Every finding on record at Jaffrey Rehabilitation and Nursing Center

Based on interview and record review it was determined that the facility failed to implement control measures from their water management plan to prevent the growth and spread of Legionella and other water borne pathogens in a facility with a census of 72 residents. Findings Include: Review on 5/20/26 of facility's Legionella Water Management Plan revealed: Control Measures and Corrective Actions 4. Flush hot water tank sediment at least annually. 7. Remove and clean shower heads (including handheld wands) used for resident bathing. Clear strainers and pressure restrictors of sediment and potential biofilm, at least annually. Interview on 5/20/2026 at 9:28 a.m. with Staff B (Director of Maintenance) confirmed that there was no documentation the above control measures were performed. Review on 5/20/26 of facility policy titled Legionella Water Management Program, revised in September 2022, revealed: 5. The water management program includes the following elements: f. The control limits or parameters that are acceptable and that are monitored .

Based on interview and record review, the facility failed to follow physician's order for 1 of 2 residents reviewed for choices in a final sample of 18 residents (Resident identifier is #1).Findings include:[NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . Review on 5/19/26 of Resident #1's May 2026 Medication Administration Record revealed the following order: a scheduled Ativan at daily bedtime. Further review revealed, Ativan was not administered on 5/5/26 through 5/9/26.Review on 5/19/26 of Resident #1's progress notes dated 5/5/26 through 5/9/26 revealed notes that the Ativan was unavailable and no documentation that the provider was notified.Interview 5/21/26 at approximately 8:20 a.m. with Staff G (Registered Nurse) confirmed the above findings.

Based on observation, interview, and record review, the facility failed to ensure that a resident's dietary preferences were taken into consideration 1 of 2 residents reviewed for choices in a final sample of 18 residents. (Resident identifier is #12.)Findings include: Interview on 5/19/26 at approximately 9:08 a.m. with Resident #12 revealed that he/she does not get what they want for breakfast. Resident #12 further revealed that, The Speech pathologist made all kinds of changes to my diet and that I can't have bacon. Resident #12 revealed that he/she would like bacon with his/her breakfast each day.Observation on 5/20/26 at approximately 8:41 a.m. of Resident #12 in the main dining room revealed the Resident #12's breakfast consisted of fried eggs, oatmeal with syrup, and pancakes.Interview on 5/20/26 at approximately 8:45 a.m. with Resident #12 revealed that he/she did not have bacon with breakfast and that I am not allowed to have bacon.Review on 5/20/26 of Resident #12's medical record Health status note 5/10/26 revealed, .ST (Speech Therapist) screened resident during lunch . Pt (patient) requested bacon be added back to [pronoun omitted] diet. Educated on current diet texture implications and pt was agreeable to bacon cut into bite sized pieces . Shared findings with RN (Registered nurse) and clarified diet order. Interview on 5/20/26 at approximately 12:46 p.m. with Staff C (Dietary Director) confirmed that bacon was on the menu for breakfast this morning and that Resident #12 did not have bacon as it is not appropriate for his/her diet and would require update from speech therapist.Interview on 5/20/26 at approximately 12:49 p.m. with Staff D (Director of Rehabilitation) revealed that Resident #12 was seen by the ST on 5/10/26 and cleared for cut up bacon. Staff D further revealed that a diet order change was given to nursing for the modification.Interview on 5/20/26 at approximately 12:53 p.m. with Staff E (Registered Nurse) revealed that he/she received the updated diet slip for cut up bacon and delivered the written order to the kitchen on 5/10/26.Review on 5/20/26 of Resident #12's diet order and diet slip dated 5/10/26 and signed by the ST revealed diet change, texture bite size and notation bacon is allowed. Interview on 05/20/26 at approximately 1:05 p.m. with Staff C revealed that he/she was not aware of the diet change. Review on 5/20/26 of Resident #12's care plan revealed: Intervention to provide and serve diet as ordered. Review on 5/20/26 of the facility's policy Interdepartmental Notification of diet (Including changes and reports) revealed, Nursing services shall notify the food and nutrition services department of a resident's orders, including any changes in the resident's diet, meal service, and food preferences 1 the nurse supervisor shall ensure that the food and nutrition services department receives a written notice of the diet order.

Based on interview and record review, the facility failed to ensure that a resident receiving psychotropic medications received a gradual dose reduction (GDR) for 1 or 5 residents reviewed for unnecessary medications in a final sample of 18 residents (Resident identifier is #6 ).Findings include: Resident #6 Review on 5/21/26 of Resident #6's medication orders revealed an order for Seroquel 50 milligrams (mg) with an order date of 8/17/23 and Remeron 30mg with an order date of 3/2/2023. Review on 5/21/26 of Resident #6's psychiatric notes dated 2/4/26, 2/18/26, 4/15/26, 5/13/26, and 5/18/26 revealed no clinical contraindication for a GDR. Review on 5/21/26 of Resident #6's progress notes for the last year revealed no documentation of a gradual dose reduction. Interview on 5/21/26 at approximately 12:30 p.m. with Staff A (Director of Nursing) confirmed Resident #6 had not had a GDR in the last year and that there was no documentation of a clinical contraindication for a GDR.in Resident #6's medical record. Review on 5/21/26 of facility policy titled Tapering Medication and Gradual Dose Reduction revised date February 2025 revealed .Policy Interpretation and Implementation 1. Gradual Dose Reduction (GDR) refers to the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed at a lower dose or if a medication can be discontinued. 2. All medications are considered for possible tapering/GDR.4. Tapering/GDR may be used as an approach to finding an optimal dose or determining if continued use of a medication will benefit the resident.Psychotropic medications.2. After the first year, the facility will attempt a GDR at least annually, unless clinically contraindicated.Documentation-Gradual Dose Reduction 1. Gradual dose reduction attempts are documented in the medical record. The documentation includes: a. the date of the GDR attempt; b. outcome of the dose reduction attempt; c. any return or worsening of symptoms; d. plan regarding any future GDR attempts. 2. Physician documentation contains the rationale for why GDR attempts are clinically contraindicated for the resident.

Based on Interview and record review, the facility failed to provide documentation that the resident or resident representative was informed in advance of treatment risks and benefits, options and alternatives prior to initiating psychotropic medications for 1 of 5 residents reviewed for unnecessary medications in a final sample of 18. (Resident identifier is #31.)Findings include: Review on 5/21/26 of Resident #31's current physician's orders revealed the following order Clonazepam Oral Tablet 0.5 MG (Milligrams) give 0.5 tablet by mouth one time a day for anxiety related to Dementia in other diseases classified elsewhere, unspecified severity with anxiety and give 1 tablet by mouth at bedtime; dated 11/14/25Review on 5/21/26 of Resident #31's medical record revealed there was no consent signed by the resident or resident representative at the initiation of the medication on 11/14/25.Interview on 5/21/26 at approximately 12:02 p.m. with Staff A (Director of Nursing) confirmed the above findings.Review on 5/22/26 of the facility's policy Psychotropic Medication use, Revision date February 2025, revealed .Informed Consent or Refusal 1. Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medications, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: a. non-pharmacological alternatives; b. the indications and rationale for the recommendations; c. the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings); and d. the resident's/representative's right to accept or decline the treatment

Based on observation and interview, the facility failed to ensure all drugs and biologicals were maintained in a locked cart in 1 of 2 medication carts observed (Chapel Unit medication cart).Findings include:Chapel Unit medication cartObservation on 5/19/26 at approximately 8:15 a.m. of Chapel Unit medication cart revealed the cart was left unlocked for approximately 3 minutes with no responsible staff nearby.Interview on 5/19/26 at approximately 8:15 a.m. of Staff H (Medication Nursing Assistant) confirmed the above finding.Review on 5/20/26 of facility policy titled Medication Labeling and Storage revised date February 2023 revealed . Policy Interpretation and Implementation.4. Compartments (including but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use.

Based on interview and record review, it was determined that the facility failed to ensure that the facility assessment included specific staffing needs for each resident unit for a census of 72 residents. Findings include:Review on 5/20/26 of the Facility Assessment revealed the following . Staffing plan 3.2 . The staffing plan is to ensure sufficient staff is available to meet the needs of the residents at any given time and will fluctuate based on acuity and staff competency Direct care staff: Day shift: 3 Licensed Nurses (RN(Registered nurse)/LPN(Licensed practical nurse)) and 7 Licensed Nurses Aides; Eve Shift: 3 Licensed Nurses (RN/LPN) and 7 Licensed Nurses Aides; Night shift: 2 Licensed nurses (RN/LPN) and 4 Licensed Nurses Aides. Further review of the facility assessment did not identify staffing needs per resident unit.Interview on 5/21/26 at approximately 10:23 a.m. with Staff F (Director of Human Resources) confirmed that the facility assessment did not break down staffing for each resident unit.

Based on interview and record review, it was determined that the facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight (8) consective hours a day, 7 days a week, for 2 days in Fiscal Year Quarter 1 2025. Findings include: Review on 4/14/25 of the Payroll Based Journal Staffing Data [NAME] Report for Fiscal Year Quarter 1 2025 revealed that the facility triggered for failing to have Registered Nurse (RN) hours for 8 consecutive hours a day for 78 days during October 2025, November 2025, and December 2025. Review on 4/16/25 of the facility's Payroll Detail and Daily Attendance Report revealed that there was no RN coverage on 10/7/24 and 11/24/24. Interview on 4/16/25 at 2:37 p.m. with Staff K (Human Resources) confirmed there was no RN coverage on 10/7/24 and 11/24/24.

Based on interview and record review it was determined that the facility failed to submit complete and accurate data for Payroll Based Journal (PBJ) for Fiscal Year Quarter 1 2025 (October 1, 2025 to December 31, 2025). Findings include: Review on 4/14/25 of the Payroll Based Journal Staffing Data [NAME] Report for Fiscal Year Quarter 1 2025 revealed that the facility failed to have Registered Nurse (RN) hours and failed to have Licensed Nursing Coverage 24 hours a day on the following dates: 10/1/24 to 10/31/24; 11/1/24 to 11/30/24; and 12/15/25 to 12/31/25. Review on 4/16/25 of the facility's Payroll Detail and Daily Attendance Report revealed that there was 24 hour of Licensed Nurse coverage on the above days. Further review revealed that there was RN coverage on all but 2 days days (10/7/24 and 11/24/24). Interview on 4/16/25 at 2:37 p.m. with Staff K (Human Resources) confirmed there was Licensed Nursing Coverage 24 hours a day and there was no RN coverage on 10/7/24 and 11/24/24. Review on 4/16/25 of Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual, Version 2.6, effective date June 2022, revealed: .Accuracy: Staffing information is required to be an accurate and complete submission of a facility's staffing records. Facilities should run the staffing reports that are available in CASPER to verify the accuracy and completeness of their final submission prior to the submission deadline .

Based on observation, interview, and record review, it was determined that the facility failed to ensure a medication error rate less than 5 percent (%) for 2 of 28 medication administrations observed. (Resident Identifiers are #38 and #224). Findings include: Resident #38 Observation on 4/14/25 at 9:02 a.m. of the morning medication administration for Resident #38 with Staff L (Licensed Practical Nurse (LPN)) revealed Staff L prepared one tablet of Calcium Carbonate 600 milligrams (mg) and one tablet of Vitamin D 1000 units and attempted to administer the medications to Resident #38. Review on 4/14/25 of Resident #38's April 2025 Medication Administration Record (MAR) revealed a physician's order for Calcium Carbonate (600 mg) with Vitamin D and minerals (400 units) and to give 1 tablet by mouth daily. Interview on 4/14/25 at 9:02 am. with Staff L revealed that the facility did not have the Calcium Carbonate (600 mg) with Vitamin D (400 units) and minerals at the facility. Interview on 4/14/25 at 1:55 p.m. with Staff L confirmed the above and that he/she had administered the incorrect medication. Resident #224 Observation on 4/14/25 at 9:40 a.m. of Staff H (LPN) administering medications to Resident #224 revealed that Staff H obtained a bag of Ceftriaxone (an antibiotic) solution 2-2.22 grams in 50 milliliters (ml) of sodium-dextrose. Further observation revealed that the instructions on the pharmacy label indicated to infuse the medication over 30 minutes. Further observation revealed that Staff H set the intravenous (IV) pump to have 30 ml to be infused at a rate of 50 minutes. Review on 4/14/25 of Resident #224's April 2025 MAR revealed an order for Ceftriaxone 2 grams IV once a day. The physician's order did not contain the volume or the rate of the Ceftriaxone to be infused. Interview on 4/14/25 at 9:43 a.m. with Staff H confirmed that he/she had set the IV pump incorrectly by reversing the numbers. Staff H then reset the IV pump to run 50 ml over 30 minutes. Review on 4/15/25 of the facilities policy titled Administering Medications revised April 2019, revealed, . 10. The individual administering the medication checks the label THREE(3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . There were 2 medication errors out of a total of 28 medication administration opportunities resulting in a 7.14% error rate.

Based on interview and record review, it was determined that the facility failed to employ, at least on a part-time basis, an Infection Preventionist who had completed specialized training in infection prevention and control. Findings include: Interview on 4/15/25 at 10:06 a.m. with Staff B (Infection Preventionist (IP)) revealed that he/she was the IP for the facility for over a year. Review on 4/15/25 of Staff B's Nursing Home Infection Preventionist Training Course revealed that under the Completion had 1 course that was required (Completion for Nursing Home Infection Preventionist Training Course) and was Not Started. Interview on 4/15/25 at 2:24 p.m. with Staff B confirmed that they had not completed the above course, and still had to complete and pass the final test.

Based on record review and interview, it was determined that the facility failed to coordinate care to the resident provided by the LTC (Long Term Care) facility staff and hospice staff for 3 of 3 residents reviewed for hospice services in a final sample of 18 residents (Resident Identifiers are #12, #38 and #23). Findings includes: Resident #12 Review on 4/16/25 of Resident #12's medical record revealed Resident #12 was admitted to on 2/6/25. Further review of Resident #12's medical record revealed that hospice was to provide Nursing and LNA (Licensed Nursing Assistant) services. Further there was no calendar or schedule of planned hospice visits in the residents's hospice binder. Resident #38 Review on 4/16/25 of Resident #38's medical record revealed Resident #38 was admitted to the facility on [DATE] on hospice. Further review of Resident #38's medical record revealed that hospice was to provide Nursing and LNA services. Further there was no calendar or schedule of planned hospice visits in the residents's hospice binder. Interview on 4/16/25 at approximately 9:50 a.m. with Staff D (LNA) revealed that he/she is not aware of the hospice schedule. He/she further revealed that the facility staff, provide the care and let hospice know if the resident needs anything, when they show up Interview on 4/16/25 at approximately 9:57 a.m. Staff C LNA revealed that he/she has no knowledge of the hospice plan, times, days of visits. Interview on 4/16/25 at approximately 11:10 AM with Staff G (Licensed Social Worker LSW)) revealed that the hospice schedule should be in the resident binder on the unit. Further Staff G revealed that he/she has a copy of the schedule in his/her email but that he/she does not place it into the binder on the floor or verify that it is present in the hospice binder for the individual resident. 49819 Resident #23 Review on 4/14/25 at approximately 2:00 p.m. of Resident #23 hospice binder revealed a hospice admitted [DATE] and no schedule of visits or services to be provided. Interview on 4/15/25 at approximately 8:20 a.m. with Staff H (Licensed Practical Nurse (LPN)) revealed nursing is unaware of when or how often hospice visits are. Review on 4/15/25 at approximately 9:00 a.m. of Resident #23's hospice care plan revealed LNA [Licensed Nursing Assistant] visits per schedule. Interview on 4/16/25 at approximately 10:45 a.m. with Staff I (Licensed Nursing Assistant (LNA)) revealed there was no prediction of when visits will take place or how often. Interview on 4/16/25 at approximately 11:15 a.m. with Staff G (Social Services) revealed he/she had thought hospice was providing the units with a visits schedule. Interview further revealed, he/she was emailed the schedules but did not provide them to the units.

Based on observation, interview and record review, it was determined that the facility failed to ensure that resident medical records were accurate for 3 residents reviewed in a final sample of 18 residents (Resident Identifiers are #40, #123 and #274.) Findings Include: Resident #40 Review on 4/16/25 of Assessing Falls and Their Causes, Nursing Services Policy and Procedure Manual for Long Term Care, copyright 2001, provided by the facility revealed . Documentation When a resident falls the following information should be recorded in the resident's medical record: 1. The condition in which the resident was found (e.g., resident found lying on floor between bed and chair). 2. Assessment data, including vital signs and any obvious injuries. 3. Interventions, first aid, or treatments administered. 4. Notification of the physician, family, as indicated. 6. Appropriate interventions taken to prevent future falls . Review on 4/15/25 of Resident #40's medical record revealed a nursing note dated 3/28/25 at 10:41 a.m. [name omitted] notified of resident's fall. The name identified in the note was the Resident's representative. Further review of the medical record revealed that there was no other documentation about Resident #40's fall. Interview on 4/16/25 at approximately 10:02 a.m. with Staff E (Director of Nursing) confirmed that there was no documentation of Resident #40's fall that contained, the resident's condition, assessment, or interventions provided. Resident #274 Review on 4/15/25 of Resident #274's medical record revealed an order for surgical dressing change every 3 days. Further the Treatment Administration Record (TAR) revealed that the dressing change was completed on 4/11/25 and not completed on 4/14/25. Observation on 4/15/25 at approximately 11:38 a.m. of the residents surgical site revealed an intact dressing dated 4/14/25. Interview on 4/15/25 at approximately 11:40 a.m. with Staff F (Registered Nurse) confirmed that the dressing had been changed on 4/14/25 but had not been signed off in the TAR. 43002 Resident #123 Review on 4/16/25 of Resident #123's December 2024 TAR revealed a physician's order for Left anterior upper thigh (left hip) with surgical wound care orders to be done every 3 days. Further review revealed that the dressing was due to be changed on the day shift on 12/3/24 and 12/6/24, but was not documented as being completed until 12/9/24. Interview on 4/16/24 at 1:20 p.m. with Staff H (LPN) confirmed that he/she was working the day shift on 12/3/24 and 12/6/24. Staff H revealed that he/she would have documented that they had done the treatment and confirmed there was no documentation that the treatment had been provided. Staff H confirmed that he/she performed the wound care on 12/9/24. Review on 4/16/25 of Resident #123's Weekly Wound Assessment for the left hip surgical incision, dated 12/3/24, revealed the weekly wound assessment was signed and dated on 12/11/24 by Staff E. Review on 4/16/25 of Resident #123's Weekly Wound Assessment for the left hip surgical incision, dated 12/10/24, revealed the weekly wound assessment was signed and dated on 12/11/24 by Staff E. Interview on 4/16/25 at 1:40 p.m. with Staff E confirmed the above for Resident #123's TAR and Weekly Wound Assessments. Staff E revealed that he/she documented the above Weekly Wound Assessment, but did not perform the wound care or visualize the surgical wound on 12/3/24 or 12/10/24. Staff E revealed that they would get the wound information from the nursing staff on a piece of paper, then enter the information into the medical record and discard the paper. Staff E revealed that there was no documentation of who actually visualized the wound and did the assessments on 12/3/24 and 12/10/24 and confirmed that there was no documentation wound care had been provided on 12/3/24 and 12/6/24. Review on 4/16/25 of the facility's policy titled Charting and Documentation, revised July 2017, revealed, . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care . 2. The following information is to be documented in the resident medical record . c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident . 3. Documentation in the medical record will be objective . completed, and accurate . 7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individual(s) who provided the care; either assessment data and/or any unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure/treatment; e. whether the resident refused the procedure/treatment; e. notification of family, physician or other staff, if indicated; and f. the signature and title of the individual documenting .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that controlled medications were maintained in separately locked, permanently affixed compartment for 1 of 1 medications rooms observed. Findings include: Observation on 4/14/25 at 11:52 a.m. of the Chapel Medication Room revealed an unlocked refrigerator that contained a removable, unlocked combination lock box. Inside this box was vial of liquid Ativan (Schedule IV controlled substance). Further observation revealed that the numbers to unlock the box were written on the outside of the lock box. Interview on 4/14/25 at 11:52 a.m. with Staff H (Licensed Practical Nurse) confirmed that the lock box should have been secured/locked and the code should not have been on the outside of the box. Interview on 4/14/25 at 2:30 p.m. with Staff E (Director of Nursing) revealed that the Ativan should have been double locked. Review on 4/15/25 of the facility's policy titled Medication Labeling and Storage, revised February 2023, revealed, .7. Controlled substances (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected .

Based on observation, interview, and record review, it was determined that the facility failed to follow professional standards for 1 of 1 residents reviewed for respiratory care in a final sample of 18 residents (Resident identifier is #223). Findings include: Resident #223 [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . Observation on 4/14/25 at approximately 9:30 a.m. of Resident #223 revealed him/her to be using oxygen via nasal canula. Review on 4/14/25 of Resident #223's physician orders revealed no orders for oxygen. Review on 4/14/25 of Resident #223 nursing admission note dated 4/13/25 revealed oxygen in use at 6 liters. Observation on 4/15/25 at approximately 2:45 p.m. of Resident #223 revealed he/she was in bed with the head of bed elevated and oxygen on at 4 liters via nasal canula. Observation on 4/16/25 at approximately 11:00 a.m. Resident #223 revealed he/she was in bed with the head of bed elevated and oxygen on at 3 liters via nasal canula. Interview on 4/16/25 at approximately 11:00 a.m. with Staff H (Licensed Practical Nurse (LPN)) confirmed Resident # 223 was recieving oxygen and that there were no physician orders in place for oxygen or oxygen titration. Review on 4/16/25 of facility policy titled Oxygen Administration dated October 2010 revealed .Preparation 1. Verify there is a physician's order for this procedure .

Based on interview and record review, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the residents' status for 2 of 3 resident reviewed for hospice in a final sample of 18 residents (Resident Identifiers are #12 and #38). Findings include: Resident #12 Review on 4/15/25 of Resident #12's medical record revealed that Resident #12 was admitted to hospice on 2/6/25. Review on 4/15/25 of Resident #12's MDS for significant change dated 2/13/25 revealed that Section O- Special Treatments, procedures and Programs, K1 Hospice was marked no. Resident #38 Review on 4/15/25 of Resident #38's medical record revealed that Resident #38 was admitted to hospice on 12/16/24 prior to his/her admission to the facility on [DATE]. Review on 4/15/25 of Resident #38's admission MDS revealed that Section O- Special Treatments, procedures and Programs, K1 Hospice was marked no. Interview on 4/16/25 at approximately 11:17 a.m. with Staff A RN- MDS Coordinator) confirmed that the MDS for Residents #12 and #38 did not correctly indicate that the resident were on hospice.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that the call bell system was equipped to allow residents to call for staff assistance for a census of 73 residents. Finding include: Resident #59 Review on 4/24/24 of Resident #59's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/6/24 revealed under Section C: Cognitive Patterns, Resident #59 had a Brief Interview for Mental Status (BIMS) score of 14, meaning, Resident #59 was cognitively intact. Review on 4/25/24 of Resident #59's care plan revised on 8/21/23 for toilet use and transfer revealed that Resident #59 required extensive staff for participation to use the toilets and with transfers. Interview on 4/24/24 at 8:25 a.m. with Resident #59 revealed he/she wishes that staff would come faster when he/she pressed the call button. Resident #59 stated that he/she has waited 45 minutes or longer. Interview further revealed that waiting 45 minutes or longer could happen at any time during the day but when he/she has to wait in the early mornings to use the bathroom it was very upsetting Resident #59 confirmed that he/she has had an accident and wet himself/herself because of the long wait times. Interview on 4/25/24 at 10:15 a.m. with Staff H (Licensed Nursing Assistant (LNA)) revealed that he/she would only know the call bell was going off from looking at the monitor located at the beginning of the South hallway across from the nursing station. Staff H stated that the call bell system does not continuously sound. Staff H said that the monitors were the only way to know if the residents pressed their call bell and the monitor was not always in view if he/she was in with another resident or at the other end of the hallway. Staff H stated that residents have complained about the long wait times. Interview on 4/25/24 at 2:00 p.m. with Staff F (Administrator in Training) revealed that when a resident initiated the call bell system there was a doorbell ring sound once and the resident's room number and location, either at the bed or bathroom would appear on the monitors that were located in the hallways of each unit. Interview on 4/24/24 at 10:30 a.m. during Resident Council revealed that 10 out of 21 residents who attended would wait 30 minutes or longer for call bells to be answered. Resident #32 and Resident #27 stated that call bell response time concerns were brought up monthly and nothing was being done. Both Resident #32 and Resident #27 stated that the problem was not that the call bell system wasn't working, the problem was that when staff was asked why it took so long, staff say that [pronoun omitted] can't hear when it goes off. Everyone who was in attendance agreed with Resident #27 and Resident #32. Interview on 4/25/24 at 9:30 a.m. with Staff O (Anonymous) revealed that he/she can't hear the call system or see the monitor if he/she is in another resident room or down the opposite end of the hall, a resident could wait a long time without an LNA even knowing. 43002 Interview on 4/25/24 at 9:58 a.m. with Staff I (LNA) revealed that he/she observes the display monitors at the end of the halls (located near the nurse's stations and the end of Chapel and South halls) to identify if a resident's call bell was ringing. Staff I revealed that he/she would not know a call light was going off when in a resident's room or if not in an area of the building where the display monitor was visible. Interview on 4/26/24 at 11:15 a.m. with Staff G (Director of Maintenance) revealed that the call bell system was mechanically functioning properly. Review on 04/26/24 of the facility's policy titled Call Bell no date, revealed: Policy: Providing timely response to residents in need of assistance is essential to ensuring high quality resident outcomes .Procedure: .8. Answer the resident's call system as soon as possible .Call Light Monitoring: 1. If feasible, implement an electronic wireless call light system with reporting capabilities for monitoring. Call light response time . complete periodic monitoring of response time through resident council meetings and or resident interview .

Based on observation, interview, and policy review it was determined that the facility failed to use Personal Protective Equipment (PPE) when handling, processing, and transporting linens to prevent the spread of infection. Findings include: Observation on 4/25/24 at 11:00 am of Staff D (Laundry Aide) exiting the South shower room revealed that Staff D exited the shower room with a cart of overflowing soiled linens. The overflowing cart of soiled linens was in contact with Staff D's clothing. Staff D proceeded down the hallway with the overflowing cart of soiled linens with residents and other staff in the hallway. Interview on 4/25/24 at 11:05 a.m. with Staff C (Infection Preventionist) confirmed that Staff D was transporting a overflowing cart of soiled linens, that was in contact with his/her clothing, down a hallway with residents and staff. Observation on 4/25/24 at 11:30 a.m. of Staff D in the dirty laundry room revealed that Staff D was loading the washing machine with soiled linens wearing gloves but no gown. Interview on 4/25/24 at 11:32 a.m. with Staff C confirmed that Staff D was not wearing a gown while loading the washing machine with soiled linens. Interview on 4/25/24 at 11:35 a.m. with Staff D revealed that he/she was not aware of the need to wear a gown when handling soiled linen. Staff D stated that when he/she collected the soiled laundry, sorted the soiled laundry, and washed the soiled laundry he/she was not wearing a gown to protect his/her clothes from contamination. Staff D stated that he/she would then fold the clean laundry in the same clothes he/she was wearing while transporting spoiled laundry. Interview further revealed when he/she delivered the clean laundry, the clean laundry was not protected with a cover. Interview on 4/25/24 at 11:40 a.m. with Staff C revealed that he/she was unable to provide documentation of education to Staff D related to the laundry process. Interview on 4/25/25 at 11:55 a.m. with Staff G (Director of Maintenance, Housekeeping and Laundry) revealed that Staff D was educated on PPE when he/she was hired 8 years ago. Review on 4/25/24 of Staff D's PPE Competency Validation dated 12/6/23 revealed that the training provided was on donning (putting on) and doffing (taking off) PPE for standard and transmission based precautions. Further review revealed no documentation of training for handling, processing and transporting linens to Staff D. Interview on 4/25/24 at 2:00 p.m. with Staff F (Administrator in Training) confirmed the above findings. Review on 04/26/24 of the facility's policy titled Laundry and Bedding, Soiled revised September 2022, revealed: .Policy Statement: Soiled laundry/bedding shall be handled, transported, and processed according to best practices for infection prevention and control .Policy Interpretation and Implementation .Handling: 1. All used laundry is handled as potentially contaminated using standard precautions (e.g., gloves and gowns when sorting). a. Contaminated laundry is bagged or contained at the point of collection (i.e. location where it was used) .Transport: 1. Contaminated linen and laundry bags/containers are not held close to the body or squeezed during transport .6. Clean linen is protected from dust and soiling during transport and storage to ensure cleanliness .

Based on observation, interview, and policy review, it was determined that the facility failed to store and serve food in accordance with professional standards for food safety to prevent foodborne illness and failed to monitor the high dishwasher temperatures to ensure proper sanitization. Food Storage: Findings include: Review on 4/23/24 of the U.S. Food and Drug Administration Food Code, dated 2017, retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2017 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines . Chapter 3 Food .3-305.11 Food Storage .FOOD shall be protected from contamination by storing the FOOD: . On-premises preparation .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded .(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded .; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods . Observation on 4/23/24 at 8:25 a.m. of the walk-in refrigerator revealed two (2) Vanilla Mighty Shakes with no thawed date or use by date. Interview on 4/23/24 at 8:26 a.m. with Staff E confirmed the above findings. Observation on 4/23/24 at 8:40 a.m. of the [NAME] Unit refrigerator revealed three (3) Vanilla Mighty Shakes with no thawed date or use by date. Observation on 4/23/24 at 8:45 a.m. of the Chapel/Activities Unit refrigerator revealed thirty six (36) Vanilla Mighty Shakes with no thawed date or use by date. Interview on 4/23/24 at 8:46 p.m. with Staff E confirmed the above findings. Staff E was unaware of when the shakes were thawed. Review on 4/23/24 of the manufacturer's instructions for Vanilla Mighty Shakes under storage and handling revealed .Store frozen. Use thawed product within 14 days. Keep Refrigerated . Holding Temperatures: Review on 4/23/24 of the temperature logs of the serving (holding temperatures) of foods from 4/1/24 to 4/22/24 revealed the following: 4/1/24 there were no internal food temperatures recorded for breakfast, lunch, and dinner. 4/2/24 there were no internal food temperatures recorded for lunch. 4/3/24 there were no internal food temperatures recorded for dinner. 4/4/24 there were no internal food temperatures recorded for breakfast and dinner. 4/5/24 there were no internal food temperatures recorded for breakfast, lunch, and dinner. 4/6/24 there were no internal food temperatures recorded for breakfast and lunch. 4/7/24 there were no internal food temperatures recorded for breakfast, lunch, and dinner. 4/9/24 there were no internal food temperatures recorded for breakfast and lunch. 4/8/24, 4/10/24, 4/11/24, and 4/12/24 there were no internal food temperatures recorded for breakfast, lunch, and dinner. 4/13/24 there were no internal food temperatures for breakfast and lunch. 4/14/24 there were no internal food temperature for dinner. 4/15/24 there were no internal food temperatures recorded for breakfast, lunch, and dinner. 4/16/24 there were no internal food temperatures recorded for dinner. 4/17/24 there were no internal food temperatures recorded for breakfast and lunch. 4/18/24 there were no internal food temperatures recorded for breakfast, lunch, and dinner. 4/19/24 there were no internal food temperatures recorded for breakfast. 4/20/24, 4/21/24, and 4/22/24 there were no internal food temperatures recorded for breakfast, lunch, and dinner. Review of 4/23/24 of the facility's policy titled Food Temperatures, no date, revealed: Policy: Foods will be maintained at proper temperature to ensure food safety .Procedures: .3. The cook is responsible to see that all food is at the proper temperature. 4. The temperature will be taken and recorded for all items at all meals. Record temperatures on extended menus . Dishwasher Tempertures: Review on 4/23/24 of the facility's dishwasher temperature logs from 4/1/24 to 4/22/24 revealed there were no dishwasher temperatures recorded for 4/3/24, 4/4/24, 4/7/24, 4/8/24, 4/9/24, 4/18/24, 4/19/24, 4/20/24, 4/21/24 and 4/22/24. Review of 4/23/24 of the facility's policy titled Dish Washing Procedure, no date, revealed: .1. Fill dish machine . Check the temperature prior to washing dishes .Refer to manufactuerer's recommended temperature range .Record temperature on dish machine temperature log .11. Dish machine temperature log will be completed for every meal .

Based on interview and record review, it was determined that the facility failed to offer therapeutic dietary recommendations to maintain body weight and failed to monitor parameters of nutritional status per facility protocol for 2 of 3 residents reviewed for nutrition in a final survey sample of 22 residents (Resident Identifiers #36 and #61). Findings include: Resident #36 Review on 4/24/24 of Resident #36's medical record revealed that Resident #36 was admitted to the facility in February 2024. Review on 4/25/24 of Resident #36's Weights and Vitals Summary revealed the following recorded weights: 3/27/24 - 126.4 pounds (Wheelchair); 4/10/24 - 126.8 pounds (Wheelchair); 4/17/24 - 117.6 pounds (Wheelchair); 4/25/24 - 116.6 pounds (Wheelchair). Review on 4/25/24 of Resident #36's Dietary Note, signed by Staff N (Dietician), dated 3/21/24, revealed a recommendation to trial 4-ounce nutrition shakes daily and to add ice cream to provide supplemental calories. Review on 4/26/24 of Resident #36's Physician and Dietary orders revealed no orders for the above Dietician recommendations from 3/21/24. Interview on 4/26/24 at 9:36 a.m. with Staff A (Director of Nursing) confirmed the above findings. Review on 4/26/24 of Resident #36's Progress Note, dated 4/19/24, revealed that Resident #36's weight was 117.6 pounds, a loss of 5 percent change over 30 days, and a loss of 3 percent change from the last weight. Staff N requested a reweight. Review on 4/26/24 of Resident #36's progress note dated 4/25/24 revealed that Resident #36's reweight was 116.6 pounds. Interview on 4/26/24 at 9:38 a.m. with Staff A confirmed the above findings. Staff A stated that Resident #36 should have been reweighed within 24 hours of the request on 4/19/24. Interview further revealed that the order for nutrition shakes was not placed until 4/19/24 a month after the dietician's recommendation. Review on 4/25/24 of the facility's policy titled Weight Management, undated, revealed, .The healthcare staff will perform the following best practice guidelines to manage the risk of significant unplanned weight change .3. Residents are weighed in a consistent manner. For example: use the same scale, consistent time off [sic] day, and consistent clothing/devices on at the time of weight .5. Weights are verified and documented in the medical record as they are obtained. 6. Check the previous monthly weight(s) for any significant weight change. If there is a significant weight change of + or - 5% in 30 days, 7.5% in 90 days or 10% in 180 days, schedule resident to be reweighed within 24 hours . 43002 Resident #61 Review on 4/23/24 of Resident #61's Care Plan revealed a risk titled weight loss, weight fluctuation, and malnutrition due to variable meal intake that was initiated on 10/16/23 and revised on 4/2/24. Further review revealed interventions revised on 4/9/24 included monitoring weight per facility protocol, ensuring consistent weighting method, and recommending 6 ounces of juice supplement daily and 30 milliliters of protein supplement twice daily for wound healing and malnutrition. Review on 4/23/24 of Resident #61's Weights and Vitals Summary revealed the following recorded weights; 2/28/24 - 267.6 pounds (Wheelchair); 3/5/24 - 310.5 pounds (Mechanical Lift); 3/28/24 - 156.1 pounds (Mechanical Lift); 4/1/24 - 255 pounds (Wheelchair). Interview on 4/25/24 at 12:38 p.m. with Staff J (Unit Manager) confirmed the above weights and revealed there should have been reweights obtained. Review on 4/25/24 of Resident #61's Progress Notes revealed the following; 3/12/24 a 42.9-pound weight gain over 6 days with inaccuracy was suspected. Weight recheck requested. This note was signed by Staff M (Dietician). 4/9/24 the resident had wide fluctuations in weight measurements and an overall downward trend was noted. Recommend 6 ounces of juice supplement daily and 30 milliliters of protein supplement twice daily for wound healing and malnutrition. This note was signed by Staff N. Review on 4/26/24 of Resident #61's Physician's Progress Note, dated 4/17/24, revealed: .Dietician was in for a follow-up visit and to review weights with new recommendations for juice supplement [by mouth] once daily, ProSource [protein supplement] [by mouth twice daily] for wound healing . Interview on 4/26/24 at 10:25 a.m. with Staff A confirmed that reweights had not been done for the above weights. Staff A confirmed that the dietary recommendations for the juice or protein supplement from 4/9/24 had not been started.