have been discontinued. She reported it was important for a resident not to take medications that were not indicated for that resident to prevent potential adverse effects. During an interview on 07/22/2026 at 2:31 PM, the Administrator indicated that Resident #78 did not use a walking device. The Administrator reported that she had seen the resident walk from their room to the main dining room unassisted, [which was greater than 150 feet]. She reported the expectation of nurses regarding following a provider order was to execute that order and clarify as appropriate. During an interview on 07/23/2026 at 5:03 PM, Licensed Practical Nurse (LPN) #11 indicated Resident #78 had a steady gait and did not need assistive devices or assistance from staff to ambulate. She verbalized the resident could walk further than 150 feet. She verified she had administered the anticoagulant medication to Resident #78 on 07/08/2026 and 07/15/2026. After LPN #11 reviewed the order for the anticoagulant medication she confirmed the resident should not have received the anticoagulant medication for the last month or two. She added the medication was discontinued earlier today. During an interview on 07/23/2026 at 1:10 PM, the Medical Director (MD) verified that when an order for an anticoagulant medication specified instructions such as, discontinue when ambulating more than 150 feet, the medication should be discontinued when the resident was up and walking more than 150 feet in a day. He reported that there was always a chance for side effects and added if a medication was not needed or it was not indicated, then the resident should not be taking the medication.

Number of residents sampled: Number of residents cited: Based on record review and interview, the facility failed to ensure a written notice of the bed-hold policy and return were provided to the resident and/or resident representative upon the resident's transfer to a hospital and specified the duration of the bed-hold policy. The facility also failed to ensure the written notice of transfer contained all required components for one (Resident #85) of one resident reviewed: The findings include: A review of an admission Record revealed Resident #85 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD) and unspecified systolic (congestive) heart failure. The admission Record also indicated Resident #85 was discharged to an acute care hospital on [DATE]. A review of the discharge-return anticipated Minimum Data Set with an Assessment Reference Date of 05/04/2026, revealed Resident #85 had a Staff Assessment for Mental Status score of 1, which indicated the resident's cognitive status was modified independence-some difficulty in new situations only. A review of the Notice of Transfer form dated 05/04/2026 revealed the following information, Please allow this letter to inform you that on 05/04/2026, [Resident #85] was transferred to [name of hospital] for the following reason/s: shortness of breath. The resident is expected to return to the facility on date TBD [to be determined]. The form contained the administrator's name, signature and title at the bottom. The form was missing the following required components:a. A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests.b. Information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request.c. The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. A review of an undated Bed-Hold Agreement form for Resident #85 was not filled out. The form did not list Resident #85's name, the maximum period of days to hold the bed or the amount of money Resident #85 was responsible for paying per day during the bed hold. The bed-hold agreement form did not have a signature of the resident or responsible party. The bed-hold agreement form was stapled to the notice of transfer form for Resident #85. During an interview with the Administrator on 07/23/2026 at 5:06 PM, she stated the Business Office Manager (BOM) completed the bed-hold information when a resident transferred to the hospital and the current BOM had only been at the facility for two weeks. The Administrator was shown the Bed-Hold Agreement that was stapled to the back of the Notice of Transfer form for Resident #85, and she acknowledged the form had not been filled out. The Administrator stated, That's why she's not here now, referring to the previous BOM. She was asked to review the Notice of Transfer letter and stated the form she reviewed was the facility's Notice of Transfer form. She stated medical records provided the forms to the residents. She was asked who put the Notice of Transfer form together and she stated, It was in use when I got here. She was asked how often she reviewed the federal regulations for changes and she stated, When I am notified there are changes.

Through observation and interview the facility failed to post the results of the most recent survey of the facility in a place readily accessible to residents, family members and legal representatives of residents. The findings are: During observations from 11/11/2024 at 1:00PM through 11/15/2024 at 9:15AM, the only time residents were seen in the vicinity of the greeting desk was with the escort of facility staff, contracted therapy staff or contracted transportation staff. During observations from 11/11/2024 at 1:00PM through 11/15/2024 at 9:15AM, the facility survey book was located on the far back right-hand side of the greeting desk. The greeting desk had a staff member assigned to the position. To obtain the facility survey book a resident or representative would be required to reach through the assigned staff members workstation. The facility survey book was back far enough to where a resident in a wheelchair would not have the ability to obtain the book without the need to ask. Observations from 11/11/2024 at 1:00PM through 11/15/2024 at 9:15AM showed there was not a facility survey book openly located in any of the resident's common areas such as dining room, day room or individual hallways. On 11/14/2024 at 1:04PM, Receptionist stated survey books were in the nurses' stations and receptionist desk at main entrance. There were not any survey facility books in the resident hall areas. Receptionist stated, a few people had asked about the facility survey book. People see the facility survey book and ask for it. Receptionist was not sure if the people who ask for the facility survey book were allowed to take it to a different location within the facility. The people who ask to look at the survey facility book usually sit at the reception desk area. On 11/14/2024 at 1:22PM, an attempt was made to locate a facility survey book in which residents, nor their representatives would need to ask assistance for the survey book. LPN #5 confirmed a facility survey book was not at the long-term nurse's desk for hall one and does not know where the facility survey book is. On 11/14/24 1:30PM, the CNA Consultant confirmed the facility had only one survey book at the receptionist desk. On 11/15/2024 at 8:25AM, during an interview, the Receptionist confirmed the survey book was kept on the far back, right-hand side of the greeting desk. Residents can ask for the survey book if they are unable to reach across the desk themselves. On 11/15/2024 at 10:00AM, the Director of Nursing (DON) and Nurse Consultant confirmed that residents should have access to the survey book. On 11/15/2024 at 10:01AM, the Administrator confirmed that residents should not have to ask for the survey book. On 11/15/24 at 10:02AM, the Administrator was informed that the Receptionist stated the book was kept at the receptionist desk and the residents had to ask for it to see it but had to stay there with it. The Administrator stated that was the wrong answer and it would be rectified.

Based on observations, interviews, and record review, it was determined that the facility failed to ensure the care plan was updated to include contracture and contracture management for 1 resident (Resident #13) of 1 resident reviewed for positioning and mobility and contracture management. Findings include: No policy was provided for contracture management. A review of the Admission Record, indicated the facility admitted Resident #13 with diagnoses that included dementia, pain, muscle wasting and atrophy, and hemiplegia (partial or complete paralysis to one side of the body). Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2024, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident had severe cognitive impairment. Resident #13 was shown to have an impairment of the upper and lower extremity for functional limitation in range of motion. A review of Resident #13's Care Plan, initiated on 11/14/2024, revealed the resident had an alteration in musculoskeletal status related to contracture (left hand and arm). This care plan was initiated after speaking with the Long-Term Care Minimum Data Set (LTC MDS) Coordinator. The newly initiated care plan did not include the restorative program or the functional maintenance plan (FMP) in which Resident #13 had been participating in. There was no mention of a hand roll or device for preventing the worsening of the left-hand contracture. A review of an Activity of Daily Living Task revealed no task was being documented. A review of the closet care plan for Resident #13 revealed a special device, a hand roll, was needed in the left hand. During an observation on 11/12/2024 at 2:58 PM, Resident #13 was in activity, in the main dining room where staff were assisting residents with painting. Resident #13 was sitting at a table with the painting supplies and picture in front of the resident. Resident #13 had left-hand lying-in lap and was not moving the left hand or arm. During an observation and concurrent interview on 11/14/2024 at 2:05 PM, the LTC MDS coordinator stated that Resident #13 had a restorative program, and that the FMP had been extended then confirmed that after Resident #13 had been evaluated by therapy, no recommendations had been made for a splint or brace. LTC MDS Coordinator confirmed Resident #13 had been receiving restorative three times a week. When asked how the staff would know what type of care to provide to Resident #13, it was confirmed the resident had a closet care plan. LTC MDS coordinator removed the closet care plan for review, and it stated that Resident #13 needed a hand roll to the left hand. During an observation on 11/14/2024 at 2:10 PM, Resident #13 was sitting in bed with the head of the bed elevated up and the over-the-bed table was across the bed in front of the resident. The lunch tray was in front of Resident #13 without anything eaten off the tray. Resident #13 was asked if help was needed to eat and the response was given, yes. LTC MDS coordinator stated that someone would help with the tray. Resident #13 did not have any device in the left hand, which was beside the resident in the bed. During an interview with a Certified Nursing Assistant (C.N.A.) #8 on 11/14/2024 at 2:14 PM, confirmation was given that Resident #13's closet care plan stated a hand roll was needed for the left hand. When C.N.A.#8 was asked if Resident #13 ever used a hand roll in the left hand, the answer was given, No. During an interview on 11/15/2024 at 11:30 AM, the DON confirmed there was no documentation concerning use of a hand roll for Resident #13 ' s left hand. The DON provided a newly initiated care plan with no mention of a hand roll, restorative program or the functional maintenance plan (FMP). When asked what guidance the LTC MDS coordinator used to develop and complete the MDS and care plan, DON stated, I am not sure, and the LTC MDS coordinator only works part time and is not at the facility today.

Based on observations, interviews, and facility policy review, it was determined that the facility failed to remove two bottles of expired tube feeding from current stock for 1 of 1 medication room and failed to label two insulin vials and three inhalers with open dates when the manufactures seal was broken in 2 of 2 medication carts reviewed for medication storage. Findings include: A review of a facility policy titled, Medication Storage in the Facility, revised in [DATE] indicated, when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened and enter the date opened. During a concurrent observation and interview on [DATE] at 9:07 AM, of the Long Term Care medication room with Licensed Practical Nurse (LPN) #5, two bottles of tube feeding in current stock were revealed to have expiration dates of [DATE]. LPN #5 stated, the bottles needed to be thrown away. During a concurrent observation and interview on [DATE] at 9:22 AM, of 300-Hall medication cart with LPN #10, two vials of insulin were found without an opened date. Open dates were on the plastic bags but not labeled on the vial. LPN #10 stated yes, the bag could become damaged or lost resulting in an unknown open date. One inhaler was found without an open date on the canister or the packaging. During a concurrent observation and interview on [DATE] at 10:00 AM, of 100-Hall medication cart with LPN #11, two inhalers were found without an open date on the canister or packaging. During an interview on [DATE] at 10:30 AM, the Director of Nursing (DON) stated LPN #5 was tasked with checking expiration dates in the Long Term Care medication room and thought checks were done weekly. The DON was unaware nursing staff was labeling the bags and not the insulin vials.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared in a method that maintained an appearance that was acceptable to the residents to encourage good nutritional intake for 2 of 2 meals observed. The findings are: 1. A review of the facility recipe titled, Egg sausage bake initiated 9/17/2024 and provided by the Dietary Manager on 11/14/2024 indicated use water or stock. 2. On 11/13/24 at 4:14 PM, Dietary [NAME] (DC) #1 placed 10 servings of egg sausage bake into a blender and pureed. DC #1 did not add broth or anything to help moisten it. At 4:24 PM, DC #1 poured the pureed sausage with egg casserole into a pan and placed it in the oven. The consistency was thick when it was placed in the oven and remained thick when it was placed on the steam table to serve. On 11/14/24 at 12:55 PM, DC #1 was asked what he used when pureeing egg sausage bake to make it moist. DC #1 indicated that he did not use anything. 3. On 11/13/24 at 4:32 PM, DC #1 placed 10 servings of biscuits into a blender, ground, then added warm milk from a pan on the counter and pureed. DC #1 scooped pureed biscuit into a pan, and it was thick. At 4:42 PM. Dietary Aide (DA) #2 transferred pureed biscuit back into a blender, added a carton of whole Milk I and pureed it some more. At 4:43 PM, DA #2 scooped pureed biscuits into a pan and placed it in warmer. The consistency was sticky and thick. 4. On 11/13/24 at 4:59 PM, DC #1 placed 10 servings of hash brown into a blender, added 3 more servings of hash brown, added milk and pureed. At 5:05 PM, DC #1 used a spatula to scrape pureed hash brown into a pan. It was sticky and thick. 5. Resident #42's Order Summary Report was reviewed and indicated the resident had a diagnosis of Dysphagia following cerebral infarction, and an order dated 10/23/2024 for Regular diet pureed texture, honey consistency, half portions. Review of a quarterly Minimum Data Set with an Assessment Reference Date of 10/23/2024, was reviewed and indicated Resident #42 had a score of 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) and required partial/moderate assistance for eating substantial/maximal assistance for personal hygiene, and partial/moderate assistance for mobility. 6. On 11/14/24 at 9:40 AM, Resident #42 was lying on back in bed. Resident #42 was served pureed pancake and pureed fruit desert. The consistency of the pureed pancake was too thick, and when attempting to cut a portion of the pureed pancake on the plate to eat was unable to do so. The resident indicated that trying to take a bite of pureed pancake, but it was too hard. At 9:43 AM, resident #42 was asked how dinner last night was. Resident #42 stated they were like this pureed and I could not eat it. 7. On 11/14/24 at 9:44 AM, the Assistant Dietary Manager (ADM) was asked about the consistency of the pureed pancake and cream of wheat served to the residents on pureed diets at the breakfast meal. She stated cream of wheat was runny and pureed pancake was too thick. She indicated that the bread on resident #42's tray looked formed and hard. When asked about the pureed biscuits and pureed sausage and egg served at the super meal on 11/13/24 ADM confirmed the pureed sausage with eggs and pureed biscuit were thick. 8. On 11/14/24 at 12:43 PM, DA #2 was asked how the pureed food items served at the supper meal on 11/13/24 looked. DA #2 stated pureed sausage with eggs were too thick and he should have added more liquid. Pureed biscuits were thick, and he should have added more liquid. Pureed hash brown was thick and needed more liquid. 9. On 11/14/24 at 12:48 PM, the Dietary [NAME] #4 was asked how cream of wheat served to the residents on pureed diets at breakfast looked. DC #4 stated most residents asked for their cream of wheat to be thin, but confirmed pureed cream of wheat should not have been soupy, it should have been a little thick. 10. On 11/15/24 at 8:42 AM, the speech therapist when interviewed was asked how the consistency of pureed diets should look. She stated it should look like pudding or mashed potato consistency, should hold its shape in a spoon with no lumps. She was asked if pureed food items should be thick, she stated the pureed foods should not be thick and residents on pureed diets should not put it in their mouth.

49981 Based on observation, interview, record review and facility policy review, the facility failed to ensure dietary staff changed gloves and washed their hands before handling food items and clean equipment when contaminated; food items stored in the refrigerator and freezer were covered, sealed, and dated; expired food items were promptly removed/discarded on or before the expiration or use by date. The findings are: 1. On [DATE] at 2:54 PM, Dietary [NAME] (DC) #1 was wearing gloves on his hands when he picked up a spray bottle and sprayed inside of the pans, contaminating the pans. Without changing gloves and washing his hands, DC #1 removed hash browns from a box and placed them on the pans to be baked and served to the residents for supper meal. 2. On [DATE] at 2:59 PM, the following observations were made on a shelf in the freezer. a. An opened box of breaded pork patties. The box was not close or sealed. b. An opened box of turkey burgers. The box was not covered or sealed. c. An opened box of pie dough. The box was not covered or sealed. 3. On [DATE] at 3:04 PM, the following observations were made on a shelf in the walk-in refrigerator. a. One container of leftover gravy indicated to use by [DATE]. b. Another container of leftover gravy indicated used by [DATE]. c. One container of taco sauce indicated used [DATE]. 4. On [DATE] 3:13 PM, an opened box of cream of wheat was on a shelf in the storage room. A container of leftover gravy was on a shelf in the refrigerator with a used by date of [DATE]. 5. On [DATE] at 3:34 PM. the following observations were made on a shelf in the emergency food supply in the kitchenette on 100-hall. a. An opened bag of brown sugar. The bag was not sealed. b. An opened plastic bag of pancake mix. The bag was not sealed. c. An opened bag of protein breadcrumbs. The bag was not sealed. 6. On [DATE] 4:18 PM, DC #1 was wearing gloves when he used a pair of scissors to cut out a piece of the plastic bag, and then inserted it into a pan. With his contaminated gloved hand, DC #1 pushed the plastic inside the pan that was intended for storing pureed food. 7. On [DATE] at 7:45 AM, Dietary Aide #3 (DA) was on the tray line assisting with breakfast meal. She picked up condiments and cartons of supplement and placed them on the meal trays. Without washing her hands, picked up glasses that contained beverages to be served to the residents for breakfast by the rims and placed them on the trays. 8.On [DATE] at 8:33 AM, DA #3 was asked what she should have done after touching dirty objects and before handling clean equipment. She stated, she should have washed her hands. 9. A review of policy titled, Proper Hand Washing procedure not dated, and provided by the Nurse Consultant indicated consider using a paper towel to create a barrier between hands and surfaces touched after hand washing (faucet and door handles). 10. On [DATE] at 11:10AM, the CNA Consultant was asked to assist with inspection of freezer and refrigerator in Activities Room of facility. The CNA Consultant opened freezer and confirmed that the temperature was 0 degrees. A box of popsicles was pulled out that had been opened with an expiration date of [DATE]. There was no open date. A container of green sherbet was observed that had not been opened and had an expiration date of [DATE]. Two boxes of cookie dough had been opened, and the bags were not sealed and no open date on either of the boxes was observed. 11. The CNA Consultant then opened the refrigerator, which had an internal temperature of 39 degrees Fahrenheit. The CNA Consultant pulled out 3 bags of ice cream sprinkles that had been opened and had no opened date. The CNA Consultant pulled from the refrigerator, a zipper sealed bag with opened brownie and pancake, opened [NAME] mix, and an opened bottle of soda, and none had opened dates. 12. On [DATE] at 11:48AM, the Activities Director (AD) was asked to describe the process for storing foods in the refrigerator and freezer in the Activities Room. The AD said the food came from the kitchen and was dated and placed in the freezer or refrigerator. Once the foods were opened, an open date was placed on container. Foods opened were sealed back up and placed back in freezer or refrigerator. The AD was asked to show opened dates on the items in the freezer and refrigerator in the Activities Room. The AD confirmed that there were no open dates on popsicles, sherbet, cookie dough, sprinkles, brownie and pancake mixes, [NAME] mix, and soda. The AD confirmed that foods should have opened dates and should be properly sealed in order to protect for food safety.

Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to properly store oxygen tubing and Continuous Positive Airway Pressure (CPAP) tubing and mask for 2 (Resident #13-oxygen tubing and Resident #52-CPAP tubing and mask) of 2 residents reviewed for Infection prevention and control of equipment or devices. Findings include: A review of a facility policy titled, Oxygen Safety, revised on 11/22/2016, indicated, the facility would properly handle oxygen. During an interview, Director of Nursing (DON) stated the facility did not have a policy regarding cleaning and storage of CPAP and oxygen tubing and other devices when not in use. A review of an Admission Record, indicated the facility admitted Resident #13 with diagnoses that included shortness of breath, Type 2 Diabetes Mellitus, and chronic obstructive pulmonary disease (COPD). Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2024, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident had severe cognitive impairment. Resident #13 had respiratory treatment which included oxygen therapy. A review of Resident #13's Care Plan, initiated on 09/19/2024, revealed the resident was on oxygen therapy. Interventions included that oxygen settings were to be set at 2-4 liters per minute via nasal cannula. A review of the Order Summary Report, revealed Resident #13 had an oxygen order for 2-4 liters per minute via nasal cannula as needed for shortness of breath. There was no order located in the electronic medical record to indicate oxygen tubing change was completed weekly to prevent infections and contamination of oxygen tubing. A review of Medication Administration Record, revealed Resident #13 had not been signed as having received Oxygen therapy for the dates of November 1, 2024, through November 14, 2024, nor was oxygen therapy marked for use from October 1, 2024, through October 31, 2024. A review Resident #13 ' s progress notes, revealed Resident #13 had one note entered on 10/17/24 noting resident's shortness of breath and being non-compliant with leaving the nasal cannula in the nose. During an observation on 11/14/2024 at 8:56 AM, after entering the room upon roommate's consent, an oxygen concentrator was heard. The curtain was pulled. Oxygen tubing was noted to be lying on Resident #13's bed with the oxygen concentrator running. The resident was not in the room at the time. A review Resident #52 ' s Admission Record, indicated the facility admitted Resident #52 with diagnoses of Alzheimer's disease, hypersomnia (excessive daytime sleepiness), and obstructive sleep apnea. Review of Resident #52 ' s annual MDS with an ARD of 09/18/2024, revealed Resident #52 had a Staff Assessment for Mental Status (SAMS) which indicated memory problems. The MDS was not marked as resident having special treatments, procedures and programs for the CPAP. A review of Resident #52's Care Plan, indicated no care plan for the use or care of the CPAP had been developed. A review of an Order Summary Report, revealed Resident #52 had an order for CPAP settings: Mode: Auto. Wife will clean nasal pillow and tubing daily. Resident #52 to wear at the hour of sleep as tolerated and is to be removed in the morning. No order for the CPAP pressure rate or how often the CPAP tubing and nasal pillow was to be changed. A review of Resident #52 ' s TAR, revealed Resident #52 had the order for the CPAP nasal pillow and tubing to be cleaned by the wife daily. Time for the task to be marked off the TAR was at 8:00 PM. Two omissions were noted on November 2 and November 10 with no signatures for the task being completed. During an observation on November 14, 2024, at 8:51 AM, the CPAP nasal pillow was lying directly on the nightstand. No plastic bag was available for the placement of the CPAP tubing or nasal pillow. During concurrent observation and interview on 11/14/2024 at 9:21 AM, the Director of Nursing (DON) was shown the CPAP nasal pillow for Resident #52, lying on the nightstand. Confirmation was given at that time by the DON was that the tubing should have been bagged. During an interview on 11/15/2024 at 9:30 AM, LPN #7 stated oxygen tubing for Resident #13 should be stored in a plastic bag when not in use and when it becomes contaminated, the tubing should be replaced. LPN #7 stated the nurses on Sunday are responsible for changing out the tubing and that it would be documented in the medical record when completed. LPN #7 stated that the nasal pillow for the CPAP for Resident #52 should be in a plastic bag. When asked if the CPAP and the cleaning of the equipment was care planned, LPN #7 stated I don't know. During an interview on 11/15/2024 at 11:30 AM, the DON confirmed nurses are responsible for cleaning and storage of oxygen tubing and supplies as well as making sure that CPAP tubing, masks and supplies are kept in a bag as well. The DON confirmed that once tubing becomes contaminated, the tubing or mask should be replaced.

Through observations, record review, and interviews the facility failed to ensure residents were able to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from their bed. This affected 4 (Residents #5, #24, #84, and #250) of 19 sampled residents. The findings are: Record Review of Resident #250 ' s Admission Report dated 10/25/2024, showed diagnoses of communication difficulties, abnormal mobility, left side weakness and/or paralysis after a stroke, and nerve malfunctions. Record Review of Resident #250 ' s Minimum Data Set, dated dated dated [DATE] showed Section C Cognitive Pattern to have a Brief Interview for Mental Status (BIMS) of 15. Section GG Functional Abilities showed impairment on one side upper and lower extremity and use of wheelchair was required. Section GG Functional Abilities on OBRA/Interim showed staff was required to help with more than half of the effort for Resident #250 to go from a seated position to a standing position and a standing position to a seated position. Resident #250 required more than half the assistance from staff to roll from side to side while in bed. Observation on 11/12/2024 at 11:50AM, of Resident #250 asleep with the call light on the right-side floor of bed. The call light cord was caught between the right side of the bed and the left side of the reclining chair. The call light cord was in a position where Resident #250 was unable to pull the call light pad within reach to be utilized for assistance. Observation on 11/12/2024 at 2:00PM of Resident #250 asleep with the call light on the right-side floor of bed. The call light was not within reach, nor had the call light been clipped to Resident #250 ' s bed covers. Record Review of Resident #84 ' s Admission Report dated 07/9/2024, showed diagnoses of decreased muscle strength and mass, altered mental state, osteoporosis, and repeated falls. Record Review of Resident #84 ' s Minimum Data Set, dated dated dated [DATE], showed Section C Cognitive Pattern to have a BIMS of 11. Section GG Functional Abilities Functional Limitation in Range of Motion showed impairment on left and right sides from hip to toes, use of a wheelchair is required. Section GG functional Abilities Admissions showed Resident #84 required total staff assistance for dressing and personal hygiene. Section GG Functional Abilities OBRA/Interim Resident #84 required total staff assistance for rolling side to side while in bed, seated position to a standing position and a standing position to a seated position. Resident #84 is unable to walk due to medical condition or safety concerns. Resident#84 was unable to maneuver wheelchair and was dependent on staff for transportation. Observation on 11/13/24 at 6:50AM, of Resident #84's call light on the floor of the right side of the bed. Resident #84 asked surveyor to place the call light where it could be reached. Resident #84 asked Surveyor to bring the bed control remote, that was at the foot of the bed, to where it could be reached. Resident #84 stated that staff was good at putting both controls at the foot of the bed. On 11/13/24 6:56 AM, Resident #84 was then able to press the call light for staff assistance. On 11/14/2024 10:45AM, Resident #84 ' s call light was dangling from the bedside rail while Resident #84 was asleep. Record Review of Resident #24 ' s Admission Report dated 10/10/2017, showed diagnoses of stroke, dementia, history of falls, pain, major depression and anxiety. Record Review of Resident #24 ' s Minimum Data Set, dated dated dated [DATE], showed Section C Cognitive Pattern to have a Staff Assessment for Mental Status of 3, severely impaired never/rarely made decisions. Section GG Functional Abilities showed Resident #24 required a wheelchair. Section GG Functional Abilities OBRA/Interim Resident #24 was dependent on staff for dressing, hygiene, rolling side to side while in bed, seated position to a standing position and a standing position to a seated position. First observation of Resident #24 on 11/14/24 at 9:32AM, call light on the stationary bedside table on the left side of bed. Resident #24 would be unable to reach cord to pull the call light due to call light cord behind the bed mattress. Second observation of Resident #24 on 11/14/2024 at 12:38PM, showed the call light remained in same position as the 9:32AM observation. Record Review of Resident #5 ' s Admission Report dated 11/14/2018, showed diagnoses of pain in right hip, anxiety, depression, dementia, glaucoma (eye disease that can lead to optic nerve damage and loss of vision), and arthritis. Record Review of Resident #5 ' s Minimum Data Set, dated dated dated [DATE], showed Section C Cognitive Pattern to have a BIMS of 4. Section GG Functional Abilities OBRA/Interim showed staff does more than half the work for Resident #5 during dressing, rolling side to side while in bed, seated position to a standing position and a standing position to a seated position. First observation on 11/14/2025 at 10:10AM of Resident #5, call light was on the floor with the call light cord behind the head of the bed and draped over the bottom metal piece that connects the handrail to the bed. The call light cord was in a position where Resident #5 would be unable to reach the cord to pull the call light to be within reach for proper use. Second observation on 11/14/2025 at 11:15AM of Resident #5 showed the call light remained in the same position as the first observation. On 11/14/24 at 3:26PM, the CNA Consultant confirmed that Resident #5 ' s call light should be within reach. The CNA Consultant placed the call light in the proper location on the bed next to Resident #5 ' s hand. The CNA Consultant confirmed the call light should be clipped to the bed covers or within a residents' reach. The call light in the proper position allows the residents to get assistance when needed. On 11/14/24 at 3:31PM, the DON confirmed the call light was needed for resident assistance. There are clips to help keep the call light in place. On 11/15/24 at 9:50AM, per Nurse Consultant the facility did not have a call light policy. On 11/15/2024 at 9:54AM, the Administrator confirmed that call light needed to be within reach of the resident. There was a clip on the call light to clip it in place. It is unacceptable for the call light to not be within reach. On 11/15/2024 at 11:15AM, the Nurse Consultant confirmed the facility had neither a policy nor procedure for call lights. The Nurse Consultant was able to provide a single call light in-service for answering call lights within a timely manner.

Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to provide written bed hold notice for 1 (Resident #97) of 1 resident reviewed for hospitalization . Findings include: A review of the policy titles, Bed Hold Policy and Return, revised on 11/22/2016 indicated, the bed hold policy was sent with the resident to the hospital in case of a transfer or emergency. The resident or their representative would be contacted the next business day to identify if they want to hold the bed. It should be documented on the bed hold form, then filed in the business office. If contact was made by phone a witness is required to listen, and two signatures are required when filling out the bed hold form. Review of an Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/11/2024, revealed Resident #97 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of Resident #97 ' s Admission Record revealed Resident #97 was their own representative, but a spouse was listed as next of kin. Review of Resident #97 ' s Order Summary Report revealed an admission order dated 09/06/2024 for skilled nursing. An order to transfer to the emergency room was placed on 09/20/2024 for altered mental status. Review of Resident #97 ' s Activity Report revealed, Business Office Manager (BOM) charted on Friday, 09/20/2024, Resident #97's spouse did not know if the resident would return and would notify the BOM by Monday. During an interview on 11/14/2024 at 1:08 PM, BOM stated, when a resident was transferred to the hospital it was their practice to call the family to see if they want to hold the bed. BOM stated, they called Resident #97's spouse, and it was unknown if the resident would return or not. BOM stated no bed hold agreement was issued for Resident #97 on 09/20/2024.

Based on observations, interviews, and record reviews, it was determined that the facility failed to ensure oxygen was on the care plan for 1 (Resident #28) of 1 sampled resident. The findings are: A review of Resident #28's Order Summary Report revealed a diagnosis of shortness of breath. A review of Resident #28's Order Summary Report revealed an order dated 10/04/2024, for oxygen 1-4 liters by nasal cannula as needed for shortness of breath. Review of a significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/09/2024, revealed Resident # 28 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #28 had oxygen therapy while a resident. A review of Resident #28's Care Plan did not indicate that Resident #28 was on oxygen. On 11/12/2024 at 2:11 PM, an oxygen tank was observed in Resident #28's room. Resident #28 indicated that he used oxygen 2 days ago. On 11/14/2024 at 3:23 PM, during an interview, the Long Term Care MDS Coordinator indicated that Resident #28 ' s oxygen was not on the care plan, and she did not know why it was not on there. On 11/14/2024 at 3:26 PM, the Skilled MDS Coordinator indicated that Resident #28 oxygen was not on the care plan, and she did not know why. On 11/15/2024 at 12:20 PM, the Administrator stated that the facility does not have a policy on care plans.

Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to send home health referrals prior to discharge for 1 (Resident #200) of 2 residents reviewed for discharge process. Findings include: On 11/14/2024 at 2:35 PM, the Administrator stated the facility did not have a policy for the discharge process but could ask the Nurse Consultant to find one. The Administrator stated they had not seen one, had no access to one, and did not use one in their discharge process. A review of an Admission Record, indicated the facility admitted Resident #200 with diagnoses that included right femur fracture, muscle weakness, abnormalities of gait and mobility, anxiety disorder, hypertension, and tachycardia. Review of a Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/12/2024, revealed Resident #200 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Discharge planning was noted as actively occurring and the resident wished to return to the community in less than three months, but referrals were not started. A review of Resident #200's Care Plan dated 07/12/2024, revealed the resident had an Activities of Daily Living (ADL) self-care performance with limited physical mobility, and was at high risk for falls. Interventions included assistance by one staff member to move between surfaces, physical therapy (PT), and occupational therapy (OT). A review of the Order Summary Report, revealed, an order dated 07/17/2027, to discharge home with PT, OT, nursing, and CNA. A review of Nursing Discharge Instructions, effective date 07/19/2024 revealed, Resident #200 had home health set up to provide physical therapy, occupational therapy, a certified nursing assistant (CNA), and nursing services. This was signed by the facility representative at discharge on 07/21/2024. During an interview on 11/13/2024 at 12:41 PM, Social Services Director (SSD) stated Resident #200's referral was either faxed one or two days prior to discharge. SSD stated, they did not keep any fax confirmations and could not prove when this referral was faxed. During an interview on 11/13/2024 at 2:22 PM a representative from the home health agency stated, faxed referrals for services were received from the facility on 07/23/2024 at 10:33 AM. A review of the home health agency fax confirmation receipt revealed a received date and time stamp of 07/23/2024 at 10:33AM on the fax coversheet and an order dated 07/17/2024 at 8:16 AM to discharge home with PT, OT, nursing, and CNA. On 11/14/2024 at 11:31 AM, Resident #200's family member stated the home health agencies did not start any services until 07/25/2024. The home health staff spoke with Resident #200 about her health status and the resident sought medical treatment at a local hospital on 07/26/2024. During an interview on 11/14/2024 at 2:35 PM, the Administrator stated when referrals were faxed, the SSD would get a fax confirmation and keep it. When informed Resident #200's home health agency had confirmation, the referral was faxed two days post discharge and the resident had a delay in care the Administrator stated, Well I guess that's that, it should not be done after discharge.

Based on observations, interviews, record review, facility document review, it was determined that the facility failed to ensure the resident was provided hand roll for contracture management for 1 (Resident #13) of 1 resident reviewed for providing contracture management. Findings include: No policy was provided for contracture management. A review of the Admission Record, indicated the facility admitted Resident #13 with diagnoses that included dementia, pain, muscle wasting and atrophy, and hemiplegia (partial or complete paralysis to one side of the body). Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2024, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident had severe cognitive impairment. Resident #13 was shown to have an impairment of the upper and lower extremity for functional limitation in range of motion. A review of Resident #13's Care Plan, initiated on 11/14/2024, revealed the resident had an alteration in musculoskeletal status related to contracture (left hand and arm). This care plan was initiated after speaking with the Long-Term Care Minimum Data Set (LTC MDS) Coordinator. The newly initiated care plan did not include the restorative program or the functional maintenance plan (FMP) in which Resident #13 had been participating in. There was no mention of a hand roll or device for preventing the worsening of the left-hand contracture. A review of an Activity of Daily Living Task revealed no task was being documented on A review of the closet care plan for Resident #13 revealed a special device, hand roll was needed in the left hand. During an observation on 11/12/2024 at 2:58 PM, Resident #13 was in activity, in the main dining room where staff were assisting residents with painting. Resident #13 was sitting at a table with the painting supplies and picture in front of the resident. Resident #13 had left hand lying in lap and was not moving the left hand or arm. During an observation and concurrent interview on 11/14/2024 at 2:05 PM, the LTC MDS coordinator stated that Resident #13 had a restorative program, and that the FMP had been extended and confirmed that after Resident #13 had been evaluated by therapy, no recommendations had been made for a splint or brace. LTC MDS Coordinator confirmed that Resident #13 had been receiving restorative three times a week. When asked how the staff would know what type of care to provide to Resident #13, it was confirmed the resident had a closet care plan. The LTC MDS coordinator removed the closet care plan for review, and it stated that Resident #13 needed a hand roll to the left hand. During an observation on 11/14/2024 at 2:10 PM, Resident #13 was sitting in bed with the head of the bed elevated up and the over-the-bed table was across the bed in front of the resident. The lunch tray was in front of Resident #13 without anything eaten off the tray. Resident #13 was asked if help was needed to eat and the response was given, yes. LTC MDS coordinator stated that someone would help with the tray. Resident #13 did not have any device in the left hand, which was beside the resident in the bed. During an interview with a Certified Nursing Assistant (C.N.A.) #8 on 11/14/2024 at 2:14 PM, confirmation was given that Resident #13's closet care plan stated a hand roll was needed for the left hand. When C.N.A.#8 was asked if Resident #13 ever used a hand roll in the left hand, the answer was given, No. During an interview on 11/15/2024 at 11:30 AM, the Director of Nursing (DON) confirmed there was no documentation concerning use of a hand roll for Resident #13 ' s left hand. The DON provided a newly initiated care plan with no mention of a hand roll, restorative program or the functional maintenance plan (FMP). When asked what guidance the LTC MDS coordinator used to develop and complete the MDS and care plan, the DON stated, I am not sure, and the LTC MDS coordinator only works part time and is not at the facility today.

Based on interviews and record review the facility failed to ensure 1 (Resident #42) of 5 sampled residents that were reviewed for unnecessary medication did not have an order to receive a PRN (as needed) medication past 14 days without justification, and an evaluation by the doctor. The findings are: Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/23/2024, revealed Resident #42 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Review of Resident #42's Care Plan initiated 7/19/2021, indicated to administer antidepressant medication as ordered by physician. Review of Resident #42's Order Summary Report with an order date of 11/11/2024, revealed anti-anxiety tablet 1 milligrams (mg) was ordered every 2 hours as needed for anxiety related to anxiety disorder for 45 Days. A rationale for the prn anti-anxiety medication was not in the clinical records. During an interview on 11/15/2024 at 8:22 AM, Physician Assistant indicated that the duration of as needed anti-anxiety medication was typically 15 days, unless evaluated for 30-60 days. Physician Assistant indicated she did not order the as needed anti-anxiety medication for Resident #42. She indicated that hospice ordered the medication, and she had to put the medication order in her name. During an interview on 11/15/2024 at 8:30 AM, Nurse Consultant indicated the facility does not have any information in the system on the rationale for the order of as needed anti- anxiety medication for Resident #42. On 11/15/2024 at 12:10 PM Director of Nurse indicated as needed anti-anxiety medication should be ordered for 14 days. She indicated if as needed anti-anxiety medication was ordered for more than 14 days a documented rationale should be in the clinical record. DON stated if the facility nurse received a verbal order from hospice the nurse should have recorded the reason for the medication. On 11/15/2024 at 12:20 PM, the Director of Nurse stated the facility does not have a policy for as needed medication.

Based on observations, interviews, and record reviews, it was determined that the facility failed to ensure a device to help keep food on a plate while eating was available for 1 (Resident #42) of 1 sampled resident who required adaptive equipment for meals. The findings are: A review of Resident #42's Order Summary Report indicated a diagnosis of unspecified lack of coordination, Parkinsonism, hemiplegia (partial or complete paralysis to one side of the body) and hemiparesis (muscle weakness or partial paralysis to one side of the body) of the cerebral dominant side (left side of the brain). Review of a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/23/2024, revealed Resident #42 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Resident #42 required partial/moderate assistant with bringing food and or liquid to the resident ' s mouth once the meal was placed in front of the resident. Review of Resident #42's Care Plan initiated 07/24/2024, indicated a plate guard should be used for all meals. Review of Resident #42 ' s tray card dated 11/12/2024, indicated that the resident should have a plate guard. On 11/12/2024 at 1:05 PM, Resident #42 was in room without staff eating lunch. Resident ' s tray card indicated that the resident was a total assist with meals. Resident #42 indicated they were supposed to have a section plate, but there was only one in the building. Resident #42 ' s food was on a regular plate. There was not a plate guard on the plate. On 11/14/24 at 9:29 AM, Resident #42 was in bed eating breakfast. The resident did not have a plate guard on the plate. Resident #42 was having trouble picking up the bread. During an interview on 11/14/24 at 9:43 AM, the Assistant Dietary Manager indicated Resident #42 did not have a plate guard on resident ' s plate but should have one. On 11/15/24 at 8:06 AM, Certified Nurse Assistant #12 was in the room assisting Resident #42 with breakfast. Resident #42 was eating with a built-up spoon and fork. Resident #42's meal was served on a divided plate. Certified Nurse Assistant #12 indicated that today was the first time she has seen Resident #42 using a divided plate. Certified Nurse Assistant #12 indicated that she has never seen Resident #42 with a plate guard. On 11/15/24 9:13 AM, the Rehabilitation Director indicated that she was informed by the Director of Nurse (DON) that Resident #42 was spilling food on self, and Resident #42 requested a section plate. The Rehabilitation Director indicated that she was not sure if Resident #42 was evaluated for spilling food on self. On 11/15/2024 at 12:03 PM, the Director of Nurse (DON) stated the facility did not have a policy on adaptive equipment.