Every finding on record at Inspiration Hills Rehabilitation Center

Based on observations, interviews and record reviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #41) reviewed for accident hazards and supervision.The facility failed to ensure Resident #41's floor mat was in place.This failure could place residents at risk for falls with the possibility of injury.Findings included:Record review of resident #41's face sheet, dated 06/02/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included unilateral primary osteoarthritis, right knee (a progressive condition characterized by cartilage degeneration, joint space narrowing and decreased function), Alzheimer's disease (a type of dementia that affects memory, thinking and behavior), unspecified fractures of the lumbar vertebra (lower back bones), shaft of left arm humerus (upper arm bone), and right femur (thigh bone).A record review of resident 41's quarterly MDS dated [DATE] revealed a BIMS of 5, indicating severe cognitive impairment.A record review of resident 41's comprehensive care plan dated 06/03/2026, revealed: resident #41 at risk for falls r/t difficulty walking, I fell on [DATE],11/8/22,06/13/23,8/18/23, 2/1/25, 4/24/26, including interventions: Anticipate and meet my needs, and May use fall mat while in bed. A record review of resident #41's order summary dated 06/04/2026 revealed: 1-2 floor mat(s) to be placed while in bed for safety, active, ordered 03/25/2026. Observations of resident #41 revealed there were no floor mats placed next to bed on 06/01/2026 at 10:30AM, 06/02/2026 at 11:00AM, 06/03/2026 at 9:15AM, and 06/04/2026 at 7:25AM while resident #41 was in bed. During an interview with CNA D on 06/03/2026 at 10:05am, CNA D stated she receives instruction from the charge nurse about individual fall interventions for residents such as fall mats. CNA D stated if a fall mat was not available for a resident, she would let the nurse know. CNA D stated she was not aware that resident #41had an order for a fall mat.During an interview with CNA E on 6/03/2026 at 10:10am, CNA E stated she was not aware of resident #41needing a fall mat. CNA E stated fall interventions are communicated to them by the nurse.During an interview with LVN B on 06/03/2026 at 4:05PM, LVN stated she was not aware that resident #41 was supposed to have a fall mat. LVN stated the resident #41 has not had a fall recently. LVN B stated she can refer to resident orders and care plans to see their fall interventions and communicate them to the CNA staff.During an interview with LVN A on 06/04/2026 at 11:05AM, LVN A stated that the interventions in place for resident #41 included a low bed and fall mat. LVN stated the charge nurses communicate to the CNAs when a fall mat is ordered. LVN stated he did not know why the fall mat was not in place for resident [NAME] on previous days. During an interview with DON on 06/04/2026 at 7:10AM, DON stated the fall interventions for resident #41 included a call light in reach, bed in low position, and she was unsure if there was an order for a fall mat, but if there was, a fall mat should be in place. During an interview with DON on 06/04/2026 at 10:45am, DON stated the importance of following care plan interventions to decrease risk of injury. DON stated the interventions such as fall mats are communicated to CNA staff by the charge nurses and the charge nurses follow the orders and the care plans.A record review of policy titles Fall and Fall Risk, Managing, dated 12/2022: 6. In conjunction with the Attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling.

Number of residents sampled: Number of residents cited: Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals) for 1 of 1 resident (Resident #32) to meet the needs of the resident, in that: The facility failed to discontinue Resident #32's order for Zyprexa 10mg when order was changed to 5mg daily resulting in resident #32 receiving the wrong dose x11 days.This failure could place residents at risk of injury by not receiving medications as ordered by the physician. The findings include:A record review of resident #32's face sheet revealed an admission date of 09/18/2020 with diagnosis of Psychotic Disorder (severe mental disorders that cause abnormal thinking and perceptions) with Hallucinations (false perceptions such as hearing, seeing, or feeling something that is not here) due to known physiological condition. A record review of resident #32's MDS dated [DATE] revealed resident is rarely/never understood indicating severely impaired cognition. A record review of resident #32's care plan dated 6/02/2026 revealed: I use psychotropic medication, interventions: Consult with pharmacy, MD to consider dosage reduction when clinically appropriate, Discuss with MD, family re ongoing need for use of medication, educate me/family/caregivers about risks, benefits and the side effects, Record/report to MD prn side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles,shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. A record review of resident #32's pharmacy recommendation which stated resident #32 has orders for Zyprexa 10mg in the evening for hallucinations. Please review and consider if a Gradual Dose Reduction could be considered for the order to Zyprexa 5mg in the evening, with written physician response Decrease Zyprexa to 5mg in the evening, and signed by physician, dated 5/22/2026. A record review of resident #32's Active Order Summary Report dated 06/02/2026 revealed: Zyprexa Oral tablet 5mg, Give 1 tablet by mouth in the evening, active, start date 5/22/2026, and Zyprexa tablet 10mg, Give 1 tablet by mouth in the evening for hallucinations, active, start date 10/16/2024. A record review of resident #32's MAR in the electronic medical record revealed Zyprexa 5mg and Zyprexa 10mg had been administered daily beginning 05/22/2026 until a clarification order was entered on 06/03/2026. During an interview with LVN A on 06/04/2026 at 1:15PM, LVN stated he received the order for a gradual dose reduction for resident #32's Zyprexa on 5/22/2026. The order was given by physician to decrease the dose from 10mg to 5mg in response to a pharmacy recommendation. LVN A stated he called resident #32's hospice provider to notify of the order change and was given approval to change the order. LVN A stated he entered the new order for Zyprexa 5mg and thought he discontinued the previous order for 10mg. LVN A stated he does not know why the order for Zyprexa10mg did not show as discontinued. LVN A stated he was not aware the order for Zyprexa 10mg still existed on the MAR and that the 10mg dose was still being given. LVN A stated that if he became aware of a medication error, he would notify the DON to take care of it. LVN A stated he has been educated on medication administration.A record review of resident #32's progress note dated 5/22/2026 at 11:13am documented by LVN A read: decreased Zyprexa per MD, hospice aware.During an interview with the DON on 06/03/2026 at 4:10PM, the DON stated that the charge nurse is responsible to enter new orders into the MAR. The DON acknowledged the gradual dose reduction order for resident #32 and stated she would get clarification about the medication dosage. During an interview with the DON on 06/03/2026 at 5:33PM, the DON stated she spoke to resident #32 hospice provider and the Zyprexa was to be increased to 15mg daily. The DON did not know the rationale for the order. During an interview with the DON on 06/04/2026 at 7:10AM, the DON provided a physician order from hospice to continue administering the dose of Zyprexa 15mg to resident #32, order dated 06/03/2026 at 5:38pm stating patient currently tolerating 15mg dose and should continue. Record review of policy titled Administering Oral Medications, dated 12/2025: Purpose: The purpose of the procedure is to provide guidelines for the safe administration of oral medications. 1. Verify that there is a physician's medication order for this procedure.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rates are not 5 percent (%) or greater. The facility had a medication error rate of 32% based on 8 out of 25 opportunities which involved two (2) of five (5) residents (Resident #2 and Resident #3), and one (1) of three (3) staff (MA A) observed for medication administration errors. 1. MA A administered medications to Resident #2 on 06/02/2026 at 10:30 a.m., 30 minutes after the scheduled administration window of 08:00 a.m. to 10:00 a.m. 2. MA A administered medications to Resident #3 on 06/02/2026 at 10:40 a.m., 40 minutes after the scheduled administration window of 08:00 a.m. to 10:00 a.m. These failures could place residents at risk of not receiving therapeutic effects from the medications and possibly experiencing adverse reactions. 1. Record review of Resident #2's admission Record, dated 06/02/2026, reflected an [AGE] year-old male, admitted [DATE]. Diagnoses included unspecified dementia(symptoms affecting memory, thinking and social abilities), hypertensive heart disease(chronic uncontrolled high blood pressure, which increases the workload on the heart), atherosclerosis of aorta(the accumulation of plaque-composed of fat, cholesterol, calcium, and other substances-within the inner walls of the aorta, the largest artery in the body) and embolism( Clot or embolic material travel through the bloodstream from another site and lodges in an artery) and thrombosis of arteries of extremities(when a blood clot forms locally inside an artery, blocking blood flow. Record review of Resident #2's Order Summary Report, printed 06/02/2026 with active orders for 06/02/2026, reflected the following order summaries: Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablets by mouth two times a day for pain management*give 2 tablets to equal 650mg* DO NOT EXCEED MORE THAN 3GM OF ACTEMINOPHEN FROM ALL SOURCES WITHIN 24HRS* Warfarin Sodium Oral Tablet 2mg (Warfarin Sodium) Give 1 tablet by mouth one time a day for DVT prevention Atenolol Oral Tablet 50MG (Atenolol) Give 1 tablet by mouth two times a day for HTN *hold if b/p <110/60 or HR <60* Enalapril Maleate Oral Tablet 10mg (Enalapril Maleate) Give 1 tablet by mouth one time a day for HTN *HOLD IF B/P <110/60 OR HR ,60* Record review of Resident #2's 06/01/2026 - 06/30/2026 Medication Administration Record, printed 06/02/2026, reflected the following orders with scheduled administration time ( Hours): Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablets by mouth two times a day for pain management*give 2 tablets to equal 650mg* DO NOT EXCEED MORE THAN 3GM OF ACTEMINOPHEN FROM ALL SOURCES WITHIN 24HRS* Administer at 9:00am and 6:00pm Warfarin Sodium Oral Tablet 2mg (Warfarin Sodium) Give 1 tablet by mouth one time a day for DVT prevention Administer at 9:00am Atenolol Oral Tablet 50MG (Atenolol) Give 1 tablet by mouth two times a day for HTN *hold if b/p <110/60 or HR <60* Administer at 9:00am and 6:00pm Enalapril Maleate Oral Tablet 10mg (Enalapril Maleate) Give 1 tablet by mouth one time a day for HTN *HOLD IF B/P <110/60 OR HR ,60* Administer at 9:00am During an observation of medication administration and interview on 06/02/2026 from 10:30 a.m. to 10:36 a.m., MA A was observed to start preparing Resident #2's medications for administration at 10:30 a.m. On MA A's electronic medication administration record screen, Resident #2's Tylenol, Atenolol, Enalapril and Warfarin were all observed to be highlighted red and scheduled for administration at 09:00 a.m. MA A was observed to administer Resident #2's medications at 10:36 a.m. MA A stated that Resident #2's medications were due at 9:00 a.m. She stated But I don't get here until 9. When asked how late administration could impact the resident she stated that it depends but generally there is no effect since the next dose will be given an hour later as well. 2. Record review of Resident #3's admission Record, dated 06/02/2026, reflected a [AGE] year-old female admitted to facility 4/16/2026. Diagnoses included hypertensive heart disease, major depressive disorder, anxiety and chronic joint pain Record review of Resident #3's Order Summary Report, dated 06/02/2026 with active orders as of 06/02/2026, reflected the following order summaries: - Norvasc Oral Tablet 5 MG (Amlodipine Besylate) Give 1 tablet by mouth one time a day for HTN. - Cymbalta Oral Capsule Delayed Release Sprinkle 20mg (Duloxetine HCL ) Give 1 capsule by mouth one time a day for anxiety.- Gabapentin 300mg Oral Capsule Give 1 capsule by mouth three times a day for nerve pain.- Gemtesa Oral Tablet 75mg. Give 1 tablet by mouth one time a day related to overactive bladder. Record review of Resident #3's 06/01/2026 - 06/30/2026 Medication Administration Record, printed 06/02/2026, reflected the following orders with scheduled administration time ( Hours): - Norvasc Oral Tablet 5 MG (Amlodipine Besylate) Give 1 tablet by mouth one time a day for HTN. Administer at 9:00 a.m.- Cymbalta Oral Capsule Delayed Release Sprinkle 20mg (Duloxetine HCL ) Give 1 capsule by mouth one time a day for anxiety. Administer at 9:00 a.m.- Gabapentin 300mg Oral Capsule Give 1 capsule by mouth three times a day for nerve pain. Administer at 9:00 a.m., 1:00 p.m., 5:00 p.m.- Gemtesa Oral Tablet 75mg. Give 1 tablet by mouth one time a day related to overactive bladder. Administer at 9:00 a.m. During an observation of medication administration on 06/02/2026 from 10:36 a.m. to 10:40 a.m., MA A was observed to start preparing Resident #3's medication administration at 10:36 a.m. On MA A's electronic medication administration record screen, Resident #3's Amlodipine, Duloxetine, Gabapentin and Gemtesa were observed to be highlighted red and scheduled for administration at 09:00 a.m. MA A was observed to administer Resident #3's medications at 10:40 a.m. During an interview on 06/04/2026 at 2:30 p.m., LVN C stated that she was trained about medication administration policies in her new hire training. She stated that 9am medications can be given from 8am to 10am but if the medication is a scheduled narcotic it cannot be given earlier than the time stated in the order. If a medication is given late, she would need to contact the MD and get a one time order to administer the medication at the later time. She would also be required to notify the DON as well as the family/RP. During an interview on 06/04/2026 at 3:07 p.m., LVN B stated that she had received training regarding medication administration, but it's been awhile. She said that she was instructed about the 5 rights and the need to double check orders. In regard to medication administration times, she stated that the staff is to administer medications no earlier than one hour before or one hour after the ordered/scheduled time. If medications are late, she is supposed to notify the DON, ADON, MD and family. The purpose of giving medications at the correct time is to prevent complications, as some medications are fast acting. During a joint interview on 6/4/2026 with facility DON and ADON, DON stated that education is provided to staff regarding medication administration times. Per DON, medications can be given one hour before or one hour after the scheduled time. If administration time is outside of that, they need to let the provider know why and get clarification on the orders. If medications are given late and more than one dose is ordered for the day, the resident could be either overdosed or underdosed. If a staff member is giving medications outside of the administration times, they should notify DON or ADON, the MD and family. DON stated that there are 3 or 4 staff members available to assist, so staff should ask for help if there is a risk of passing medications outside of the acceptable times. Record review of facility's policy titled, Administering Oral Medications, dated December 2025, revealed no specific policy regarding medication administration times. Requested the Administering Medications policy referenced within this policy and the Facility Administrator stated that they do not have this policy.

Based on observation, interview and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food storage, preparation, and distribution. The facility failed to ensure food in refrigerators and freezers were labeled or dated and canned foods were not dented and damaged. This failure could place residents at risk for health complications, foodborne illnesses, and decreased quality of life.The findings included:During an observation and interview on 06/01/2026 at 9:10 a.m., the initial kitchen tour revealed food items in the commercial refrigerator and freezers were uncovered, unlabeled, and undated and canned foods were dented and damaged. The 102-ounce canned mangos and canned pineapples contained deep dents, deep enough to lay a finger in, the commercial freezer contained a pot roast partially unwrapped, unlabeled, and undated with freezer burn. The Dietary Manager stated she was not sure why canned foods were not labeled with date the supplier delivered them. She stated she was new in this role, for four weeks, and she had been educating dietary staff to understand the importance of labelling foods. She stated she did not know why dented cans of fruit were on the rack and she was observed removing them during the initial tour. She stated that the dented cans should have been removed from the rack and put in the trash. She stated she does not return the cans dented to the supplier as there was a long delay and process to have food replaced and she opted to throw it out completely. She stated the dietary staff were trained in labelling foods when delivered by the supplier and she planned to continue educating them.During an interview on 06/03/2026 at 11:44 a.m., the Dietary Aide stated that labeling food helped with food safety and stated dietary staff may have missed some food items.During an interview on 06/03/2026 at 10:43 a.m. requested policies for Kitchen and Food/Nutrition from the Administrator. The Administrator stated there were no specific policies for the kitchen.

Based on record review and interview, the facility failed to provide the resident or resident representative with access to personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual, if it is readily producible in such form and format (including in an electronic form or format when such records are maintained electronically), or, if not, in a readable hard copy form or such other form and format as agreed to by the facility and the individual, within 24 hours (excluding weekends and holidays) for 1 of 8 residents (Resident #30) reviewed for record access.The facility failed to ensure Resident #30, and her RP, were provided with requested medical records. This failure could place residents at risk of not obtaining medical services needed to maintain their health.The findings included: Record review of Resident #30's admission Record, dated 06/03/2026, revealed an [AGE] year-old female admitted [DATE] and re-admitted [DATE]. Resident #30 was not listed as her own RP. Record review of Resident #30's Medical Diagnoses, undated and accessed 06/03/2026 at 6:22 p.m., revealed diagnoses including type 2 diabetes (chronic condition characterized by insulin resistance and high blood sugar levels), anxiety disorder (mental health condition characterized by excessive uncontrollable worry about everyday issues, affecting daily functioning and quality of life), adult failure to thrive (condition that affects appetite, weight, and activity), and vascular dementia (decreased blood flow to areas of your brain). Record review of Resident #30's quarterly MDS assessment, dated 05/08/2026 and signed 05/10/2026 as completed, reflected a BIMS score of 04 indicting severe cognitive impairment. Resident #30 was documented as not having exhibited any behavioral symptoms. Resident #30's functional abilities were documented as requiring dependent assistance to requiring supervision or touching assistance.Record review of Resident #30's Medical Power of Attorney, dated 01/03/2020, revealed a hospital MPOA signed by Resident #30 authorizing RP as her representative to make all and every health care decision on Resident #30's behalf.During an observation of Resident #30 on 06/02/2026 at 12:30 p.m., she was noted to be lying in bed. Attempted interview with Resident #30 revealed she was not interviewable as she responded to questions inappropriately.During an interview on 06/02/2026 at 12:30 p.m., RP stated she spoke to Medical Records, Social Worker, Director of Nursing, and the Administrator regarding access to Resident #30's medical records and they informed her that she was not her legal representative and the MPOA, or POA, she had on file for Resident #30 was not valid and she would not have access to medical records. During a telephone interview on 06/03/2026 at 9:50 a.m., the Ombudsman stated the facility was questioning Resident #30's signed POA. She stated the facility did not believe it was valid thereby denying Resident #30's RP's request for medical records.During an interview on 06/04/2026 at 4:13 p.m., the DON stated that Resident #30's RP was recently denied medical records because there were some questions regarding the validity of POA and MPOA in Resident #30's medical chart. She stated she did not know the details for the denial of request. She stated the facility found an MPOA in Resident #30's hardcopy medical chart located in storage. She stated the legal team was reviewing the MPOA for validity, but they had been out of the office for a few weeks, and she did not have a follow-up. During an interview on 06/04/2026 at 5:39 p.m., the Administrator revealed that she was aware of Resident #30's RP's concerns with the delayed request for medical records. She stated there were delays into Resident #30's RP's request for medical records due to MPOA not being valid. She stated she did not know the full details, and it would be best to address Medical Records. Record review of a facility policy titled, Resident admission Agreement, dated March 2021, revealed .If a family member or friend is your legal guardian, he or she has the right to look at all medical records about you and make important decisions on your behalf. You have the following rights regarding your medical care: To access all your records and reports, including clinical records (medical records and reports) promptly (on weekdays). Your legal guardian has the right to look at all your medical records and make important decisions on your behalf.Record review of a facility policy titled, Release of Information dated December 2023, revealed . 9. A resident may have access to his or her records within 24 hours (excluding weekends or holidays) of the resident's written or oral request. 10. A resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight (48) hour (excluding weekends and holidays) advance notice of such request. A fee may be charged for copying services. The facility may recommend that the resident or representative review the active chart in the presence of a knowledgeable staff person who can discuss the information and answer questions capably.

Based on interview and record review, the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which had not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay for 1 of 8 residents (Resident #30) reviewed for grievances. The facility failed to generate a grievance report for Resident #30's RP's grievance made on 05/14/2026 when Resident #30's RP complained that she continues to be denied access to Resident #30's medical records. The facility failed to generate a grievance report for the Ombudsman's grievance made on 05/14/2026 when the Ombudsman noted her concerns regarding the RP's denials to access Resident #30's medical records.The facility failed to generate a grievance report for Resident #30's RP's grievance made on 05/19/2026 when the RP complained that Resident #30 was injured by the facility staff. These failures could place residents at risk for demoralized spirits and low self-esteem.The findings included:Record review of Resident #30's admission Record, dated 06/03/2026, revealed an [AGE] year-old female admitted [DATE] and re-admitted [DATE]. Resident #30 was not listed as her own RP. Record review of Resident #30's Medical Diagnoses, undated and accessed 06/03/2026 at 6:22 p.m., revealed diagnoses including type 2 diabetes (chronic condition characterized by insulin resistance and high blood sugar levels), anxiety disorder (mental health condition characterized by excessive uncontrollable worry about everyday issues, affecting daily functioning and quality of life), adult failure to thrive (condition that affects appetite, weight, and activity), and vascular dementia (decreased blood flow to areas of your brain).Record review of Resident #30's quarterly MDS assessment, dated 05/08/2026 and signed 05/10/2026 as completed, reflected a BIMS score of 04 indicting severe cognitive impairment. Resident #30 was documented as not having exhibited any behavioral symptoms. Resident #30's functional abilities were documented as requiring dependent assistance to requiring supervision or touching assistance.During an observation of Resident #30 on 06/02/2026 at 12:30 p.m., she was noted to be lying in bed. Attempted interview with Resident #30 revealed she was not interviewable as she responded to questions inappropriately.During an interview on 06/02/2026 at 12:30 p.m., RP stated she had requested access to Resident #30's medical records for two years in a row and she had been denied both times. She stated she voiced her concerns and frustrations with Medical Records, Social Worker, Director of Nursing, and the Administrator and each time there was no resolve, just more delays.During a telephone interview on 06/03/2026 at 9:50 a.m., the Ombudsman stated she had a family member with recent concerns regarding medical records release. She stated this case was very strange and an ongoing thing. She stated the RP requested records on behalf of Resident #30 as her RP. She stated the facility noted Resident #30 had severely impaired cognition. She stated the facility was challenging the validity of family's POA and MPOA on file. The Ombudsman stated that she did not understand what the big deal was about requesting Resident 30's medical records. She stated that she asked the facility what was going to happen to Resident #30 if something occurred that required someone to make medical decisions on her behalf. She stated she was concerned about Resident #30's care and she addressed these concerns with the facility. She stated she believed the facility was fearful the RP was trying to gather evidence against them. She stated the RP continued to call her about the facility's denial of medical records. She stated she had never encountered these actions from a facility before. She stated the family member was very agitated and rightfully so. She stated she would like these concerns reviewed.During an interview on 06/04/2026 at 3:02 p.m., CNA A stated if a resident had a grievance or complaint they were directed to the Social Worker for assistance.During an interview on 06/04/2026 at 4:13 p.m., the DON stated that Resident #30's RP did bring up concerns during the 05/14/2026 care plan meeting, but she did not recall all the details. She stated that she believed all was taken care of during the care plan meeting and there was no need to file grievance. She stated she was not sure what the outcome of said concerns were. She stated that Resident #30's RP contacted law enforcement as she alleged Resident #30 was injured by the facility staff. She stated that during incontinent care Resident #30 became combative with direct care staff and she scratched her right ring finger causing it to bleed. She stated that no grievance or self-report was made about the incident and law enforcement unsubstantiated the allegations as it was not a concern During an interview on 06/04/2026 at 5:03 p.m., the Social Worker revealed that she was present for the care plan meeting on 05/14/2026. She stated Resident #30's RP was hard to work with. She stated she wanted medical records. She stated the RP received another denial letter about her request for Resident #30's medical records. She stated she directed Resident #30's RP her to Medical Records staff to submit another request or to request information into the denial reason. The Social Worker stated that Resident #30's RP informed her that she never received the first denial letter. She stated she did not know the outcome of Resident #30's RP's concerns regarding delayed medical records request. She stated this concern was not a grievance and Resident #30's RP never said it was a complaint and because she helped the RP fill out the records request form that this was considered a quick resolution, and no further action was required. She stated she understood that the facility's legal team was involved with the request, but they have been away from the office for the last two weeks. She stated she did not have further information and as it was not a grievance she did not track if resolved.During an interview on 06/04/2026 at 5:39 p.m., the Administrator revealed that she was aware of Resident #30's RP's concerns with the delayed request into medical records. She stated she was aware of Resident #30's RP's first and second requests made for medical records and due to an invalid address and she believed was an invalid POA in Resident #30's chart the RP was denied access to Resident #30's medical records. She stated she was not sure of the turnaround time for medical records request but believed it could be up to two weeks at most. She stated it was only recently that the team found an old POA listing Resident #30's RP as her representative to make all and every health care decision on Resident #30's behalf s that was submitted during Resident #30's admission. She stated the hardcopy POA was in storage. Record review of a facility policy titled, Resident admission Agreement, dated March 2021, revealed .Rights of the Elderly. (f) An elderly individual may complain about the individual's care or treatment. The complaint may be made anonymously or communicated by a person designated by the elderly individual. The person providing service shall promptly respond to resolve the complaint. Record review of a facility policy titled, Resident Rights, dated December 2016, revealed, . Employees shall treat all residents with kindness, respect, and dignity. These rights include the resident's right to: . u. voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal. v. have the facility respond to his or her grievances.

Based on record review and interview, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 8 Residents (Resident #30) reviewed for reporting. The facility Administrator failed to report allegations of abuse and neglect following the incident on 05/19/2026 that resulted in a deep gash to Resident #30's hand and law enforcement being dispatched to the facility. This failure could place residents at risk of harm by not having alleged violations of abuse and neglect investigated.The findings included: Record review of Resident #30's admission Record, dated 06/03/2026, revealed an [AGE] year-old female admitted [DATE] and re-admitted [DATE]. Resident #30 was not listed as her own RP.Record review of Resident #30's Medical Diagnoses, undated and accessed 06/03/2026 at 6:22 p.m., revealed diagnoses including type 2 diabetes (chronic condition characterized by insulin resistance and high blood sugar levels), anxiety disorder (mental health condition characterized by excessive uncontrollable worry about everyday issues, affecting daily functioning and quality of life), adult failure to thrive (condition that affects appetite, weight, and activity), and vascular dementia (decreased blood flow to areas of your brain).Record review of Resident #30's quarterly MDS assessment, dated 05/08/2026 and signed 05/10/2026 as completed, reflected a BIMS score of 04 indicting severe cognitive impairment. Resident #30 was documented as not having exhibited any behavioral symptoms. Resident #30's functional abilities were documented as requiring dependent assistance to requiring supervision or touching assistance.During an observation of Resident #30 on 06/02/2026 at 12:30 p.m., she was noted to be lying in bed. Attempted interview with Resident #30 revealed she was not interviewable as she responded to questions inappropriately.Record review of Resident #30's EMR Misc. tab on 06/04/2026, did not reveal documentation of State Agency report of allegations of abuse made by RP on 05/19/2026.During an observation and interview of Resident #30 on 06/02/2026 at 12:30 p.m., she was noted to be lying in bed. Attempted interview with Resident #30 revealed she was not interviewable as she responded to questions inappropriately. She was noted to have a bandage on her right ring finger and bruising on her arms and hands that were healing.During an interview on 06/02/2026 at 12:30 p.m., Resident #30's RP stated that roughly three weeks back Resident #30 had an incident where she injured her finger and sustained a deep gash to her right ring finger and bruising on her hands and arms. She stated that she reported this injury to the Director of Nursing and Social Worker and was told that Resident #30 had become aggressive with CNA J and was pulling his hair during incontinent care. She stated that Resident #30 did not recall the incident. She stated the Social Worker and the Director of Nursing told her they would look into the incident and would let her know what occurred. She stated she had not received a follow-up since her request.During an interview on 06/03/2026 at 9:45 a.m., CNA F stated she received education on abuse and neglect, and the abuse coordinator was the Administrator.During an interview on 06/03/2026 at 9:45 a.m., CNA G stated she received education on abuse and neglect, and the abuse coordinator was the Administrator.During an interview on 06/03/2026 at 11:45 a.m., LVN C stated she received training on abuse, neglect, and falls/accidents.During an interview on 06/03/2026 at 4:05 p.m., LVN B stated she referred to residents' physician's orders and care plans to see their fall interventions. LVN B stated she received education on abuse and neglect.During an interview on 06/03/2026 at 4:30 p.m., CNA H stated he was trained on abuse and neglect.During an interview on 06/03/2026 at 4:35 p.m., CNA I stated she was trained on abuse and neglect.During an observation and interview on 06/04/2026 at 2:30 p.m., the Wound Care Nurse stated she received abuse, neglect, and exploitation training frequently, the Administrator was the Abuse Coordinator, and she was required to report witnessed or suspected ANE immediately. She was knowledgeable about ANE and provided examples. She stated she was made aware of an incident on 05/19/2026 involving Resident #30. The Wound Care Nurse was observed to review Resident #30's electronic medical record to identify the incident reported on 05/19/2026. She stated Resident #30's electronic medical record documented the 05/19/2026 incident of abuse allegations. She stated that on 5/19/2026 at 9:45 p.m., LVN F entered Resident #30's room. She stated Resident #30 was yelling and being combative with CNA M when he was providing her with incontinent care. LVN F observed blood on Resident #30's fingers, he offered to help her and cleaned it up and put on a band aid. LVN F notified the provider, Wound Care Nurse, and the RP following the incident. She stated the RP arrived shortly after the notification and became upset and accused staff of abusing Resident #30 and she immediately called law enforcement. The Wound Care Nurse stated law enforcement arrived at the facility along with the Director of Nursing and Administrator. She stated that law enforcement conducted their investigation and did not find any concerns of abuse. She stated she was not aware of the bruising on Resident #30's hands and arms, but it was likely she sustained them during the physical aggression incident.During an interview on 06/04/2026 at 3:02 p.m., CNA A stated he had received education on abuse, neglect, and resident rights. He stated the abuse coordinator was the Administrator, and he would report all allegations of abuse and neglect to her. He was knowledgeable about ANE and resident rights and provided examples. He stated the impact to a resident if abused, neglected, or rights violated, could be huge and could affect the residents mentally and they could start to detach. He stated he was not present for the incident on 05/19/2026 involving Resident #30, but he was provided with information as he helped to care for her. He stated Resident #30 tends to become angry and agitated during incontinent care, and she would become physically aggressive. During an interview on 06/04/2026 at 4:13 p.m. the Director of Nursing revealed that Resident #30 was wheelchair bound, on psych meds, can become combative, had dementia, verbal and physical aggression tendencies and on 05/19/2026 she had an incident. She stated the incident resulted in a skin tear to her finger. She stated that during incontinent care Resident #30 became combative and began pulling the aide's hair. She stated she scratched herself with her nails and caused the skin to tear and bruises on her hands and arms. She stated the charge nurse notified the provider, the RP, and nursing management. She stated the RP was contacted to help with calming down Resident #30. She stated instead the RP alleged the facility staff caused the injuries. The RP alleged the facility was abusing Resident #30 and called law enforcement. She stated that she and the Administrator were notified of the incident as law enforcement was present at the facility. The Director of Nursing stated law enforcement investigated the matter and informed the facility and the RP that the allegations of abuse was not substantiated. She stated that the incident was not reported to the State Agency as it was investigated by law enforcement. She stated any further investigation or report to the State Agency would be the responsibility of the Abuse Coordinator, the Administrator.During an interview on 06/04/2026 at 5:03 p.m., the Social Worker revealed that she provided ANE and resident rights education to the staff. She was knowledgeable of ANE and resident rights and provided examples. She stated the Administrator was the Abuse Coordinator and staff were expected to report ANE immediately. She stated she was aware of the incident on 05/19/2026 that caused a wound to Resident #30's skin. She stated that she was not present but was made aware of it on her following shift. She stated that the Administrator was responsible for conducting abuse and neglect allegations and she was unsure if this incident was reported.During an interview on 06/04/2026 at 5:39 p.m., the Administrator revealed that she and the Social Worker provided ANE and resident rights education to facility staff. She stated that she was the Abuse Coordinator and the expectation was for staff to report ANE immediately. She stated allegations of ANE needed to be reported to the State Agency within 2 hours after being reported to her. She stated she would observe the situation, find out what occurred, and make the decision about what to call into the State Agency. She would then complete the provider investigation report. She stated not following this process could be detrimental to a resident and set the tone to staff that they could do anything they wanted to a resident. She stated it started with her; she was responsible for these residents as well as the staff. She stated she was notified by the Director of Nursing about the incident on 05/19/2026 involving Resident #30. She stated during her provider investigation she found that on 5/19/2026 Resident #30 was aggravated, upset, angry and scratched herself while combative with incontinent care. She stated the RP was notified and she arrived at the facility and she called the police as she felt staff caused Resident #30's injury to her ring finger. She stated Resident #30's RP alleged that Facility #1's staff abused Resident #30. She stated the police arrived and investigated the incident and found the allegations unsubstantiated and no further action was taken. She stated that law enforcement's investigation was sufficient to unsubstantiate the allegations made by Resident #30's RP and she did not believe the incident was reportable. She stated she did not investigate the incident further.Record review of a facility policy titled, Abuse Investigation and Reporting dated March 2017, revealed .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. 1. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 3. The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation. 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility.Record review of a facility policy titled, Resident admission Agreement dated March 2021, revealed .Rights of the Elderly. (2) has the right to be free from abuse, neglect, and exploitation. c. An elderly individual has the right to be free from physical and mental abuse.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet the resident's psychosocial needs for 3 of 8 residents (Residents #26, Resident #27, and Resident #34) reviewed for comprehensive care planning. The facility failed to ensure residents' preferences for activities and leisure were addressed in the comprehensive care plans for Resident #26 and Resident #34.The facility failed to ensure residents' preferences for device to treat a medical symptom was no longer necessary and was addressed in the comprehensive care plan for Resident #27. This failure could place residents at risk for decreased quality of life. The findings included: 1. Record review of Resident #26's admission Record, 06/04/2026, revealed a [AGE] year-old female admitted [DATE]. Resident #26 was listed as her own RP with her [family member] listed as Emergency Contact #1.Record review of Resident #26's Medical Diagnoses, undated and accessed 06/04/2026 at 12:45 p.m., revealed diagnoses including coronary artery disease (CAD) (narrowing of coronary arteries), hypertension (condition of high pressure in the vessels that carry blood from the heart to the rest of the body), Renal Failure, or End-Stage Renal Disease (ESRD) (gradual loss of kidney function), Diabetes Mellitus (DM) (characterized by impaired ability of the body to produce or respond to insulin), Cerebrovascular Accident (CVA) (commonly known as a stroke), and Depression (mood disorder characterized by persistent feelings of sadness, loss of interest, and a range of emotional physical problems. Record review of Resident #26's quarterly MDS assessment, dated 03/14/2026 and signed 03/28/2026 as completed, reflected a BIMS score of 13, indicating cognition intact. Resident #26 was documented as having pain occasionally and receiving pain management care. Resident #26's functional abilities were documented as requiring dependent to setup or clean-up assistance and requiring manual wheelchair for ambulating.Record review of Resident #26's care plan, undated and accessed 04/06/2026 at 12:47 p.m., revealed Resident #26's focus I will attend activities of my choice date initiated and last revised on 05/05/2026 and goal I will maintain involvement in cognitive stimulation, social activities as desired through review date dated initiated 07/03/2025 and last revised on 04/22/2026 and interventions I need assistance/escort activity function.Invite me to scheduled activities. Provide a program of activities that is of interest and empowers the resident byencouraging/allowing choice, self-expression and responsibility initiated and last revised on 08/15/2025; however, additional comments not provided and independent bedbound room activities not noted as an intervention.Record review of Resident #26's Activity Progress Note dated 05/05/2026, revealed . [Resident #26] participates in activities of choice weekly. Bingo, Loteria, salon visits, socials, Resident council meetings, music, parties, family visits, TV, phone (social media) and others of choice. AD [Activity Director] provides visits and activities calendar. Resident currently prefers activities in room, such as cell phone, social media, visits with family on phone, games, texting, and reading daily chronicle. AD [Activity Directory] will cont. [continue]to encourage to OOR [out of room] activities.Record review of Resident #26's Pressure Ulcer Risk Evaluation dated 05/01/2026, revealed .Activity: Bedfast. Resident [Resident #26] is Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.Record review of Resident #26's Social Service Assessment, dated 04/07/2026, revealed . Resident is alert and oriented x3 and she requires assistance with some ADLs that includes transfers. Resident has been in bed more and is now needing assistance due to incontinency. She will sit in a wheelchair but prefers to stay in bed. Resident eats independently with meal set up in her room per her choice. She is on psych services due to DX [history] of Depression, Anxiety, and Mood disorder. She does her own independent activities and also attends large group activities.Record review of Resident #26's Nurse's Note dated 03/03/2026, revealed .Resident [Resident #26] complains of bilateral knee pain limiting her ability to stand. Resident also voices difficulty self propelling her wheel chair due to decreased strength to bilateral upper extremities.During an observation and interview of Resident #26 on 06/01/2026 at 11:18 a.m. she was noted to be lying down in bed watching television. She stated that due to pain in her lower extremities it is difficult to walk and she is unable to participate in group activities. She stated that when she was ambiguating on her own, she would participate in numerous group activities offered by Facility #1. She stated now that she is bedbound, she cannot participate in group activities, she stated she did not believe the staff provided in-room activities as they are constantly busy and seem to be in a hurry. She stated she would enjoy in-room activities if it were offered to her. 2. Record review of Resident #27's admission Record, dated 06/03/2026, revealed a [AGE] year-old male admitted [DATE]. Resident #27 was not listed as his own RP with her [family member] listed as Emergency Contact #1.Record review of Resident #27's Medical Diagnoses, undated and accessed 06/03/2026 at 2:32 p.m., revealed diagnoses including coronary artery disease (CAD) (narrowing of coronary arteries), hypertension (condition of high pressure in the vessels that carry blood from the heart to the rest of the body), Diabetes Mellitus (DM) (characterized by impaired ability of the body to produce or respond to insulin), non-Alzheimer's dementia (the loss of memory and other intellectual functions severe enough to cause problems in one's abilities to perform their usual personal, social, or occupational activities), and depression (mood disorder characterized by persistent feelings of sadness, loss of interest, and a range of emotional physical problems). Record review of Resident #27's quarterly MDS, 05/07/2026 and signed 05/21/2026 as completed, reflected a BIMS score of 14, indicating cognition intact. Resident #27's functional abilities were documented as requiring supervision or touching assistance to set up or clean-up assistance.Record review of Resident #27's care plan, undated and accessed 06/03/2026 at 2:45 p.m., revealed Resident #27's focus .Risk for Wandering/Elopement Identified Wander guard in place. date initiated 01/13/2026 and last revised on 04/12/2026 and goal .The resident will not leave facility unattended.The Resident's safety will be maintained. date initiated 01/13/2026 and last revised during survey, 06/02/2026. Did not reveal mention of Resident's ability to sign himself out of the facility and leave into the community unattended. Did not reveal updates to the alarm (wanderguard) being used to sound alarms when Resident #27 gets near an exit door, but that it would be turned off during the day.Record review of Resident #27's Interdisciplinary Team Care Conference dated 05/28/2026, revealed . Resident [Resident #27] is oriented and alert x2-3 [oriented to person and place, and time] w [with]/some forgetfulness. He requires limited assistance with ADLs and is now using a walker. He also is a big part of resident life and he also signs himself out to visit his girlfriends who lives in the community from time to time. and did not reveal mention of Resident #27's elopement risk level was reduced and that he returned to the facility daily.During an observation and interview with Resident #27 on 06/02/2026 at 11:00 a.m. he was noted to be sitting upright in his bed. He was agitated and upset. He stated that he and 15 other residents are the chosen ones that are required to wear the WanderGuard alarm bracelet. He stated that he does not want to wear the WanderGuard and he compared it to an ankle bracelet worn by prisoners or individuals on parole. He stated due to an incident a few months back he was informed by the Administrator that he would need to wear the WanderGuard if he wanted to remain a resident at Facility #1. He stated he is allowed to leave on his own and signs out of Facility #1 daily. He stated he goes into the community and takes a bus all over town, but he cannot remove the WanderGuard. He stated that he feared his medical care would end if he did not wear WanderGuard. 3. Record review of Resident #34's admission Record, dated 06/04/2026, revealed a [AGE] year-old male admitted [DATE] and re-admitted [DATE]. Resident #34 was not listed as his own RP with his (family member) listed as his Emergency Contact #1.Record review of Resident #34's Medical Diagnoses, undated and 06/04/2026 at 12:09 p.m., revealed diagnoses including hypertension (condition where the force of blood against the artery walls is consistently too high), peripheral vascular disease (condition characterized by narrowed arteries that reduce blood flow to the limbs), renal insufficiency (renal failure), neurogenic bladder (condition that affects bladder function due to nervous system problems, diabetes mellitus (condition that occurs when the body cannot properly use blood sugar) cerebrovascular accident (sudden interruption of blood flow to the brain, which can lead to brain damage), hemiplegia (paralysis or severe weakness affecting one side of the body, and anxiety disorder (frequently have intense, excessive and persistent worry and fear about everyday situations.Record review of Resident #34's quarterly MDS, dated [DATE] and signed 05/22/2026 as completed, reflected a BIMS score of 07, indicating severe cognitive impairment. Resident #34's functional abilities were documented as requiring dependent to substantial/maximal assistance and requiring manual wheelchair for ambulating.Record review of Resident #34's care plan, undated and accessed 06/04/2026 at 12:34 p.m., revealed Resident #34's focus Resident [Resident #34] attends activities of choice date initiated and last revised on 05/01/2026 and goal Resident will participate in activities of choice through the next review date date initiated 02/02/2026 and last revised on 06/02/226 with interventions Encourage resident to participate in activities.Invite resident to group activities. however, additional comments not provided and psychiatric treatment recommendations not noted as an intervention.Record review of Resident #34's psychiatric services dated 05/23/2026, revealed .Treatment Recommendations: Participation in an exercise program, if approved by the treating physician, and physical therapy may support mood, stress management, and muscle strength. Patient needs intervention related to current medical conditions. Patient should continue social functions including spending time with friends and family, which may help prevent further cognitive decline. Continue to engage in cognitively stimulating activities, including reading the newspaper. Patient may benefit from listening to audiobooks and/or using online brain exercise programs. During an observation and interview of Resident #34 on 06/01/2026 at 9:28 a.m. he was noted to be lying in bed. Attempted interview with Resident #34 revealed he had difficulties with speech and could not be understood. He was noted to have his right hand in a splint, foley in privacy bag hung at bedside. When asked resident was able to locate call light clipped to bedding. During an interview on 06/04/2026 at 1:24 p.m. the MDS Coordinator stated that care plans required the Interdisciplinary Team to come together and this usually consisted of the Social Worker, Assistant Director of Nursing, Director of Nursing, Therapy Manager, Activity Director, and Dietary Manager and each would make changes pertaining to their department. She stated she was unsure of the last time she received training on care plans. She stated care plans gave a picture of the specific care that a resident needs. She stated a care plan gave specific care instructions for staff to follow, such as a guide. She stated if the care plan was not updated and depending on what area of the care plan it could range from less serious to possibly something more serious. The MDS Coordinator stated that immediately following the IDT meeting the care plan should be updated to avoid any delays in care.During an interview on 06/04/2026 at 3:02 p.m., CNA A stated he reviewed the resident care plans for specific care to provide a resident in his hall. He stated if the care plans not updated there could be a delay in care.Record review of a facility policy titled, Comprehensive Assessments and the Care Delivery Process, dated December 2025, revealed . Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. (1) Gather relevant information from multiple sources, including: (f) consultant reports. a. Selecting and Implementing interventions, based on the results. a. Periodically reviewing progress and adjusting treatments. (1) Continue to define or refine objectives of specific treatments as well as overall care and services.Record review of a facility policy titled, Care Planning - Interdisciplinary Team dated September 2013, revealed . Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.

Based on observation, interview and record review, the facility failed to ensure residents received an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 of 8 residents (Residents #26 and Resident #34) reviewed for activities. The facility failed to ensure Resident #26 and Resident #34 were provided individual and independent activities to meet the residents' psychosocial needs and preferences during February 2026 - June 2026. This failure could result in decreased psychosocial well-being or decreased quality of life. The findings included: 1. Record review of Resident #26's admission Record, 06/04/2026, revealed a [AGE] year-old female admitted [DATE]. Resident #26 was listed as her own RP with her [family member] listed as Emergency Contact #1.Record review of Resident #26's Medical Diagnoses, undated and accessed 06/04/2026 at 12:45 p.m., revealed diagnoses including coronary artery disease (CAD) (narrowing of coronary arteries), hypertension (condition of high pressure in the vessels that carry blood from the heart to the rest of the body), Renal Failure, or End-Stage Renal Disease (ESRD) (gradual loss of kidney function), Diabetes Mellitus (DM) (characterized by impaired ability of the body to produce or respond to insulin), Cerebrovascular Accident (CVA) (commonly known as a stroke), and Depression (mood disorder characterized by persistent feelings of sadness, loss of interest, and a range of emotional physical problems. Record review of Resident #26's quarterly MDS, dated [DATE] and signed 03/28/2026 as completed, reflected a BIMS score of 13, indicating cognition intact. Resident #26 was documented as having pain occasionally and receiving pain management care. Resident #26's functional abilities were documented as requiring dependent to setup or clean-up assistance and requiring manual wheelchair for ambulating.Record review of Resident #26's care plan, undated and accessed 04/06/2026 at 12:47 p.m., revealed Resident #26's focus I will attend activities of my choice date initiated and revised on 05/05/2026 and goal I will maintain involvement in cognitive stimulation, social activities as desired through review date dated initiated 07/03/2025 and last revised on 04/22/2026 with interventions I need assistance/escort activity function.Invite me to scheduled activities. Provide a program of activities that is of interest and empowers the resident byencouraging/allowing choice, self-expression and responsibility initiated and last revised on 08/15/2025; however, additional comments not provided and independent bedbound room activities not noted as an intervention.Record review of Resident #26's Activity Progress Note dated 05/05/2026, revealed . [Resident #26] participates in activities of choice weekly. Bingo, Loteria, salon visits, socials, Resident council meetings, music, parties, family visits, TV, phone (social media) and others of choice. AD [Activity Director] provides visits and activities calendar. Resident currently prefers activities in room, such as cell phone, social media, visits with family on phone, games, texting, and reading daily chronicle. AD [Activity Directory] will cont. [continue]to encourage to OOR [out of room] activities.Record review of Resident #26's Pressure Ulcer Risk Evaluation dated 05/01/2026, revealed .Activity: Bedfast. Resident [Resident #26] is Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.Record review of Resident #26's Social Service Assessment, dated 04/07/2026, revealed . Resident is alert and oriented x3 and she requires assistance with some ADLs that includes transfers. Resident has been in bed more and is now needing assistance due to incontinency. She will sit in a wheelchair but prefers to stay in bed.,, She is on psych services due to DX [history] of Depression, Anxiety, and Mood disorder. She does her own independent activities and also attends large group activities.Record review of Resident #26's Nurse's Note dated 03/03/2026, revealed .Resident [Resident #26] complains of bilateral knee pain limiting her ability to stand. Resident also voices difficulty self propelling her wheel chair due to decreased strength to bilateral upper extremities.During an observation and interview of Resident #26 on 06/01/2026 at 11:18 a.m. she was noted to be lying down in bed watching television. She stated that due to pain in her lower extremities it is difficult to walk and she is unable to participate in group activities. She stated that when she was ambiguating on her own, she would participate in numerous group activities offered by Facility #1. She stated now that she is bedbound, she cannot participate in group activities, she stated she did not believe the staff provided in-room activities as they are constantly busy and seem to be in a hurry. She stated she would enjoy in-room activities if it were offered to her. 2. Record review of Resident #34's admission Record, dated 06/04/2026, revealed a [AGE] year-old male admitted [DATE] and re-admitted [DATE]. Resident #34 was not listed as his own RP with his (family member) listed as his Emergency Contact #1.Record review of Resident #34's Medical Diagnoses, undated and 06/04/2026 at 12:09 p.m., revealed diagnoses including hypertension (condition where the force of blood against the artery walls is consistently too high), peripheral vascular disease (condition characterized by narrowed arteries that reduce blood flow to the limbs), renal insufficiency (renal failure), neurogenic bladder (condition that affects bladder function due to nervous system problems, diabetes mellitus (condition that occurs when the body cannot properly use blood sugar) cerebrovascular accident (sudden interruption of blood flow to the brain, which can lead to brain damage), hemiplegia (paralysis or severe weakness affecting one side of the body, and anxiety disorder (frequently have intense, excessive and persistent worry and fear about everyday situations.Record review of Resident #34's quarterly MDS, dated [DATE] and signed 05/22/2026 as completed, reflected a BIMS score of 07, indicating severe cognitive impairment. Resident #34's functional abilities were documented as requiring dependent to substantial/maximal assistance and requiring manual wheelchair for ambulating.Record review of Resident #34's care plan, undated and accessed 06/04/2026 at 12:34 p.m., revealed Resident #34's focus Resident [Resident #34] attends activities of choice date initiated and last revised on 05/01/2026 and goal Resident will participate in activities of choice through the next review date date initiated 02/02/2026 and last revised on 06/02/226 with interventions Encourage resident to participate in activities.Invite resident to group activities.Record review of Resident #34's Activity Progress Note dated 06/02/2026, revealed .AD [Activity Director] went to provide room visit to resident [Resident #34] today. Resident [Resident #34] was sleeping.Record review of Resident #34's psychiatric services dated 05/23/2026, revealed .Treatment Recommendations: Participation in an exercise program, if approved by the treating physician, and physical therapy may support mood, stress management, and muscle strength. Patient needs intervention related to current medical conditions. Patient should continue social functions including spending time with friends and family, which may help prevent further cognitive decline. Continue to engage in cognitively stimulating activities, including reading the newspaper. Patient may benefit from listening to audiobooks and/or using online brain exercise programs.Record review of Resident #34's Activity Progress Note dated 05/01/2026 revealed .AD [Activity Director] went to visit resident [Resident #34] today and invite to OOR [out of room] programs. Resident declined and stated he prefers family visits, TV, snacks, and music. Resident [Resident #34] states he is not interested in large group activities at this time. AD [Activity Director] will cont. [continue] to visit and invite to all programs. During an observation and interview of Resident #34 on 06/01/2026 at 9:28 a.m. he was noted to be lying in bed. Attempted interview with Resident #34 revealed he had difficulties with speech and could not be understood. He was noted to have his right hand in a splint, foley in privacy bag hung at bedside. When asked resident was able to locate call light clipped to bedding. During an observation and interview on 06/04/2026 at 2:09 p.m., the Activities Director stated that if residents do not come out of their room, she will visit them. She stated bedbound residents are provided with in-room activities 3 times per week. She stated individual activities provided for a bedbound resident were documented in their electronic medical record or on the hard copy daily activity roster. She stated if a resident who is bedbound was not receiving activities could cause them to become depressed, isolated, and no stimulation. She stated she was unsure why Resident #26's electronic medical record only documented one activity progress note for a 12-week period (03/04/2026 to 06/04/2026). The Activity Director was observed reviewing her hard copy daily activity roster and activity progress notes and stated Resident #26 should have been documented in the report, but she could not find it. The Activity Director stated she had recently gone to visit Resident #26 in her room, and she observed her on her phone. She stated she could not recall the date, and she was unsure as to why she did not return to Resident #26's room to offer individual activities. She stated that Resident #34 had declined in-room activities. She stated she would do a compassion visit and Resident #34 does not show any interest in playing cards. She stated she was unsure why Resident #34's electronic medical record only documented two activity progress notes for a 16-week period (02/01/2026 to 06/04/2026). The Activity Director was observed reviewing her hard copy daily activity roster and activity progress notes and stated Resident #34 should have been documented in the report, but she could not find it.Record review of a facility policy titled, Activities dated November 2017, revealed .It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility sponsored group and individual activities and independent activities will be designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, as well as, encourage both independence and interaction within the community. 1. Each resident's interest and needs will be assessed on a routine basis. The assessment shall include, but is not limited to: . b. Activity assessment to include resident's interest, preferences and needed adaptations. 2. Activities will be designed with the intent to: a. Enhance the resident's sense of well-being, belonging, and usefulness. b. Promote or enhance physical activity. c. Promote or enhance cognition. d. Promote or enhance emotional health. e. Promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence. 4. Activities may be conducted in different ways: a. One-to-One Programs. b. Person Appropriate - activities relevant to the specific needs, interests, culture, background, etc. for the resident they are developed for. c. Program of Activities - to include a combination of large and small groups, one-to-one, and self-directed as the resident desires to attend. 9. Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs. These include, but are not limited to, considerations for: e. Residents who have withdrawn from previous activity interest/customary routines, and isolates self in room/bed most of the day.

Based on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 2 (Resident #7 and Resident #34) of 2 residents reviewed for incontinent care and indwelling urinary catheters. 1. The facility failed to ensure Resident #7's indwelling urinary catheter tubing was secured during personal care to prevent dislodgement and injury. 2. The facility failed to ensure while providing incontinent care, CNA J and CNA G cleaned the inner thigh areas and the right buttock area for Resident #34.These failures could place residents who require incontinence care at risk for cross contamination, skin breakdown, the development of skin or urinary tract infections and risk of accidental pulling of the catheter tubing and/or injury The findings include: 1. Record review of Resident #7's face sheet, dated 06/02/2026, reflected an [AGE] year-old female with current admission date of 05/14/2026. Diagnosis included obstructive and reflux uropathy (a blockage of urine flow causing urine to back up and exert pressure on the kidneys). Record review of Resident #7's MDS dated [DATE] revealed resident #7 is rarely/never understood and has an indwelling catheter. Record review of Resident #7's physician order dated 05/15/2026 revealed: Foley Catheter 16F with 10 ml balloon DX for Foley Catheter use: Obstructive Uropathy, and Monitor Foley Catheter leg strap for proper placement QShift and PRN as needed. Record review of Resident #7's comprehensive care plan dated 06/02/2026 revealed: I have Indwelling Catheter 16fr 10ml balloon Dx: obstructive and reflux, with goals: I will be/remain free from catheter-related trauma through review date, and I will show no s/sx of Urinary infection through review date, date initiated: 05/15/2026. Observation of indwelling urinary catheter care on 06/03/2026 at 10:25AM for resident #7 performed by CNA D and CNA E revealed foley catheter was not secured to resident #7's leg. During an interview with CNA D on 06/03/2026 10:45am CNA D stated she did not realize resident #7 did not have a catheter anchoring device while providing care. CNA D stated catheters are supposed to be secured to the residents' leg to avoid twisting or pulling of the catheter which could result in injury to the resident. During an interview with CNA E on 06/03/2026 at 10:45am. CNA E stated she did not notice resident #7 did not have her catheter secured during catheter care. CNA E stated the catheter should be secured so the moving of the resident does not cause trauma by pulling on the catheter. CNA E stated the nurse applies the leg strap or leg device to secure the catheter. During an interview with LVN A on 06/04/2026 at 11:05AM, LVN stated urinary catheters should be secured to the resident's leg to keep the tubing from getting tangled up or being pulled but sometimes they come off and the CNA staff should notify the nurse so it can be reapplied. An interview with the DON on 06/03/2026 at 4:10PM, the DON stated indwelling catheters should be secure to prevent pulling of the catheter and possible injury. A record review of policy titled Catheter Care, Urinary, dated 06/18/2018: Changing Catheters, 2. Ensure the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh) and Steps in Procedure, 19. Secure catheter utilizing a leg band. 2. Record review of Resident #34's face sheet, dated 06/01/2026, indicated that the resident was a [AGE] year-old male, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with diagnoses which include: cerebral infarction(when the blood supply to part of the brain is blocked or reduced. This prevents brain tissue from getting oxygen and nutrients. Brain cells begin to die in minutes.), flaccid hemiplegia(occurs when one side of the body becomes paralyzed and the muscles are soft, floppy, and unable to contract voluntarily.) affecting right dominant side and neuromuscular dysfunction of bladder(occurs when nerve damage disrupts communication between the brain, spinal cord, and bladder, leading to urinary control problems). Record review of Resident #34's quarterly MDS assessment, dated 05/20/2026, indicated Resident #34's BIMS score was 7 out of 15 which indicated that the resident had severe cognitive impairment. Resident #34 was always incontinent of bowel while urinary continence was not rated due to presence of indwelling catheter. Resident #34 required substantial/maximal assistance with mobility and personal hygiene and was noted to be dependent on staff for toileting, shower/bathing, as well as upper and lower body dressing. Record review of Resident #34's comprehensive care plan, dated 03/16/2026, indicated I have bowel incontinence r/t immobility The goal stated: I will remain clean, dry and comfortable with timely incontinence care after each episode: Interventions include: cleanse perineal area with mild cleanser after each episode. Observation on 06/03/2026 at 10:44am., revealed CNA J and CNA G unfastened Resident #34's brief and rolled it down between his legs. CNA J wiped both sides of penis head and under penis (scrotum), then wiped catheter tubing downwards towards the legs using different wipes each time. Resident was assisted by CNA G to turn to his left side. CNA J rolled old brief and pushed it under the resident. CNA J cleansed left buttock with wipe then resident produced small bowel movement. CNA J wiped perineum thoroughly. Resident was rolled slightly to the right and CNA G removed the soiled brief and disposed of it in a nearby trash can. CNA J and CNA G washed hands and changed gloves. CNA G turned Resident #34 slightly to the left side and CNA J pushed a clean brief under resident. Resident #34 was rolled to the right side (to straighten out clean brief) then laid onto his back. New brief was then pulled up between his legs and fastened closed without either CNA cleaning the resident's inner thigh areas or the right buttock area. During a joint interview on 06/03/2026 at 11:26 a.m., following the incontinence care observation, CNA J stated that she was not aware that she had not cleaned Resident #34's inner thighs or right buttock area and said that she should have wiped the areas to make sure that Resident #34 was clean. She said that they usually provide incontinent care to Resident #34 3x a day or more often if he has a bowel movement. CNA G stated that she had received training on incontinent care and remembers to wash hands and change gloves while providing care. CNA G stated, if the inner thigh and buttocks areas were not properly cleaned, I guess he could like get an infection or something. During an interview on 06/04/2026 at 2:47 p.m., CNA K stated that he had worked at the facility for 9 months. He said that he received training in incontinent care at the facility. He said that he was instructed to be sure to wipe top to bottom, pat the skin instead of scrubbing it, change gloves and sanitize his hands between handling of the dirty and clean items, lower bed and place call light within reach after care. He stated that it is important to clean all of the areas during incontinent care or the resident could get sores on the skin or get an infection. During a joint interview on 6/04/2026 at 3:07 p.m. with the facility DON and ADON, the expectations for CNAs providing incontinent care to the residents include hand hygiene; sanitizing hands before and after care. Training is offered to CNAs on a yearly basis typically, unless they notice that UTI rates are increasing – then they would offer training sooner than that. DON stated that it is important to keep the residents safe and free from infections. Record review of the facility's Perineal/Incontinent Care policy, dated December 2025, indicated the following: For a male resident: Continue to wipe the perineal area including the penis, scrotum and inner thighs and Wipe the rectal area thoroughly, including the area under the scrotum, the anus and the buttocks.

Based on observations, record reviews and interviews, the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #34) reviewed for enteral feeding (method to provide nutrition and fluids directly into digestive tract via a feeding tube). CNA G and CNA J failed to contact nurse to stop Resident #34's tube feeding infusion prior to laying the head of the bed flat and providing incontinence care. This deficient practice could place residents who receive enteral nutrition at increased risk for experiencing nausea and vomiting, choking, aspiration, infection, and abdominal discomfort.The findings included: Record review of Resident #34's face sheet, dated 06/01/2026, indicated that the resident was a [AGE] year-old male, originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with diagnoses which included: cerebral infarction (stroke), dysphagia following unspecified cerebrovascular disease (difficulty swallowing food or liquids) and encounter for attention to gastrostomy (surgical procedure in which a tube is inserted directly into the stomach through the abdominal wall to provide a way to deliver nutrition, fluids, or medications).Record review of Resident #34's quarterly MDS assessment dated [DATE] indicated the resident BIMS score was 7 out of 15 which indicated that the resident had severe cognitive impairment. Resident displayed signs and symptoms of a possible swallowing disorder and utilized an abdominal feeding tube. Resident has unclear speech and sometimes his verbal expressions are not clearly understood. Resident #34 is dependent on staff to complete his ADLs, and he receives substantial/maximal assistance from staff for mobility needs.Record review of Resident #34's Order Summary Report dated 06/01/2026 revealed the following physician orders: NPO and/or TUBE FEEDING diet NPO texture, NPO consistency Enteral Feed Order every shift Isosource 1.5 @ 75ml/hr. This provides 2475 kcal, 112 g pro and 1146 mlfree water. Addl fluid needs are 1300 ml/day Enteral Feed Order every shift Ensure HOB elevated 30-45 degrees QShift Record review of Resident #34's comprehensive care plan with initiation date of 1/28/2026 reflected he has ADL self-care performance deficit r/t CVA (cerebrovascular activity) with interventions which included: Eating - I am NPO and receive Tube Feedings so I am totally dependent of staff for my daily nutrition.Observation on 06/03/2026 at 10:44 a.m. of Resident #34's incontinence care revealed that CNA G and CNA J lowered Resident #34's head of the bed to the flat position while enteral feeding pump continued to infuse feeding. CNA J stated We usually let the nurse know to come and stop the pump. The CNAs continued to provide incontinent care while the feeding infused. By 10:55 a.m., Resident #34 grunted and patted the top of his head. CNA G asked, Are you okay? Do you want a pillow? CNA G placed a pillow behind Resident #34's head and said We're almost done. Resident #34 produced a bowel movement which required additional cleaning. The resident was observed to grasp handrail, groaned and appeared to be in discomfort. Incontinent care was completed at 11:20 a.m. and the head of Resident #34's bed was returned to 30 degrees. Resident then appeared comfortable and in no distress after lying with head of bed flattened for 36 minutes while enteral feeding was infusing.During an interview on 06/03/2026 at 11:27 a.m., CNA J stated she should have but had forgotten to call the nurse in to stop the pump before they began incontinent care. She stated that she had received training in the past about Gtubes and knows that the resident could possibly choke if his head is lowered while the feeding is going.During an interview on 06/03/2026 at 12:53 p.m., with LVN C, she stated the CNAs will call her into the room to stop the feeding pump when they needed to provide care. LVN C stated CNAs providing incontinent care for approximately 30 minutes with Resident #34's head flat and feeding infusing is not the norm. She stated that the pump must be off when he is flat or he could aspirate.During an interview on 6/04/2026 at 2:20 p.m. with CNA L, she stated that she has frequently been assigned to work with Resident #34. She said that she received training regarding Gtube care. CNA L stated that she was trained not to mess with it and if she were to see something concerning, she would get the nurse to check the Gtube to be sure. If she needs to reposition Resident #34 to provide care, she said that she calls the nurse to stop the tube feeding because he could start coughing or choke.During an interview on 6/04/2026 at 2:47 p.m., CNA K, stated that he has received training on Gtube care. If he needs to provide care to a resident with a Gtube, he stated that he would first ask the nurse to disconnect the feeding so that the resident would not get hurt.During a joint interview with DON and ADON on 6/04/2026 at 3:15 p.m., regarding Gtube care, DON stated that the CNAs are trained to call the nurse for assistance with the feeding tube and pump. Only the nurses are allowed to handle the Gtubes and the pumps. DON stated that the resident could potentially aspirate if the head of the bed was in the flat position for more than 30 minutes with the tube feeding infusing.Record review of facility policy titled Enteral Nutrition dated December 2025 revealed: 1. Staff caring for residents with feeding tubes will be trained on potential adverse effects of tube feeding, such as: Reduced opportunity for socialization;Diminished sensory experience;Restriction of movement; andFeeding-tube associated complications.Staff caring for residents with feeding tubes will be trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube, such as:Aspiration;Leaking and skin breakdown around insertion site;Perforation of the stomach or small intestine leading to peritonitis;Esophageal swelling, strictures, fistulas; andClogging of the tube.Staff caring for residents with feeding tubes will be trained on how to recognize and report complications relating to the administration of enteral nutrition products, such as:Nausea, vomiting, diarrhea and abdominal cramping;Inadequate nutrition;Metabolic abnormalities:Interactions between feeding formula and medications; andAspiration. Risk of aspiration will be assessed by the Nurse and Physician and addressed in the individual care plan. Risk of aspiration may be affected by:Diminished level of consciousness;Moderate to severe swallowing difficulties;Improper positioning of the resident during feeding; andFailure to confirm placement of the feeding tube prior to initiating the feeding

Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences in 1 (Resident #7) of 2 residents reviewed receiving supplemental oxygen via nasal cannula. The facility failed to ensure that Resident #7's oxygen tubing was handled properly to prevent contamination. Resident 7's nasal cannula was on the floor in her room and CNA C placed it back on resident. This failure could put residents receiving supplemental oxygen via nasal cannula at risk for cross-contamination and respiratory infection.The findings included: Record review of Resident #7's face sheet, dated 06/02/2026, reflected an [AGE] year-old female with current admission date of 05/14/2026. Diagnosis includes hypertensive heart disease (high blood pressure causes damage to the heart) and atherosclerotic heart disease (hardening of the arteries). Record review of Resident #7's MDS dated [DATE] revealed resident #7 is rarely/never understood and receives oxygen therapy. Record review of Resident #7's physician order dated 05/14/2026, indicated Oxygen at 2 lpm via nasal cannula continuously every shift. Record review of Resident #7's comprehensive care plan dated 06/02/2026 revealed: Impaired Gas Exchange r/t Respiratory Failure. Oxygen at 2 lpm via nasal cannula to maintain O2Sats > 92%, Date Initiated: 06/02/2026. Observation on 06/01/2026 at 11:10 am, resident #7 in bed with head of bed elevated approximately 30 degrees, oxygen concentrator located on left side of bed was running and set at 2 L/min with tubing above resident's head and nasal cannula lying on the floor on right side of bed. CNA C came into room and while surveyor was checking the oxygen concentrator filter, CNA C picked up nasal cannula from the floor and placed it back on resident's face with prongs in the nares. LVN A entered the room at this time. LVN A stated the cannula was contaminated and immediately changed it out. During an interview with CNA C on 06/01/2026 at 11:15am, CNA C stated she put resident 7's nasal cannula back on because she didn't think it had touched the floor. CNA C stated the nasal cannula could be contaminated and cause infection by touching the floor. CNA C stated resident#7 receives oxygen continuously. CNA C stated if she found respiratory equipment on the floor, she should notify the nurse to replace it.During an interview on 06/01/2026 at 11:20am, LVN A stated he changed out the nasal cannula and tubing for resident #7 because it had touched the floor and was contaminated which can cause infection. LVN A stated resident #7 has been receiving continuous oxygen since recently returning from the hospital. DON interview 06/01/2026 at 3:20pm, DON stated her expectation is that if tubing or nasal cannula were on the floor, they are to be changed out to prevent infection. Review of policy titled Oxygen Administration dated 12/2025, did not specify preventing or procedure for contamination of oxygen equipment.

Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 of 4 resident (Residents #1) reviewed for infection control. The facility failed to ensure CNA A washed her hands before donning gloves and failed to change soiled gloves prior to touching clean brief and linens during an incontinent care observation for Resident #1 on 03/04/2026. This deficient practice could place residents at risk of cross contamination and infections.Findings included:Record review of Resident # 1's electronic face sheet dated 03/04/2026 reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: unspecified cerebral infarction (medical condition occurs when blood flow to a part of the brain is obstructed which leads to the death of brain cells due to lack of oxygen and essential nutrients), contracture of the left hand (permanent fixed tightening or shortening of muscles, tendons, skin or tissues), unspecified neuromuscular dysfunction of bladder (condition where the normal communication between the bladder and the nervous system is disrupted, leading to bladder control issues such as incontinence ), unspecified dementia with psychotic disturbance (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities with psychotic manifestations ), constipation (a condition characterized having fewer than 3 bowel movements a week).Record review of Resident #1's quarterly MDS assessment, dated 02/07/2026, revealed a BIMS score of 06, which indicated severe cognitive impairment. Further review of the MDS revealed the resident was dependent on staff for her toileting hygiene and was frequently incontinent of bowel and bladder.Record review of resident #1's care plan, dated 05/17/2026, did not reveal a focus or problem for incontinent care. The Care Plan revealed Resident #1 had potential actual impairment to skin integrity related to fragile skin, incontinence, limited mobility and hemiplegia w/ interventions to include, keep skin clean and dry.Observation on 03/04/2026 at 4:13 pm revealed CNAs A and B performed incontinent care for Resident #1. CNA A washed her hands, then with bare hands grabbed Resident #1's bed control and positioned Resident #1 for incontinent care, CNA A then grabbed the corner of the bed frame and pulled the bed away from the wall. Further observation revealed CNA A (without washing her hands) donned clean gloves and proceeded to grab clean wet wipes from a zip locked bag and arraigning the wet wipes on a clean surface. After completing incontinent care of Resident #1's perineal area CNA A, with the same gloves used to perform incontinent care, grabbed and prepared the clean brief and clean bed pad. After CNA A prepared the clean brief and clean pad with soiled gloves, she removed the soiled gloves and proceeded to wash her hands. After washing her hands, CNA A donned clean gloves and placed the prepared brief and bed pad under Resident #1. CNA A and CNA B continued and completed incontinent care for Resident #1.During an interview with CNA A on 03/04/2026 at 4:35 pm, CNA A stated she had worked as a CNA in the facility for almost one year. CNA A stated after touching the bed control and bed frame of Resident #1's bed, she should have washed her hands before applying gloves. CNA A stated after cleaning Resident #1, she should have removed her gloves, washed her hands, and applied new gloves before touching the clean brief and bed pad. CNA A further stated she should wash her hands between all glove changes. CNA A stated the purpose of washing hands after touching room items and applying clean gloves was because the items were considered dirty. CNA A stated it was the facility's policy to wash hands after every glove change to avoid contamination. CNA A stated not washing hands per policy could lead to residents getting infections to include UTI's (urinary tract infections).During an interview with the Director of Nurses on 03/04/2026 at 5:15 pm, the Director of Nurses stated CNAs should always wash their hands before donning gloves per facility policy and staff training. The Director of Nurses stated staff should remove all dirty items first and completely and then wash hands and replace gloves before handling or putting new linens in place. The Director of Nurses stated CNAs should always wash their hands between glove changes. The Director of Nurses stated staff were provided with a minimum of 2 in-services a year regarding incontinent care and hand washing.During an interview with the Assistant Director of Nurses LVN (Infection Preventionist) on 03/04/2026 at 5:35 pm, the Assistant Director of Nurses LVN stated she had an active role in providing in-services and training to staff for handwashing and incontinence care. The Assistant Director of Nurses LVN stated training was done every six months and as needed. The Assistant Director of Nurses LVN stated staff should wash their hands after each glove change. The Assistant Director of Nurses LVN stated staff should wash their hands after touching items in the room and before gloving. The Assistant Director of Nurses LVN stated the risk to residents related to this failure was infection.Record review of CNA A's training file revealed a competency evaluation dated 01/08/2026 that CNA A was evaluated for handwashing by the Director of Nurses on 01/08/2026.Record review of CNA A's training file revealed a competency evaluation dated 01/08/2026 that CNA A was evaluated for Donning PPE (personal protective equipment) and removing PPE by the Director of Nurses on 01/08/2026.Record review of CNA A's training file revealed a competency evaluation dated 01/08/2026 that CNA A was evaluated for PeriCare (incontinent care of perineal and rectal area) by the Director of Nurses on 01/08/2026.Record review of CNA A's training file revealed a Certificate of Completion for CNA A for completion of Infection Control Guidelines training course dated 07/01/2025.Record review of the facility's policy titled, Handwashing/Hand Hygiene, dated August 2015, read: Policy Statement, This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All staff shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. 7. Use alcohol-based hand rub containing at least 62% alcohol: or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . b. Before and after direct contact with residents, d. Before performing any non-surgical invasive procedures: e. before and after handling an invasive device (e.g., urinary catheters, IV access sites), f. before donning sterile gloves, g. Before handling clean or soiled dressings, gauze pads, etc., h. Before moving from a contaminated body site to a clean body site during resident care, i. After contact with resident's intact skin.l. after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident, m. after removing gloves.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 4 residents (Resident #1) reviewed for care plans: The facility failed to ensure Resident #1's comprehensive care plan was completed in a timely manner and included behaviors she had refusing care or being combative during care. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services. The findings included:The findings included: Record review of Resident #1's admission record, dated 11/26/25, revealed a [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses including lack of coordination, dementia, and adult failure to thrive. Record review of Resident #1's admission MDS assessment, dated 11/07/25, revealed Resident #1's cognition was severely impaired. Record review of Resident #1's Comprehensive Care Plan, initiated on 11/01/25, last revised on 11/18/25, did not contain a focus or interventions for when the resident became combative during care. Record review of Resident #1's progress note, dated 11/05/25, stated .Pt (patient) aggressive with staff, pending psych eval. written by the physician. Record review of Resident #1's progress note, dated 11/05/25, stated Resident refused a.m shower. Multiple attempts made x3 to shower resident. Final attempt to shower resident continued to refuse and became combative by scratching and punching staff members. RP was notified, vm left. Plan of care continues. Written by RN A. Record review of Resident #1's progress note, dated 11/07/25, stated Resident refused scheduled showers for a.m shift. Multiple attempts made x3 to get resident to comply with showers but was unsuccessful. Resident did comply with peri-care after multiple attempts. RP was notified, VM left. No distress noted. Plan of care continues. Written by RN A. Record review of Resident #1's progress note, dated 11/12/25, stated RP returned phone call to this nurse. RP stated that resident was resistant of care and forcefully pulling hands away when RP was attempting to provide nail care and trim residents very long nails. RP stated resident pulled her hands away several times and in the process hit herself in the face. RP was notified of the bruise to this residents face as well as the skin tear to residents hand. Resident denies pain when asked and shows no signs of distress. She is resting peacefully in bed at this time. Written by MDS Coordinator. Record review of Resident #1's psych noted, dated 11/12/25, stated Staff report Patient is aggressive, combative during care. She is refusing her PO meds. She is not eating good as well. [AGE] year-old female with h/o Dementia with agitation. Written by PMHNP C. Record review of Resident #1's progress note, dated 11/12/25, stated Resident refused scheduled shower. Multiple attempts made by staff to shower but was unsuccessful. Bed bath was offered and was also refused. Written by RN A. Record review of Resident #1's progress note, dated 11/24/25, stated This nurse was doing treatment; resident was combative with this nurse and CNA that was helping. Resident scratched, hit and bit this nurse, and was hitting CNA. Dressing was changed and intact. Told residents nurse to monitor behaviors. Written by Treatment Nurse B. During an interview on 11/26/25 at 2:32 p.m. Treatment Nurse B stated Resident #1 was sometimes not calm during care and would fight staff. She stated 2 staff went into the residents room for care. She stated the aides would call the nurse to come talk to the resident if she was refusing care like a shower and if she became combative they would stop care and return at a later time to try again. She stated the resident had recently bit and scratched her. The nurse raised her arm to show a purplish raised area on her forearm. During an interview on 11/26/25 at 3:00 p.m. Resident #1's RP stated she was a difficult patient because she will scratch and lash out at staff. Resident #1's RP stated she does a lot of self-inflicting scratches due to her long nails and behaviors. Resident #1's RP stated she experienced trauma in the past, had anxiety, and would pick at herself or lash out. The RP stated they would redirect Resident #1 and ask her to rub her hands to warm them up instead. During an observation on 11/26/25 at 3:16 p.m. Resident #1 was laying in bed scratching her arm, constantly rubbing her arms together, and picking under her nails. During a joint interview on 11/26/25 at 4:15 p.m. The SW and the MDS Coordinator stated they would normally complete a care plan meeting and comprehensive care plan for residents within 21 days of them being admitted to the facility. They stated they added a focus area on 11/26/25 day for the resident resistance to care and behaviors because they had not done it prior and should have. They stated there was an incident on 11/12/25 where the resident was being combative and hit herself in the face while her nails were being trimmed. The SW stated she was busy working between two buildings and just had not had a chance to add the focus area. They stated the care plan should be updated to help staff know what the interventions were to care for the resident. During an interview on 11/26/25 at 4:27 p.m. the DON stated Resident #1 was known to be combative with staff during care. The DON stated they had psychiatry visit the resident and she was on anti-anxiety medication for about 1 week. The DON stated the care plan should have been updated after the incident on 11/12/25. The DON stated it was important to update the care plan so the interdisciplinary team would all be on the same page of how to care for the resident. Record review of the facility's policy, titled Care Plans, Comprehensive Person-Centered, dated 12/2020, stated Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 8.The comprehensive, person-centered care plan will: g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 facility reviewed for food service safety. 1. The facility failed to maintain the cleanliness of the facility ice maker. 2. Two open food items were observed in the medication storage fridge, undated and unlabeled. 3. Three open and unrefrigerated containers of fluid drinks intended for residents were observed on two medication carts. This failure could place residents who receive food and/or snacks from the facility at risk for food borne illness. The findings included: 1. Observation on 04/03/2025 at 11:32 AM revealed a black substance build-up within the ice maker. The ice machine was observed to have a sticker on it stating the contracted cleaning company had last cleaned the ice machine in March of 2025, and it would next be cleaned in September of 2025. Observation on 04/03/2025 at 11:45 AM revealed water pitchers with ice in them and an ice chest in the hallway with ice in it for staff to provide to residents with water and/or ice when requested. Interview on 04/04/2025 at 2:19 PM, the DON stated that all she saw in the photo of the ice machine was condensation. The DON stated the risk to residents with having ice from a dirty ice machine was illness. Interview on 04/04/2025 at 2:19 PM, the ADM was shown a photo of the ice machine and stated that it was dirty and she expected it to be cleaner, since the contracted cleaning company had recently come to clean it. The ADM stated the facility had a company who was contracted to clean the ice machine every 6 months. The ADM stated that other than the contracted cleaning service every 6 months, there was not a schedule for cleaning the facility ice machine, and that if they notice the machine needs to be cleaned then maintenance will clean it. The ADM stated the risk to residents with having ice from a dirty ice machine is the possibility of residents becoming sick. 2. During an observation and interview on 04/02/2025 at 1:55 pm, the medication refrigerator in Hall C was observed to have two opened food containers on the top shelf - a Styrofoam container of red liquid and a clear, plastic container with orange liquid. No medications were located on this shelf. Neither item was labeled with a date indicating when it was opened. The DON stated the food items should not be stored in the medication refrigerator. The DON then disposed of the items into a nearby trashcan. 3. During an observation on 04/03/2025 at 11:3 am, an open container of Sysco brand thickened lemon flavor water was observed on the medication cart for Hall C. This container was labelled with an open date of 2/17/2025. On the back of the carton, the manufacturer label stated: Refrigerate prior to serving. Shake well before using. Twist the cap to open, then pour and serve. After opening, may be kept up to 7 days under refrigeration. The carton was warm to the touch, and no ice or cooling method was observed on the cart. Observation on 04/05/2025 at 11:35 AM revealed an additional carton of the same thickened lemon flavor water within a locked drawer of the medication cart in Hall B with an open date of 03/31/2025. The carton was warm to the touch, and no ice or cooling method was observed on the cart. An interview was conducted with CMA C on 4/03/2025 at 11:35 AM. CMA C stated she was unaware that the thickened lemon flavor water required refrigeration. She was unsure when it should be discarded after opening. CMA C also reported that it was routine practice at the facility to keep the thickened lemon flavor water stored in the medication carts, unrefrigerated after opening. A third observation was made on 4/02/2025 at 07:35 AM of Sysco brand Med Plus 2.0 Vanilla flavored nutritional drink on top of the medication cart in hall B. The carton was warm to the touch, and no ice or refrigeration method was observed. The carton was labelled as opened on 4/3. An interview was conducted with RN D on 4/02/2025 at 07:25 AM. RN D stated that the carton was present when he arrived for his shift at 06:00 AM and was likely put there by the overnight staff from the previous shift. RN D stated that the facility practice is to store these cartons on ice on top of the medication cart. An interview was conducted with the DON and the Admin on 4/04/2025 at 1:55PM, and the observations made by the survey team of the thickened water and nutritional supplement were reviewed. The DON disagreed with the surveyor assessment that the cartons required refrigeration after opening and stated that she would consult with the facility pharmacist. A review of the manufacturer's website (www.sysco.com) indicated the following: 1. Med Plus 2.0 Vanilla: refrigerate after opening and use within three days 2. Thickened lemon flavored water: refrigerate for up to 7 days after opening No follow-up information from the facility pharmacist was offered by the DON or Admin before the survey team exited. Record review of facility policy titled, Production, Storage, and Dispensing of Ice, undated, reflected, The ice dispenser will be cleaned and sanitized at least monthly and/or as needed. Inside and outside of the machine and the area around the machine will be cleaned.

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 5 (Residents #8, #15, #31, #62, and #77) of 18 residents reviewed for care plans. 1. The facility failed to develop care plan interventions for Resident #77's hospice services. 2. The facility failed to develop care planning related to Resident #15's ordered Wanderguard device and known tendencies to wander the facility in attempts to elope. The care planning for this resident also did not include monitoring for the resident's ordered, psychotropic medications. 3. The facility failed to develop care planning related to Resident #62's known tendency to wander the facility in attempts to elope as well as care planning monitoring the resident's specific medication regimen. 4. The facility failed to implement care plan interventions for Resident #8 and identify interventions for Resident #31 for contractures. These failures could place residents at risk of not receiving care and services related to their identified needs to maintain or reach their highest practicable physical, mental, and psychosocial wellbeing. The findings included: 1. Record review of Resident #77's Admission Record, dated [DATE], reflected a [AGE] year-old resident with an initial admitted [DATE] and diagnoses including parkinsonism (a clinical syndrome characterized by tremor, bradykinesia, rigidity, and postural instability), cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain), and type 2 diabetes. Further review revealed Resident #77 was on hospice and expired on [DATE]. Record review of Resident #77's Order Summary Report, dated [DATE], reflected, Resident has been admitted to Hospice Services with an order date of [DATE]. Record review of Resident #77's Comprehensive Person-Centered Care Plan, dated printed [DATE], did not reflect a focus area relating to Resident #77's hospice care, goals for the hospice care, or interventions/tasks related to hospice care. Interview on [DATE] at 1:55 PM, the DON stated that care plans should have hospice care included. The DON stated that the care plan including hospice should describe and include how to ensure a resident on hospice remains comfortable. 2. Review of Resident #15's face sheet reflected an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included psychotic disorder with delusions due to known physiological condition, vascular dementia (a progressive disorder that affects a person's cognition), mood disorder due to known physiological condition with depressive features, anorexia (lack of food intake related to low appetite), and history of falling. Review of the resident's quarterly MDS submitted on [DATE] reflected that a BIMS score was unable to be assessed as the resident was unable to be understood during interviews. A review of the resident's active orders on [DATE] revealed that the following orders: a. May have wander guard bracelet (order date [DATE]) b. Ativan gel 0.5mg/mL Gel, apply to wrist topically every 8 hours as needed for anxiety (order date [DATE]) c. Dronabinol capsule 2.5mg, give 1 capsule by mouth two times a day for appetite stimulant/store in locked narcotic box in refrigerator (order date [DATE]) d. Hydroxyzine Hcl Oral tablet 25 mg, give 1 tablet by mouth three times a day for anxiety (order date [DATE]) e. Sertraline HCl tablet 100mg, give 1 tablet by mouth one time a day for MDD [major depressive disorder] (order date [DATE]) f. Trazodone HCl oral tablet 50mg, give 1 tablet by mouth at bedtime for insomnia (order date [DATE]) Resident #15 was observed with Wanderguard bracelet in place on her right wrist on [DATE] at 11:50 AM. In an interview on [DATE] at 11:54 AM, LVN L was questioned about Resident #15's wandering tendencies. LVN L explained that Resident #15 has days where she is good and didn't wander and some nights where she was confused, tell staff that she needed to leave, and moved in her wheelchair to the exit. LVN L was then asked how the wander guard is monitored for placement on every shift. LVN L stated it is checked during skin assessments. A record review revealed 7 total documented skin assessments between the dates of [DATE] and [DATE]. None of the 7 assessments contained documentation describing the Wandergard device. Additionally, all 7 assessments included the statement resident does not have an external device. A record review of the TAR on for [DATE] did not reveal any documentation of the wander guard device nor a task requesting staff to ensure placement. A record review of Resident #15's active care plan, date printed [DATE], also did not reveal any care planning related to the Wanderguard or safety measures related to wandering. The care plan contains planning for falls (last revised [DATE]) and cognitive loss/alteration (last revised [DATE]), but neither of these focus areas mention the Wanderguard or tendency to wander. It was also noted during record review of the care plan that the areas related to psychotropic medication failed to specifically state the medications, related diagnosis, and symptoms for monitoring. Examples included: a. I use psychotropic medications (specify medications) r/t [no additional text] date initiated: [DATE] b. Monitor/record occurrence of for target behavior symptoms (Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. Date initiated [DATE] c. I use antidepressant medication (Specify medications) r/t [no additional text] date initiated [DATE] 2. Review of Resident #62's face sheet reflected a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified dementia, unspecified severity, with other behavioral disturbance; major depressive disorder, recurrent, unspecified; anxiety disorder; Alzheimer's disease (a progressive brain disorder that primary affects memory, thinking, and behavior); unsteadiness on feet; and unspecified abnormalities of gait and mobility. Resident #62 was observed on [DATE] at 9:40 AM resting in her wheelchair in the hallway near the nurse's station. CNA A was present at the time of observation and stated Resident #62 has a tendency to wander and needed continuous monitoring. Similar observations of Resident #62 at the nurse's station were also made on [DATE] at 2:57 PM and [DATE] at 4:26 PM. Record review on [DATE] of the resident's quarterly MDS submitted on [DATE] reflected that a BIMS score was unable to be assessed as the resident was unable to be understood during interviews. Section E of the MDS indicated that Resident #62 exhibited wandering behavior ,d+[DATE] days of the 2 week period included in the evaluation period. Record review of Resident #62's current care plan, date printed [DATE], did not reveal care planning related to wandering or the need for increased observation. Focus areas were noted for fall risk planning (last revised [DATE]) and cognitive loss (last revised [DATE]), but interventions did not include the interventions reflected in the aforementioned CNA interview (increased observation). Furthermore, review of the care plan reflected care areas and planning without specific details related to the resident. Examples included: a. I have (acute/chronic) pain r/t [no additional text] date initiated: [DATE] b. I use anti-anxiety medications (Specify medications) r/t [no additional text] date initiated: [DATE] c. I use antidepressant medication (Specify medications) r/t [no additional text] date initiated [DATE] An interview was conducted on [DATE] at 1:55 PM with the Admin and the DON. They were asked how staff are expected to ensure placement of the wander guard. The DON responded that it is a task documented on the TAR. When told that Resident #15 does not have the task on the TAR, the Admin explained that the front door receptionist will often serve as an added alert to notify staff that a resident is attempting to leave the facility. The Admin also stated that the need for the wander guard was being re-evaluated during care plan meetings as the resident no longer exhibited wandering tendencies. The interview with LVN L describing the resident's continued wandering behavior was recounted to the Admin. The DON and the Admin were then asked if the wander guard should be included on the care plan, and they both stated yes, wander guard planning and wander risks should both be on the care plan. The DON and the Admin were also notified of the non-specificity of care plans reviewed by the survey team. The DON and Admin stated care plans should include medication names and symptoms specific to the resident. 4. Record review of Resident #8's face sheet revealed a [AGE] year-old female admitted [DATE] and readmitted [DATE]. Resident 38's diagnoses include paranoid schizophrenia (a type of brain disorder than can cause a person to experience paranoia), anxiety, MDD (a mental disorder characterized by persistent low mood, loss of interest), glaucoma (a group of eye diseases that can lead to damage of the optic nerve), osteoporosis (a condition that causes bones to become weak and brittle, making them more susceptible to fractures), dysphagia (difficulty swallowing), cerebral palsy (a group of disorders that affect movement and muscle tone or posture), dementia (a group of symptoms affecting memory, thinking and social abilities). Record review of Resident #8's Quarterly MDS dated [DATE], of Section C revealed BIMS Score 99 indicating severe cognitive impairment. Section GG revealed impairment to one side upper extremity and bilateral (both left and right side) impairment of lower extremity and total dependence in all areas of ADL concern. Section O revealed the resident was not receiving a Restorative Nursing Program and did not indicate use of splint or brace assistance. Record review of Resident #8's OT Evaluation & Plan of Treatment dated [DATE] revealed the resident had contracture of the muscle, multiple sites to include left hand flexion contracture of all digits with pain upon attempting passive stretch. Record review of Resident #8's physician's order dated [DATE] revealed Patient may wear Left palm protector to patient tolerance, and order dated [DATE] Patient may wear left hand palm protector. Record review of Resident #8's care plan focus problem dated [DATE], revised [DATE] revealed impaired physical mobility related to contractures to bilateral lower extremities, left upper extremity, let hand, right ankle secondary to Cerebral Palsy. Interventions/Tasks revealed splints may be applied per physicians' orders dated [DATE]. Focus problem dated [DATE] revealed resident will wear left palm protector. Record review of Resident #8's Restorative Nursing Program Communication Form dated [DATE] revealed application of palm protector to left hand 5 times per week. In an interview with CNA B on [DATE] at 10:29 a.m. revealed she does not put anything in Resident #8's hand to prevent further contracture. In an interview with CNA J on [DATE] at 10:29 a.m. revealed she will clean inside Resident #8's hand with a wipe but does not put anything in hand to prevent further contracture. In an interview with CNA H, Rehabilitation Technician on [DATE] at 2:14 p.m. revealed he applies left hand palm protector to Resident #8, Monday-Friday, 4 hours / day. CNA H stated he applied left hand palm protector for Resident #8 after lunch. Stated he applied palm protector on [DATE]. Interview with CNA G on [DATE] at 8:47 a.m. revealed she will utilize positioning pillows under Resident #8's lower back or side to help relieve pressure but does not put anything on her hand to prevent contracture. In an interview with DON on [DATE] at 10:12 a.m. revealed therapy identifies contractures and puts interventions in place. DON stated she will review with DOR to see if nursing should monitor. In an interview with DOR I on [DATE] at 10:46 a.m. revealed the RNP for Resident #8 was initiated on [DATE] and includes application of palm protector to left hand. Record review of Resident #31's face sheet revealed a [AGE] year-old male admitted [DATE] and readmitted [DATE]. Diagnoses include apraxia (difficulty with movements even when a person has the ability to do them) follow intracranial hemorrhage (bleeding in the brain), Hypertension, anemia (a condition in which the blood does not have enough healthy red blood cells to carry oxygen all through the body), CVA (Cerebrovascular accident or stroke, damage to the brain from interruption of its blood supply), seizure disorder, psychotic disorder with delusions, mood disorder with depressive features, anxiety. Record review of Resident #31's Quarterly MDS dated [DATE] of Section C revealed resident unable to complete cognitive testing indicating severe cognitive deficit. Section GG revealed impairment to upper and lower extremity and resident was dependent in toileting, bathing, UB/LB dressing, required maximum assistance in bed mobility and set-up assistance with ambulation. Review of Resident #31's Quarterly MDS dated [DATE] of Section O, revealed resident was not receiving a Restorative Nursing Program for range of motion or splint/brace assistance. Record review of Resident #31's Restorative Nursing Program revealed no Occupational Therapy Restorative Nursing Program was implemented. Record review of Resident #31's physician's orders printed [DATE] revealed no orders in place for contracture management / prevention device or monitoring. Record review of Resident #31's Care Plan printed [DATE] revealed impaired physical mobility related to contracture(s) to left arm .secondary to CVA with interventions to include PROM and AROM joint exercises to prevent contractures, stimulate circulation and build endurance. In observation of Resident #31 on [DATE] at 10:32 a.m., [DATE] at 8:20 a.m., [DATE] at 12:20 p.m. revealed resident right hand contracture with no assistive device in place. In an interview with DOR I on [DATE] at 10:46 a.m., DOR stated she completed spot checks to ensure the RNP programs were implemented and she was responsible for ensuring RNP program were initiated and on-going. In an iterview with the DON on [DATE] at 10:12 a.m. revealed that not utilizing palm protector for Resident #8 could increase contractures. In an interview on [DATE] at 10:24 a.m. the DON revealed that request for contracture management device for Resident #31 had been requested thru Medicaid and denied. The DON stated she advised the DOR to identify the appropriate device for Resident #31 and purchase / implement the device for the resident. DON stated that failure to address contractures could lead to increase of contractures, pain concerns and potential alteration in skin integrity. Review of Contracture Prevention Policy and Procedure, revised [DATE], revealed a 1. Contracture Risk Assessment will be performed . to determine a residents risk score for having contractures, 3. Plan of care established by physical therapy or nursing .and physician's orders obtained, 9. Contracture prevention programs may include .A. positioning .E. splints, F. prevented by exercise. Record review of Facility Policy titled, Care Planning - Interdisciplinary Team, dated reviewed [DATE], reflected, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 50531 51512

Based on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 8 residents (Resident #9, #28, and #40) reviewed for personal hygiene. 1. The facility failed to provide Resident #9, 8 of 13 scheduled showers between 03/04/2025 and 04/03/2025. 2. The facility failed to provide Resident #28, 8 of 13 scheduled showers between 03/04/2025 and 04/03/2025. 3. The facility failed to provide Resident #40, 4 of 14 scheduled showers between 03/04/2025 and 04/03/2025. This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections. The findings included: 1. Record review of Resident #9's Admission Record, dated 04/04/2025, reflected a [AGE] year-old resident with an initial admitted [DATE]. Resident #9 had diagnoses that included dysphagia (difficulty swallowing), cerebral infarction (the pathologic process that results in an area of necrotic (dead) tissue in the brain) and need for assistance with personal care. Record review of Resident #9's Quarterly MDS Assessment, signed and completed on 02/03/2025, reflected Resident #9 had a BIMS score of 4, indicating the resident was severely cognitively impaired. Resident #9's MDS assessment indicated that Resident #9 was Dependent (helper does ALL of the effort) for showering/bathing. Record review of Resident #9's Comprehensive Person-Centered Care Plan, undated, reflected I have an ADL Self Care Performance Deficit Cerebral Infarction, abnormalities in gait and mobility, with interventions, I require (X1) staff participation with bathing. Resident #9's Comprehensive Person-Centered Care Plan does not describe behaviors of refusals of showers, or refusals of any other type of care. Record review of Resident #9's tasks in his electronic health record reflected that the resident's shower days were Monday, Wednesday, and Friday in the evening. Further review revealed Resident #9 did not receive 8 of the 13 showers scheduled. Between 03/04/2025 and 04/03/2025, Resident #9 received showers on the following dates: 03/08/2025, 03/22/2025, 03/25/2025, 03/29/2025, and 04/01/2025. There were no other showers documented on the resident's electronic health record. An interview was attempted on 04/04/2025 at 10:47 AM with Resident #9, who was unable to answer questions relating to their showers due to their cognitive status. 2. Record review of Resident #28's Admission Record, dated 04/04/2025, reflected a [AGE] year-old resident with an initial admitted [DATE]. Resident #28 had diagnosis of cerebral infarction (the pathological process that results in an area of necrotic tissue in the brain), contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the right hand, right thigh, right knee, left knee, left shoulder, left elbow, and multiple other sites. Record review of Resident #28's Quarterly MDS, signed and completed on 02/14/2025, reflected Resident #28 had a BIMS score of 0, indicating the resident was severely cognitively impaired. Resident #28's MDS assessment indicated that Resident #28 was Dependent (helper does ALL of the effort) for showering/bathing. Record review of Resident #28's Comprehensive Person-Centered Care Plan, undated, reflected, I have an ADL Self Care Performance Deficit r/t chronic pain syndrome, dyspnea/resp. abnormalities, seizure d/o, muscle weakness, lack of cord. And contractures to BLE, with interventions, I require extensive total assistance from staff participation with bathing. Resident #28's Comprehensive Person-Centered Care Plan does not describe behaviors of refusals of showers, or refusals of any other type of care. Record review of Resident #28's tasks in her electronic health record reflected that the resident's shower days were Monday, Wednesday, and Friday in the evening. Further review revealed Resident #28 did not receive 8 of the 13 showers scheduled. Between 03/04/2025 and 04/03/2025, Resident #28 received showers on the following dates: 03/08/2025, 03/15/2025, 03/17/2025, 03/27/2025, and 04/02/2025. There were no other showers documented on the resident's electronic health record. An interview was attempted on 04/04/2025 at 11:14 AM with Resident #28, who was unable to answer questions relating to their showers due to their cognitive status. 3. Record review of Resident #40's Admission Record, dated 04/04/2025, reflected a [AGE] year-old resident with an initial admitted [DATE]. Resident #40 had diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning), transient cerebral ischemic attack (a brief stroke-like attack that is caused by a brief blockage of blood flow to the brain), and need for assistance with personal care. Record review of Resident #40's Quarterly MDS Assessment, signed and completed on 03/22/2025, reflected Resident #40 had a BIMS score of 4, indicating the resident was severely cognitively impaired. Resident #40's MDS assessment indicated that Resident #40 was Dependent (helper does ALL of the effort) for showering/bathing. Record review of Resident #40's Comprehensive Person-Centered Care Plan, undated, reflected I have an ADL Self Care Performance Deficit r/t OTHER LACK OF COORDINATION, with interventions, I require (X) staff participation with bathing. Resident #40's Comprehensive Person-Centered Care Plan does not describe behaviors of refusals of showers, or refusals of any other type of care. Record review of Resident #40's tasks in his electronic health record reflected that the resident's shower days were Tuesday, Thursday, and Saturday in the evening. Further review revealed Resident #40 did not receive 4 of the 14 showers scheduled. Between 03/04/2025 and 04/03/2025, Resident #40 received showers on the following dates: 03/07/2025, 03/17/2025, 03/19/2025, 03/21/2025, 03/24/2025, 03/26/2025, 03/28/2025, 04/02/2025, and 04/03/2025. There were no other showers documented on the resident's electronic health record. An interview was attempted on 04/04/2025 at 11:20 AM with Resident #28, who was unable to answer questions relating to their showers due to their cognitive status. Interview on 04/04/2025 at 12:23 PM, CNA M stated he works any shift at the facility that was available for him to pick up, and that he was able to see when each resident showers by going into their task schedule in PCC, the facilities electronic health record. CNA M stated there was also a paper schedule at the nurse's station. CNA M stated that if any CNA is not able to bathe a scheduled resident on their shift, they will discuss it with the nurse and typically it is assigned to the next shift to complete. Interview on 04/04/2025 at 12:26 PM, the ADON stated that typically if a CNA does not have time to complete any assigned and scheduled showers on their shift, it should be communicated to the nurse and a progress note would be written. Interview on 04/04/2025 at 1:59 PM with the ADM and DON, the DON stated she was not aware residents were not receiving showers as scheduled, and that while it was unlikely the residents did not receive a shower, they did not have documentation apart from what was in each residents Electronic Health Record. The DON stated her expectation for if a resident refuses a shower is for it to be documented by the CNA and Nurse. The DON stated the risk to residents could include breakdown in skin integrity. The DON stated that all residents who were listed as not having a shower have a long history of refusals which is care planned and documented. The ADM stated that in their morning rounds that are completed on residents as administration staff, they sometimes have to tell nursing staff that a resident needs to be showered. Record review of facility policy, dated reviewed December 2024, titled, Shower/Tub Bath reflected The following information should be recorded on the resident's ADL record and/or in the resident's medical record: 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath.

Based on observations, interviews, and records review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident receives adequate assistance devices to prevent accidents for 3 of 3 resident halls reviewed for infection control and 1 resident (Resident #64) of 3 residents reviewed for accidents and hazards. 1. The facility failed to store hand sanitizer in a way that prevented residents to access the hazardous substance without supervision. 2.The facility failed to ensure that fall mats were in place for Resident #64. These failures could place resident at risk for injuries due to not having adequate supervision or devices. 1.Observation and interview during the initial facility tour on 4/01/2025 beginning at 09:49 AM, it was observed that hand sanitizer dispensers were not present outside of resident rooms in Hall B or within the PPE cart located in front of room B7. Surveyors on Halls A and C confirmed that dispensers were not present on their respective halls at this time. LVN L was present during this observation and asked about the availability of hand sanitizer. LVN L stated hand sanitizer was kept at the nurse's station and provided a bottle for surveyor use. LVN L was overheard notifying the DON that the surveyor was asking about hand sanitizer. At 10:21 , full bottles of hand sanitizer were noted to be present on top of the EBP carts in Hall B. The DON was present during this observation stocking hand sanitizer. Surveyors on Halls and C confirmed similar observations at this time. An interview was conducted with the DON and the Admin on 4/04/2025 at 1:55 PM. When asked about the availability of hand sanitizer, the DON and the Admin both confirmed that storing individual bottles of hand sanitizer on top of the EBP carts for staff and visitor use is the usual storage method for the facility. The Admin clarified that on Hall C, staff will hide the sanitizer within the EBP drawers because there are several residents residing in the hall that have altered cognition and will steal supplies. As the EBP carts at the facility consisted of unlocked, plastic drawers, the Admin was asked how residents who are at risk for misusing the substance are kept safe from obtaining the hand sanitizer. The Admin stated that staff will monitor the residents and act as physical barriers between the hand sanitizers and the drawers, if necessary. At the conclusion of the interview, the facility MSDS book was reviewed to ensure that the hand sanitizer was included, in the event of ingestion. The information was not contained within the book. 2.Review of Resident #64's face sheet, dated 4/04/2025, reflected a [AGE] year-old female with an initial admitted [DATE]. Relevant diagnoses included muscle wasting and atrophy (the loss and breakdown of muscle), other lack of coordination, unspecified dementia (a progressive disorder that affects a person's thinking skills), unsteadiness on feet, weakness, and muscle weakness. Review of the quarterly MDS submitted on 3/11/2025 reported a BIMS score of 04, indicating severe cognitive impairment. On 2/28/2025, the facility self-reported an incident regarding a fall sustained by Resident #64. P ER the provider report, reviewed 3/31/2025, the resident fell from bed, causing a facial injury. An initial x-ray indicated a possible right-sided orbital fracture (the bone surrounding the eye area), and the facility transferred the resident to the hospital for treatment. The hospital determined that the resident did not have a fracture through additional diagnostic testing, and the resident returned to the facility. The facility reported an investigation process that included the planned interventions of bed was lowered, call light w/in [within] reach, fall mats. The resident was interviewed on 4/02/2025 at 08:20 AM. The resident recalled the fall and stated she was trying to reach an object that had fallen from the bed at the time of the fall. The resident denied concerns with care provided by the facility. At this time, the resident was observed in bed with the call light within her reach, and the bed was lowered. Fall mats were not observed to be present next to the bed. The resident was again observed on 4/03/2025 at 1:02 PM. The resident was in bed, the bed was lowered, and the call light was in the bed near the resident. Fall mats were not present next to the bed. The resident was observed a third time on 4/04/2025 at 7:40 AM. At that time, the resident was asleep in the low-positioned bed. The location of the call light could not be determined due to the position of the resident and the blankets covering her. Fall mats were not present next to the bed. An interview was conducted with the DON on 4/4/2025 at 1:55 PM. The DON was asked to review the investigation process for the fall incident for Resident #64. The DON stated staff was educated to make sure that beds are low, to make sure that call lights are within reach, residents should be wearing non-skin socks, and decluttering rooms. The DON also reported changes were made because of the investigation, and she reported instituting a fall mat when she was in bed and ensuring that the resident had an electric bed that could be easily lowered.

Based on observations, interviews, and record reviews, the facility failed to revise the comprehensive care plan after each assessment for 1 (Resident #64) out of 8 residents reviewed for care planning. The facility failed to revise the care plan after investigating a fall sustained by Resident #64. The facility investigation included planned interventions that were not included care plan revision. This failure could result in the resident not receiving planned care or additional falls. The findings included: Review of Resident #64's face sheet, dated 4/04/2025, reflected a [AGE] year-old female with an initial admitted [DATE]. Relevant diagnoses included muscle wasting and atrophy, other lack of coordination, unspecified dementia (a progressive disorder that affects a person's thinking skills), unsteadiness on feet, weakness, and muscle weakness. Review of the quarterly MDS for Resident #64 submitted on 3/11/2025 revealed a BIMS score of 04, indicating severe cognitive impairment . On 2/28/2025, the facility self-reported an incident regarding a fall sustained by Resident #64. Per the provider report, the resident fell from the bed, causing a facial injury. An initial x-ray indicated a possible right-sided orbital fracture (the bone surrounding the eye area), and the facility transferred the resident to the hospital for treatment. The hospital determined that the resident did not have a fracture through additional diagnostic testing, and the resident returned to the facility. The facility reported an investigation process that included the planned interventions of bed was lowered, call light w/in [within] reach, fall mats. Resident #64 was interviewed on 4/02/2025 at 08:20 AM. The resident recalled the fall and stated she was trying to reach an object that had fallen from the bed at the time of the fall. The resident denied concerns with care provided by the facility. At the time of the interview, the resident was observed in bed with the call light within her reach, and the bed was lowered. Fall mats were not observed to be present next to the bed. Resident #64 was again observed on 4/03/2025 at 1:02 PM. The resident was in bed, the bed was lowered, and the call light was in the bed near the resident. Fall mats were not present next to the bed. Resident #64 was observed a third time on 4/04/2025 at 7:40 AM. At that time, the resident was asleep in the low-positioned bed. The location of the call light could not be determined due to the position of the resident and the blankets covering her. Fall mats were not present next to the bed. A record review of Resident #64's current care plan, date printed 4/03/2025, reflected an update signifying the fall occurrence in the focus area of I am at risk for falls r/t [related to] NEED FOR ASSISTANCE WITH PERSONAL CARE, MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED MULTIPLE SITES [sic]. The interventions/tasks associated with the focus area showed most recent updates on 8/08/2024. Fall mats were not listed as an associated intervention, nor was bed in lowered position. An interview was conducted with the DON on 4/4/2025 at 1:55 PM. The DON was asked to review the investigation process for the fall incident for Resident #64. The DON stated staff were educated to make sure that beds were low, to make sure that call lights were within reach, residents should be wearing non-skin socks, and decluttering rooms. The DON also reported changes were made because of the investigation, and she reported instituting a fall mat when she was in bed and ensuring that the resident had an electric bed that could be easily lowered. The DON was then asked if the care was updated to reflect these changes, and the DON reported that yes, it should be updated .

Based on observation , interview and record review, the facility failed to ensure that residents receive proper treatment to maintain vision abilities and assist the resident in making appointments for 1 (Resident #18) of 6 residents reviewed for communication and sensory problems. The facility failed to reschedule an ophthalmology appointment for Resident #18 to evaluate and treat the resident's medical condition affecting her eyesight. This failure could lead to diminished or loss of vision and decreased quality of life. The findings included : Record review of Resident #18's face sheet reflected she was an [AGE] year-old female originally admitted on [DATE]. Relevant diagnoses included type 2 diabetes mellitus without complication (a medical disorder that causes difficulty in regulating blood sugar levels), dementia (a progressive disorder that impairs thought processes such as memory, thinking, and reasoning), and cognitive social or emotional deficit following unspecified cerebrovascular disease. A review of the resident's Quarterly MDS submitted 11/11/2024 reflected a BIMS score of 08, indicating moderately impaired cognition . In an interview and observation conducted on 4/01/2025 at 3:25 PM, Resident #18 reported difficulty participating in facility hosted activities due to vision problems. The resident was wearing glasses at the time of interview and stated that even with the glasses, she had difficulty seeing. She was unsure if she had seen an optometrist or if she had any diagnoses related to her vision other than requiring glasses . A record review of Resident #18's current orders indicated a standing order for ophthalmology to evaluate and treat, effective 2/18/2025. A scanned photocopy of an evaluation by an optometrist dated 10/03/2024 was located within the medical record . This document indicated that Resident #18 complained of blurred vision to both eyes and watery eyes. The optometrist included a diagnosis of cataracts to both eyes as well as prolif diab rtnop with macular edema [sic] (proliferative diabetic retinopathy with macular edema, or damage to the nerves of the eye from diabetes causing vision loss) to both eyes. The note from the optometrist indicates refer to an ophthalmologist for retinal evaluation and cataract evaluation. A list of referrals for ophthalmology physicians was included with instructions to schedule an appointment. Further record review of Resident #18's medical record revealed a progress note documented by LVN L on 9/25/2024 that reflected: Resident was sent to eye doctor appointment with arrangements for [family member] to go meet her at her appointment. The family member was reminded of this appointment and out it on her phone on her last visit to see resident. Eye dr office called back stating the family member did not show up and they will have to reschedule appointment. This nurse called RP to inform her of the no show and she stated she didn't know if her car would be working and couldn't go. This nurse told her eye dr will reschedule and call her back with new appointment [sic]. No additional progress notes or scanned documents regarding the rescheduled appointment were located within the entirety of the electronic medical record. In an interview with LSW K on 4/04/2025 at 09:28 AM, LSW K recalled the need for an appointment relating to vision services for Resident #18. Written documentation was in LSW K's files reflecting the ophthalmology appointment on 9/25/2024. LSW K was unaware that the resident was not able to be evaluated at theis appointment and the need for a rescheduled appointment. LSW K stated that she would research the issue further and discuss again when she had obtained more information. In an interview on 4/04/2025 at 11:20 with LVN L recalled the unsuccessful ophthalmology appointment and was unsure if the appointment had been rescheduled . LVN L felt that Resident #18's vision had been declining and that it was affecting her (the resident's) ability to do things. LVN L stated she was going to call the physician's office to see if the appointment had been rescheduled and would schedule an appointment if one had not been created. On 4/04/2025 at 01:02 PM, LVN L provided an update to survey team regarding the opthalmology appointment appointment. LVN L reported that after speaking with surveyor, she called the opthalmology office and scheduled a new appointment for the end of April. She had arranged for facility staff to accompany the resident to ensure that she was evaluated successfully. Documentation from the ophthalmology office was provided by LVN L on 4/04/2025 at 2:00 PM. Review of the document reflected the missed appointment on 9/25/2024 with rationale Patient was note seen due to family member not present for exam to assist the patient. Transport was called to pick-up.

Based on observations, interviews and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 7 of 9 residents (#9, 12, 30, 32, 43, 45, 219 ) reviewed for care, in that: 1. LVN H did not wash her hands or clean equipment after performing blood glucose monitoring to Residents #9, 30, 43, 45 and 219. Resident #9 was on contact isolation precautions. 2. Resident #32 was on contact isolation precautions. a. Resident #32's indwelling catheter was on the floor. b. CNA C did not wash her hands after transferring Resident #32 from his wheelchair to his bed. c. Resident #32 did not have an isolation biohazard bag or trash can in his room. 3. a. CNA I did not wash or sanitize her hands during perineal care when changing gloves for Resident #12. b. CNA I and MA K did not wear protective gear (gown and gloves) when entering Resident #12's room in which Resident # 12 was on contact isolation precautions. 4. Staff did not ensure that a visitor used isolation precautions or washed hands after contact with Resident #32 who was on contact isolation precautions. 5. The facility failed to monitor staff compliance for isolation precautions and in-service or train staff when the facility had an increase in urinary tract infections and resident's on contact isolation. These failures could affect all residents and could result in more infections and a decline in resident's health. Findings: 1. Review of Resident #30's face sheet, dated 10/25/19 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's face sheet, dated 10/25/19 revealed an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's Consolidated Physician order [REDACTED]. Review of Resident # 45 face sheet, dated 10/22/19 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident # 219, dated 10/22/19 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident # 43 face sheet, dated 10/22/19 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation of med pass on 10/22/19 at 11:25 am revealed LVN H walked out of Resident # 30's room without washing her hands or using hand sanitizer and opened the medication cart on hallway B. LVN H the proceeded to dawn on gloves but did not put on a gown and entered Resident #9's room who was on contact isolation. LVN H then performed blood glucose monitoring on Resident #9 then walked back to the cart without removing her gloves and placed glucometer machine on the cart and touched several items on the medication cart. LVN H then removed gloves but did not wash her hands or use hand sanitizer and then went to Resident #43's room and performed blood glucose monitoring without cleaning the machine from the last use in the room that was contact isolation at which time surveyor intervened. Interview on 10/22/19 at 11:33 am LVN H confirmed she did not wash her hands after exiting the contact isolation room. Observation on 10/22/19 at 11:36 am revealed LVN H performed blood glucose monitoring on Resident #45. LVN H washed her hands but did not sanitize the glucometer machine after use. Observation on 10/22/19 at 11:38 am revealed LVN H performed blood glucose monitoring on Resident # 219. LVN H washed her hands but did not sanitize the glucometer machine after use. Surveyor intervened at this time for a second time. Interview with LVN H 10/22/19 11:59 AM confirmed that she did not sanitize the glucometer machine between use. LVN H stated, I think I might have wiped the with alcohol after using it with the contact isolation resident, but I can't remember. LVN H revealed Sani-wipes were the required sanitation method and she stated, I do not have any Sani-wipes with me. During further interview LVN H confirmed she did not wash or sanitize her hands after having contact with residents or use a gown when she entered the contact isolation room. Record review of facility's policy on Cleaning and Disinfection of Resident -Care Items and Equipment revised (MONTH) 2014 read Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions. Record review of glucometer manufacturers' user guide (2018) read Cleaning and disinfecting your meter and lancing device is very important in the prevention of infectious disease. Cleaning also allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter and lancing device surface. Record review of Centers for Disease Control and Prevention; Infection Prevention during Blood Glucose Monitoring and Insulin Administration dated 2/21/19 read .if blood glucose meter must be shared , the device should be cleaned and disinfected after every use, per manufacturer's instructions. retrieved on 11/6/19 from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html 2. Review of Resident # 32's face sheet dated 10/24/19 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident # 32's physician order [REDACTED]. Review of Resident # 32's Quarterly MDS dated [DATE] revealed Resident # 32 had an indwelling catheter. Review of Resident # 32's Care Plan dated 9/19/19 revealed Resident # 32 had an Indwelling Catheter and on 10/22/19 revealed Resident # 32 had a Urinary Tract Infection:Ertapenem Sodium (antibiotic) Solution Reconstituted 1 GM Use 1 gram intravenously one time a day for Urinary Tract Infection [MEDICAL CONDITION] - Proteus Mirabilis & Citrobacter Freundii (type of bacteria) for 10 Administrations until finished IV daily x 10 days and [MEDICATION NAME] (antibiotic) Tablet 600 MG (Linezolid) Give 1 tablet by mouth two times a day for UTI until 10/30/2019 Contact isolation for proteus mirabilis (type of bacteria). Observation 10/22/19 at 9:49 AM revealed Resident #32 had an isolation cart in front of his room and a note on his door to see the nurse. Further observation in Resident #32's room revealed he was sitting in his wheelchair and his indwelling catheter tubing was on the floor, (b)CNA C did not wash her hands after transferring Resident #32 from his wheelchair to his bed, and (c) Resident #32 did not have an isolation biohazard bag or trash can in his room. Interview on 10/22/19 at 9:56 AM with CNA C confirmed she did not wash her hands after transferring Resident #32 and placed her isolation garments and gloves in the regular trash can in Resident #32's room. 3. Review of a face sheet for Resident #12 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Consolidated Physician orders [REDACTED]. Observation on 10/23/19 11:02 AM of peri-care on Resident # 12 revealed CNA I changed gloves while providing peri-care to the resident but did not wash or sanitize her hands. Interview on 10/23/19 11:09 AM with CNA I confirmed that she did not wash or sanitize her hands after glove changes during peri-care for Resident #12. CNA I stated, Oh, I forgot. Observation on 10/23/19 11:18 AM of Resident #12 revealed that CNA I walked into the resident room without gowning or gloving for isolation precautions and shut the door behind her blocking the view. Further observation revealed CNA I walked out of the room. Interview on 10/23/19 11:20 AM with CNA I confirmed she went into the room without gowning and gloving or using isolation precautions. CNA I stated, I was just turning on the TV real quick. Observation of Resident # 12 on 10/23/19 11:26 AM revealed staff MA K entered Resident #12's room without gowning or gloving and picked up a blanket and call light. Interview on 10/23/19 at 11:30 AM MA K confirmed she did not use a gown and gloves when entering the room. Further interview revealed Resident #12's infection was in the urine and she only needed to use precautions when changing the residents brief. 4. Review of Resident #32's face sheet, dated 10/25/19 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #32's Consolidated Physician order [REDACTED]. Observation of Resident #32's wound care on 10/25/19 at 12:05 PM with the ADON and LVN K revealed the resident's family member came into the room during the care without a gown or gloves on. The family member hugged and kissed Resident #32 before leaving the room without washing her hands. Interview with LVN K on 10/25/19 at 12:05 PM confirmed Resident #32's family member did not gown glove or wash her hands before leaving Resident #32's room. The interview further revealed that visitors should be given education on isolation precautions and should be told to at least wash their hands before leaving the room. Interview with DON on 10/25/19 12:09 PM confirmed that visitors should use a gown and glove and utilize the same isolation precautions as staff. 5. Review of the facilities Infection Control Log for 2019 revealed 12 residents had facility acquired infections for (MONTH) 2019 and 19 residents who had facility acquired infections in (MONTH) 2019 with an increased prevalence of UTI. Further review of the facility log revealed that there was no common pathogen although [NAME]ella [NAME]ii was the pathogen with the most frequency. The infections were located on all 4 hallways of the facility. Interview on 10/25/19 at 3:42 PM the DON confirmed she was aware of the trend for UTIs. The DON stated the Medical Director was aware of the infections in the facility and that they have increased fluids for residents with UTI, and would continue to monitor for trends. Interview on 10/25/19 at 4:05 PM the Regional Nurse Consultant revealed she did not feel comfortable answering questions regarding monitoring or implementation of the infection control surveillance program and deferred to the DON. Interview with MA M on 10/25/19 at 4:12 PM confirmed no new training had been given to staff since the infection rate had increased in the facility. Interview with LVN N on 10/25/19 at 4:20 PM confirmed no new or additional training since infection rate and increase utilization of isolation precautions had increased in the facility. Interview with the DON on 10/25/19 at 4:45 PM revealed the last in-service provided to staff was on 8/14/19 which included linen change and peri-care. The DON revealed that she monitored peri care for compliance, monitors handwashing while monitoring peri care but relied on the staff to do the right thing by washing their hands after resident care. The DON confirmed that since the infections began increasing that she had not provided any additional training or monitoring to staff. Review of a facility policy titled Infection Control Guidelines for All Nursing Procedures dated (MONTH) (YEAR) revealed, 1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on general infection and exposure control issues including a. facility protocols for isolation precautions 2. Prior to having direct care responsibilities for residents, staff must have appropriate in-service training on managing infections in residents, including b. methods of preventing their spread. 3. employees must wash their hands for 10-15 seconds using .soap and water under the following conditions a. before and after direct contact with residents .c. after contact with blood, body fluids, secretions, mucous membranes, non-intact skin d. after removing gloves e. after handling items potentially contaminated with blood . Review of a facility policy titled Isolation-Categories of Transmission-Based precautions dated (MONTH) 2012 revealed Contact Precautions 4. Gloves and Handwashing a. In addition to wearing gloves outlined under standard precautions, wear gloves when entering the room b. while providing care for a resident c. remove gloves before leaving the room and perform hand hygiene, d. after removing gloves and washing hands, do not touch potentially contaminated environmental surfaces or items in the resident room. 5. gown a). wear a disposable gown upon entering the contact precautions room. Interview on 11/6/19 at 10:20 a.m. the DON reported they had discussed infection control and precautions at their Quality Assurance (QA) meeting on 10/28/19. The Administrator reported the facility had discussed infection control in the last 2 to 3 QA meetings that are held monthly. The DON reported they now had 2 glucometers on each hall to allow time for cleaning and allowing glucometer to dry. The DON reported they had decreased their number of residents on isolation from 9 to 6. Interview on 11/6/19 at 10:45 a.m. the facility's Medical Director revealed he had been Medical Director for the facility for 6 weeks. He reported he found out a short while ago (at QA meeting 10/28/19) about the number of residents with infections and on antibiotics and they had discussed the practice of transmission-based precautions.

Based on observations, interviews and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 7 of 9 residents (#9, 12, 30, 32, 43, 45, 219 ) reviewed for infection control in that: 1. LVN H did not wash her hands or clean equipment after performing blood glucose monitoring to Residents #9, 30, 43, 45 and 219. Resident #9 was on contact isolation precautions. 2. Resident #32 was on contact isolation precautions. a. Resident #32's indwelling catheter was on the floor. b. CNA C did not wash her hands after transferring Resident #32 from his wheelchair to his bed. c. Resident #32 did not have an isolation biohazard bag or trash can in his room. 3. a. CNA I did not wash or sanitize her hands during perineal care when changing gloves for Resident #12. b. CNA I and MA K did not wear protective gear (gown and gloves) when entering Resident #12's room in which Resident # 12 was on contact isolation precautions. 4. Staff did not ensure that a visitor used isolation precautions or washed hands after contact with Resident #32 who was on contact isolation precautions. 5. The facility failed to monitor staff compliance for isolation precautions and in-service or train staff when the facility had an increase in urinary tract infections and resident's on contact isolation. These failures could affect all residents and could result in more infections and a decline in resident health. Findings: 1. Review of Resident #30's face sheet, dated 10/25/19 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's face sheet, dated 10/25/19 revealed an admitted [DATE] with a readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's Consolidated Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 45 face sheet, dated 10/22/19 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 219, dated 10/22/19 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 43 face sheet, dated 10/22/19 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of med pass on 10/22/19 at 11:25 am revealed LVN H walked out of Resident # 30's room without washing her hands or using hand sanitizer and opened the medication cart on hallway B. LVN H the proceeded to dawn on gloves but did not put on a gown and entered Resident #9's room who was on contact isolation. LVN H then performed blood glucose monitoring on Resident #9 then walked back to the cart without removing her gloves and placed glucometer machine on the cart and touched several items on the medication cart. LVN H then removed gloves but did not wash her hands or use hand sanitizer and then went to Resident #43's room and performed blood glucose monitoring without cleaning the machine from the last use in the room that was contact isolation at which time surveyor intervened. Interview on 10/22/19 at 11:33 am LVN H confirmed she did not wash her hands after exiting the contact isolation room. Observation on 10/22/19 at 11:36 am revealed LVN H performed blood glucose monitoring on Resident #45. LVN H washed her hands but did not sanitize the glucometer machine after use. Observation on 10/22/19 at 11:38 am revealed LVN H performed blood glucose monitoring on Resident # 219. LVN H washed her hands but did not sanitize the glucometer machine after use. Surveyor intervened at this time for a second time. Interview with LVN H 10/22/19 11:59 AM confirmed that she did not sanitize the glucometer machine between use. LVN H stated, I think I might have wiped the with alcohol after using it with the contact isolation resident, but I can't remember. LVN H revealed Sani-wipes were the required sanitation method and she stated, I do not have any Sani-wipes with me. During further interview LVN H confirmed she did not wash or sanitize her hands after having contact with residents or use a gown when she entered the contact isolation room. Record review of facility's policy on Cleaning and Disinfection of Resident -Care Items and Equipment revised July 2014 read Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions. Record review of glucometer manufacturers' user guide (2018) read Cleaning and disinfecting your meter and lancing device is very important in the prevention of infectious disease. Cleaning also allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter and lancing device surface. Record review of Centers for Disease Control and Prevention; Infection Prevention during Blood Glucose Monitoring and Insulin Administration dated 2/21/19 read .if blood glucose meter must be shared , the device should be cleaned and disinfected after every use, per manufacturer's instructions. retrieved on 11/6/19 from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html 2. Review of Resident # 32's face sheet dated 10/24/19 revealed he was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 32's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 32's Quarterly MDS dated [DATE] revealed Resident # 32 had an indwelling catheter. Review of Resident # 32's Care Plan dated 9/19/19 revealed Resident # 32 had an Indwelling Catheter and on 10/22/19 revealed Resident # 32 had a Urinary Tract Infection:Ertapenem Sodium (antibiotic) Solution Reconstituted 1 GM Use 1 gram intravenously one time a day for Urinary Tract Infection ([CONDITION(S)]) - Proteus Mirabilis & Citrobacter Freundii (type of bacteria) for 10 Administrations until finished IV daily x 10 days and [MEDICATION(S)] (antibiotic) Tablet 600 MG ([MEDICATION(S)]) Give 1 tablet by mouth two times a day for [CONDITION(S)] until 10/30/2019 Contact isolation for proteus mirabilis (type of bacteria). Observation 10/22/19 at 9:49 AM revealed Resident #32 had an isolation cart in front of his room and a note on his door to see the nurse. Further observation in Resident #32's room revealed he was sitting in his wheelchair and his indwelling catheter tubing was on the floor, (b)CNA C did not wash her hands after transferring Resident #32 from his wheelchair to his bed, and (c) Resident #32 did not have an isolation biohazard bag or trash can in his room. Interview on 10/22/19 at 9:56 AM with CNA C confirmed she did not wash her hands after transferring Resident #32 and placed her isolation garments and gloves in the regular trash can in Resident #32's room. 3. Review of a face sheet for Resident #12 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Consolidated Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 10/23/19 11:02 AM of peri-care on Resident # 12 revealed CNA I changed gloves while providing peri-care to the resident but did not wash or sanitize her hands. Interview on 10/23/19 11:09 AM with CNA I confirmed that she did not wash or sanitize her hands after glove changes during peri-care for Resident #12. CNA I stated, Oh, I forgot. Observation on 10/23/19 11:18 AM of Resident #12 revealed that CNA I walked into the resident room without gowning or gloving for isolation precautions and shut the door behind her blocking the view. Further observation revealed CNA I walked out of the room. Interview on 10/23/19 11:20 AM with CNA I confirmed she went into the room without gowning and gloving or using isolation precautions. CNA I stated, I was just turning on the TV real quick. Observation of Resident # 12 on 10/23/19 11:26 AM revealed staff MA K entered Resident #12's room without gowning or gloving and picked up a blanket and call light. Interview on 10/23/19 at 11:30 AM MA K confirmed she did not use a gown and gloves when entering the room. Further interview revealed Resident #12's infection was in the urine and she only needed to use precautions when changing the residents brief. 4. Review of Resident #32's face sheet, dated 10/25/19 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #32's Consolidated Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #32's wound care on 10/25/19 at 12:05 PM with the ADON and LVN K revealed the resident's family member came into the room during the care without a gown or gloves on. The family member hugged and kissed Resident #32 before leaving the room without washing her hands. Interview with LVN K on 10/25/19 at 12:05 PM confirmed Resident #32's family member did not gown glove or wash her hands before leaving Resident #32's room. The interview further revealed that visitors should be given education on isolation precautions and should be told to at least wash their hands before leaving the room. Interview with DON on 10/25/19 12:09 PM confirmed that visitors should use a gown and glove and utilize the same isolation precautions as staff. 5. Review of the facilities Infection Control Log for 2019 revealed 12 residents had facility acquired infections for September 2019 and 19 residents who had facility acquired infections in October 2019 with an increased prevalence of [CONDITION(S)]. Further review of the facility log revealed that there was no common pathogen although Morganella Morganii was the pathogen with the most frequency. The infections were located on all 4 hallways of the facility. Interview on 10/25/19 at 3:42 PM the DON confirmed she was aware of the trend for UTIs. The DON stated the Medical Director was aware of the infections in the facility and that they have increased fluids for residents with [CONDITION(S)], and would continue to monitor for trends. Interview on 10/25/19 at 4:05 PM the Regional Nurse Consultant revealed she did not feel comfortable answering questions regarding monitoring or implementation of the infection control surveillance program and deferred to the DON. Interview with MA M on 10/25/19 at 4:12 PM confirmed no new training had been given to staff since the infection rate had increased in the facility. Interview with LVN N on 10/25/19 at 4:20 PM confirmed no new or additional training since infection rate and increase utilization of isolation precautions had increased in the facility. Interview with the DON on 10/25/19 at 4:45 PM revealed the last in-service provided to staff was on 8/14/19 which included linen change and peri-care. The DON revealed that she monitored peri care for compliance, monitors handwashing while monitoring peri care but relied on the staff to do the right thing by washing their hands after resident care. The DON confirmed that since the infections began increasing that she had not provided any additional training or monitoring to staff. Review of a facility policy titled Infection Control Guidelines for All Nursing Procedures dated August 2017 revealed, 1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on general infection and exposure control issues including a. facility protocols for isolation precautions 2. Prior to having direct care responsibilities for residents, staff must have appropriate in-service training on managing infections in residents, including b. methods of preventing their spread. 3. employees must wash their hands for 10-15 seconds using .soap and water under the following conditions a. before and after direct contact with residents .c. after contact with blood, body fluids, secretions, mucous membranes, non-intact skin d. after removing gloves e. after handling items potentially contaminated with blood . Review of a facility policy titled Isolation-Categories of Transmission-Based precautions dated January 2012 revealed Contact Precautions 4. Gloves and Handwashing a. In addition to wearing gloves outlined under standard precautions, wear gloves when entering the room b. while providing care for a resident c. remove gloves before leaving the room and perform hand hygiene, d. after removing gloves and washing hands, do not touch potentially contaminated environmental surfaces or items in the resident room. 5. gown a). wear a disposable gown upon entering the contact precautions room. Interview on 11/6/19 at 10:20 a.m. the DON reported they had discussed infection control and precautions at their Quality Assurance (QA) meeting on 10/28/19. The Administrator reported the facility had discussed infection control in the last 2 to 3 QA meetings that are held monthly. The DON reported they now had 2 glucometers on each hall to allow time for cleaning and allowing glucometer to dry. The DON reported they had decreased their number of residents on isolation from 9 to 6. Interview on 11/6/19 at 10:45 a.m. the facility's Medical Director revealed he had been Medical Director for the facility for 6 weeks. He reported he found out a short while ago (at QA meeting 10/28/19) about the number of residents with infections and on antibiotics and they had discussed the practice of transmission-based precautions.