Every finding on record at Jennings Terrace

Based on observation, interview and record review the facility failed to assess a resident for limited ROM (range of motion) and implement interventions to prevent a decline in ROM. This failure resulted in one resident developing a hand contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to restricted joint mobility).This applies to 1 resident (R45) reviewed for complications of immobility in a sample of 16.The findings include:On 01/20/2026 at 11:34 AM, R45 was observed sitting in the dining / activity area. R45's left hand was contracted with four fingers bent towards her palm. R45 moved the thumb of her left hand with her right hand but was unable to extend the four fingers on her left hand. R45 did not have any device in use for her contracted left hand. R45 was unable to answer questions about her hand, or any treatments / interventions for her hand contracture. V13 CNA (Certified Nursing Assistant) assigned to R45 stated R45 was unable to open her hand. R45 did not have a splint or any device in place for her contracted hand.On 01/21/2026 at 3:15 PM, V14 CNA also stated R45 could open her left hand a little, but not very much. V14 agreed R45 did not use any splint or device for her left hand.On 01/21/2026 at 3:53 PM, V16 MDS (Minimum Data Set) Coordinator stated she is an LPN (Licensed Practical Nurse) and is responsible for completing the resident functional assessments. V16 stated she last completed R45's contracture risk assessment on 11/24/25. V16 stated R45 did not have any contractures to her hand and was able to feed herself. V16 stated if R45 had any contractures, it would be a new occurrence. V16 stated R45 did not have any physician orders for splint use or other devices for contractures and did not have anything care planned regarding contractures or splints. At 4:08 PM, V16 re-evaluated R45 at the bedside. V16 verified R45's left hand did not open and stated she did not know when R45's hand became contracted. V16 stated the Restorative Aide (V17 Therapy Aide) sees R45 Monday through Friday for ROM exercises.On 01/21/2026 at 3:41 PM, V2 DON (Director of Nursing) stated no one was specifically assigned to the role of restorative nurse. V2 stated V17 (Therapy Aide) provided restorative services. On 01/21/2026 at 4:10 PM, V17 stated he had not seen R45 since early in the year 2025. V17 stated R45 had slight contractures in one of her hands, but it was not completely contracted, and he did not remember which hand. V17 stated R45 did not have any splint or device ordered for her contracture. V17 stated documentation for ROM exercises was being done by the CNAs for R45.On 01/22/2026 at 12:46 PM, V19 CNA. assigned to R45 stated he provided restorative services for R45 during her shower earlier but did not do any ROM exercises to her left hand because it does not open. V19 stated he had worked in the facility for over a year and R45 never had any splints ordered.On 01/22/2026 at 2:30 PM, V20 (Physician) stated a splint was ordered for R45, but he was unsure of when because he rounds at multiple facilities. V20 stated if a splint was ordered for R45 and it was not used, there should be documentation of her refusals. V20 stated he did not know when R45 developed the contracture.R45 current diagnosis list included rheumatoid arthritis, Alzheimer's disease, stiffness of unspecified Joint, and reduced mobility. R45's 11/24/2025 Contracture Risk Evaluation showed she did not have contractures, required staff assistance to turn and reposition, and her current diagnoses predisposed R45 to contractures minimally to moderately. R45's current physician orders do not include orders for a splint or contracture-preventing device. R45's current care plan stated R45 has rheumatoid arthritis and will be / remain free of complications related to arthritis (contractures, joint stiffness, swelling or decline in mobility) through review date. Interventions included daily range of motion exercises, both active and passive, as tolerated. Monitor / document / report to MD as needed the signs and symptoms or complications related to arthritis, joint pain, joint stiffness, usually worse on wakening, swelling, decline in mobility, decline in self-care ability, contracture formation / joint shape changes, crepitus (creaking or clicking with joint movement), pain after exercise or weight bearing. R45 care plan also includes R45 has impaired physical mobility related to history of falls COPD, Alzheimer's, and osteoarthritis. Goals include the resident will be free of complications of immobility. Encourage the resident to work with the restorative aide to perform daily range of motion exercise. Interventions include consult physical therapy per order. R45's 11/27/2025 MDS (Minimum Data Set) showed R45 did not exhibit the behavior of rejecting evaluation of care. R45's functional limitation in range of motion assessment of the upper extremity (shoulder, elbow, wrist, hand) documented no impairments.The facility's March 2018 Functional Impairment - Clinical Protocol policy showed the staff and physician will identify individuals with potential for significant improvement in function or significant decline in function, including the ability to perform activities of daily living (ADLs). The staff will monitor and document the resident / patient's function and will discuss this with the physician periodically in conjunction with a discussion of medical interventions and plans of care. The physician will identify the subsequent relevance of therapy services, based on reviewing the resident / patient's progress relative to his/her care goals and the status of conditions and the current treatment regimen that have been identified as affecting his/her function.The facility policy Restorative Nursing Services dated July 2017 states residents will receive restorative nursing care as needed to help promote optimal safety and independence.

Based on observation, interview and record review the facility failed to maintain the kitchen in a manner that prevents food borne illness.This applies to all 44 residents receiving dietary services. Findings include:On 01/23/2026 at 9:42 AM, V1 Administrator stated 44 residents received meal services from the dietary department as of the survey start on 01/20/2025.On 01/20/2026 at 9:52 AM, the kitchen tour began with V11 Dietary Manager.The three-compartment sink and red sanitizing buckets were tested by V12 Dietary Aide / Dishwasher. The three-compartment sink tested at 400 PPM (Parts Per Million). Red Sanitization Bucket testing: Bucket #1 -200 PPM; Bucket #2- 400 PPM; Bucket #3- 0 PPM. The testing strips used to test the sanitizer level in the three-compartment sink and red sanitization buckets expired on 10/15/25. V12 stated she did not check the expiration date on the test strip before using them.V11 Dietary Manager tested the disinfectant level of the dishwasher.The low temperature dishwasher tested at 100 PPM. V11 Dietary Manager stated the dishwasher disinfects with chlorine. The parts per million should be 50 PPM.Walk in Cooler:Floors in the walk-in cooler were dirty. Five heads of iceberg lettuce were wilted and had a brown substance.Reach in Cooler:Two 5lb (pound) tubs of cottage cheese expired on 1/17/26.Dry Storage:Two 6lb 2oz (ounce) dented cans of yams were present. V11 identified as the dented can shelf was not labeled.Walk in Freezer:A large plastic bag containing bread sticks was open to air and had no labels or dates.General Kitchen:The tomato slicer stored on open kitchen shelving was dirty.The covered meat slicer was dirty. The plastic covering on the meat slicer was greasy.A drawer with cooking utensils had crumbs at the bottom.A personal insulated cup was on a food counter in the open kitchen area.On 01/22/2026 at 12:30 PM, V18 [NAME] was in the process of food preparation and did not have any covering on his full-face beard.On 01/22/2026 at 12:34 PM, V11 Dietary Manager stated the test strips to check sanitizer shouldn't be expired. We need to make sure the reading for the testing is accurate and the disinfectant is appropriate. The chlorine for the dishwasher should be 50 PPM per the facility policy. If the chlorine level is too high, a technician needs to be called out to fix it the same day. If the chlorine is too high the residents can get sick from too much chlorine. V11 stated kitchen staff should have hair coverings, so the hair does not contaminate the food. Dented cans should be labeled and separated so staff know not to use them. Food is labeled and dated so we know when to discard it. Food should be sealed so it doesn't build up ice or get contaminated. It's important to keep the kitchen and the utensils clean so no bacteria get into the food. Staff should not be storing their personal items or food in the kitchen because it can cause a cross contamination of food.V11 stated logging daily entries for the cooler, freezer, sink, red buckets and three-compartment sink is important to make sure the equipment is functioning and doesn't cause spoilage and so the disinfectant level is appropriate to kill the bacteria.The facility provided kitchen logs for review (testing strips expired 10/15/2025). The November 2025 sanitizing bucket log had seven missed days of entries for sanitizer level. The December 2025 sanitizing bucket log had eight missed days of entries for sanitizer level. The January 2026 sanitizing bucket log had five missed days of entries for sanitizer level.The facility did not provide a sink-testing log for November 2025. The December 2025 three-compartment sink sanitizer log had ten days of missed entries for the sanitizer level. The January 2026 three-compartment sink sanitizer log had six missed days of entries for the sanitizer level.The November 2025 dishwasher sanitization log showed five missed days of entries, the December 2025 log showed six missed days of entries, and the January 2026 log showed four missed days.The November 2025 freezer log showed two days of missed entries, and December showed three missed days of entries.The November 2025 and December cooler log each showed three missed days of entries.The facility policy Manual Sanitizing in Three-Compartment sink dated 2021 states a test strip is used to accurately determine the concentration of the sanitizing solution. The test strip results are recorded on the PPM log.The facility's 2021 Sanitation Buckets / Wiping Food Contact Surfaces and Equipment Too Large to Immerse in the Sink policy showed using the appropriate test strip, the strength of the sanitizing solution will be tested each time the sanitation buckets are changed.The facility policy Machine Washing and Sanitizing dated 2021 states the final rinse will have 50 parts per million (PPM) hypochlorite (chlorine) on dish surface. The final rinse will be tested with the appropriate test strip, and the results will be recorded on the low temperature dishwashing machine log.The facility policy Storage of Dry Goods / Foods dated 2021 stated dented cans are stored in a designated area to be returned to vendors.The facility policy Storage of Refrigerated Foods dated 2021 states that air temperature inside the refrigerator is checked and recorded twice daily on both the external and internal thermometers is recorded.The facility policy Cleaning Procedure for Equipment and Utensils dated 2021 states equipment and utensils used in food preparation will be cleaned and sanitized according to standard procedure. The facility policy Hair Restraints / Jewelry / Nail Polish/ False Eyelashes dated 2021 states food and nutrition services employees shall wear hair restraints and beard guards. Employees shall avoid wearing excessive jewelry, nail polish or acrylic nails and false eyelashes.

Based on observation, interview, and record review, the facility failed to obtain and record pacemaker device information, report new skin concerns, and follow physician's orders for glucose monitoring.This applies to 4 of 4 (R22, R30, R49, and R54) residents reviewed for nursing services in a sample of 16. The findings include:1. R22's face sheet documents that he was admitted to the facility on [DATE]. R22 had diagnosis of chronic atrial fibrillation, presence of cardiac pacemaker, and occlusion and stenosis of bilateral carotid arteries. On 1/20/26 at 11:08 AM, a pacemaker monitor was observed on R22's nightstand. On 1/21/26 at 11:20 AM, V3 (LPN) said he is unable to locate the medical identification card that indicated R22 has a pacemaker. He said he could not find any documentation about R22's pacemaker in his EMR (Electronic Medical Record). He said it should be information recorded in the EMR so they can relay information to emergency responders. On 1/21/26 at 11:30 AM and 11/22/26 at 11:13 AM, V2 (DON-Director of Nursing) said she does not know of R22's medical identification card that indicated R22 has a pacemaker, and she said she does not have any information regarding R22's pacemaker. She said it is important to know the pacemaker information for managing the device's function of tracking heart rhythms. R22's EMR was reviewed, no information regarding R22's pacemaker seen. R22's care plan for pacemaker did not have information. Facility's Policy on Care of a Resident with Pacemaker dated 2015 documents the following: .Monitoring .5. Make sure the resident has a medical identification card that indicates he or she has a pacemaker. The medical record must contain this information as well. When the resident is transferred to another facility, this information must be communicated to the receiving facility in the discharge summery. Documentation.1. For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission: a. The name, address and telephone number of the cardiologist; b. type of pacemaker; c. Type of leads; d. Manufacturer and model; e. serial number; f. Date of implant; and g. paced rate. 2. R49's face sheet documents she was admitted on [DATE]. Diagnoses include type II diabetes mellitus, osteoarthritis, rheumatoid arthritis, osteoporosis, hypertension, anemia, depressive disorder, fibromyalgia and anxiety. R49's MDS (Minimum Data Sheet) dated 10/13/25 documents that she has moderate cognitive impairment. R49 needs substantial maximal assistance with personal hygiene. On 1/20/26 at 10:15 AM, while V4 (CNA-Certified Nurse Assistant) was providing bed bath, redness under R49's left breast was observed. V4 said it has been there for more than a week, and she informed the nurse about it and was given a powder to apply. After bed bath was done, V4 went to V10 (RN-Registered Nurse). V4 came to the room, assessed R49's left breast and said this was the first time he knew about the skin issue. He said he will inform R49's physician and will obtain an order. V10 said the redness looks like a fungal infection. V10 came back to the room after approximately five minutes with Nystatin in hand. He said he talked to R49's physician and was given an order for Nystatin. He then applied the powder under R49's breast. On 1/20/26 at 2:10 PM and 1/21/22 at 2:30 PM, R49's POS (Physician Order Sheet) was reviewed, there was no order for Nystatin powder. On 1/22/26 at 11:15, V2 said she expects her CNAs to inform the nurses of any skin issues so the physician can be informed, and a treatment order can be obtained. She said reporting promptly is important so the resident can get prompt treatment. 3. On 1/21/2026 at 9:45 AM, V6 (LPN) administered R54's scheduled morning medications. R54 told V6 he believed he did not eat breakfast and was hungry. V6 said R54 was a diabetic and ate breakfast at approximately 7:30 AM. V6 said R54 had scheduled Lispro Insulin per sliding scale at 8 AM. R54's EMAR showed his ordered 8 AM blood glucose check with his meal was not done. V6 said she would now check R54's blood glucose level because it had not been done as ordered with his breakfast. V6 said blood glucose levels had to be checked and recorded as ordered by the physician to ensure diabetic residents were monitored for abnormal levels, such as hypoglycemia and hyperglycemia. On 1/21/2026 at 3:20 PM, V2 (Director of Nursing/DON) said nurses were expected to follow blood glucose orders as ordered. V2 said nurses were also expected to record blood glucose results in the residents' EMRs to ensure they were monitored for diabetic complications. R54's care plan said he was a diabetic and had to be monitored for complications such as abnormal blood glucose levels. The interventions included monitoring fasting blood sugar as ordered by doctor. R54's Order Summary Report showed an active order for Lispro Insulin (fast-acting insulin) which included specific instructions to check blood sugar levels before each meal. R54's EMR on 1/21/2026 showed R4's ordered blood sugar was not completed before his breakfast meal as ordered. The facility's policy title Diabetes-Clinical Protocol dated 2017, said the facility staff would work with the physician to assess residents with diabetes or glucose intolerance, as the condition impacts the resident's function and quality of life. Staff will follow the physician's glucose orders. They will obtain, record, and monitor glucose levels to ensure the physician can evaluate and determine their proper diabetes management. The physician's orders for lab tests, including periodic finger sticks, would indicate specific parameter instructions. The specific parameters will be incorporated into the Medication Administration Record and care plan. Staff will identify and report any abnormal findings to ensure proper management of diabetes complications such as hypoglycemia and hyperglycemia. 4. On 1/21/2026 at 8:50 AM, V6 (Licensed Practical Nurse/LPN) administered R30's scheduled oral morning medications, including anti-glycemics Acarbose 25 mg (milligrams) and Glipizide 5 mg. V6 said R30 was a diabetic and had twice-a-day scheduled blood glucose checks. R30's EMAR (Electronic Medication Administration Record) showed her ordered 6 AM glucose check was not done. V6 said she was unsure if the prior shift checked R30's blood sugar because it was not recorded in her EMAR or given during nursing report. R30's care plan said she was a diabetic and had to be monitored for complications such as abnormal blood glucose levels. The interventions included monitoring fasting blood sugar as ordered by doctor. R30's Order Summary Report showed an active order for AccuChecks two times a day FOR TYPE 2 DIABETES MELLITUS. R30'S EMR (Electronic Medical Record) on 1/21/2026 showed R30's ordered 6 AM blood sugar was not completed as ordered.

Based on observation, interview, and record review, the facility failed to maintain its mechanical lift in operating condition.This applies to 5 of 5 (R30, R27, R11, R5, and R41) residents reviewed for mechanical lift transfers in a sample of 16. The findings include:On 1/20/2026 at 1:30 PM, V7 and V21 (Certified Nurse Assistants/CNAs) transferred R30 from her wheelchair to the bed using a mechanical lift, the transferring equipment was labeled South. V21 assisted by supporting R30, while V7 used the hand control remote to operate the machine. The hand control remote was connected to the machine's vaulted battery box via a wire cord. The wire's protective layer was entirely stripped off (the length was approximately four feet long), with exposed multi-colored electrical wires. V7 failed to perform a safety check on the machine prior to using it for R30's transfer. After R30's transfer, V21 placed the machine back into circulation in the unit's clean utility room for further use. V21 also failed to perform a safety check on the machine.On 1/21/2026 at 1:20 PM, V9 (CNA) said the North unit had multiple residents who required the use of a mechanical lift for transfers. V9 then assessed the mechanical lift machine labeled South, which was stored in the clean utility room, available for use. V9 said the machine could only be operated with the remote because the manual switch was only for emergency use. V9 said the remote's wire had been stripped for more than a month, and she had reported the issue to V8 (CNA Supervisor). V9 said the lift was still in circulation for use, but she felt unsafe using it because of the potential hazard risks. V9 said the lift should have been removed from the unit to prevent its use. On 1/21/2026 at 1:30 PM, V8 (CNA Supervisor) said she was notified of the mechanical lift's stripped wire more than a month ago. V8 said she notified V5 (Maintenance Director), and due to the machine being an older model, the part was not able to be replaced. V8 said the North unit had 5 residents (R30, R27, R11, R5, and R41) who required the use of a mechanical lift for their transfers. V5 said the machine should not have been available for use and was not aware it was still in circulation on the unit for use. On 1/21/2026 at 1:40 PM, V5 (Maintenance Director) said he assessed the lift's stripped wire when he was notified more than a month ago. V5 said the remote and the connecting wire had not been replaced due to limited availability. V5 said he believed the mechanical lift was removed from circulation and stored in the unit's soiled utility room. V5 said the mechanical lift was unsafe for transfer use due to the battery voltage connection, making it an electrical hazard. On 1/22/2026 at 11:10 AM, V2 (Director of Nursing/DON) said the mechanical lift should have been put out of circulation to prevent its further use. V2 said nursing staff should be assessing transfer lift equipment prior to use and routinely to ensure they are safe to operate. The facility's resident roaster document dated 1/21/2026 said R30, R27, R11, R5, and R41 resided on the North unit and required the use of a mechanical lift for their transfers.The [Lift Equipment Company's] Operation Manual for the facility's mechanical lift said it was important that the lift's transferring device be maintained and used to ensure the efficiency of the lift and maximize the safety transfer of residents and staff. The manual said the lift machine operated with a battery set with a voltage meter to DCV (Direct Current Voltage) of 200 and when charged, set to operate at 26-27 electric volts. The manual indicated that periodic maintenance was a vital component of keeping the equipment device in a safe operating condition. A machine that is not properly maintained could create a potentially hazardous situation for nursing staff and patients.The facility's document titled Environmental Services: Work Order dated 12/18/2025 said the North unit's mechanical lift had wires exposed. The document said the lift was to be removed from circulation use. On 1/19/2026, there was an update added to the document saying the replacement device was unable to be purchased due to not being available. The facility's untitled and undated policy for mechanical lift said the facility focused on resident safety when using mechanical lifts for transfers. They followed mandated safety handling practices to prevent residents' risks for injury during transfers. A key safety component during the use of mechanical lifts included equipment checks before each use. Staff must verify the lift's battery, ensure the correct sling size is used, and inspect all attachments for proper fit and function.

Based on interview and record review, the facility failed to respond to a resident's (R1) family representative billing concern. This applies to 1 of 3 residents (R1) reviewed for grievances. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE] and discharged on [DATE]. On 1/28/2025 at 11:35 AM, V5 (R1's Family Member) said that on 9/20/2024 he contacted the facility after reviewing R1's billing for the months of April through June 2023 (from over a year earlier) when R1's family was paying out of pocket after R1 was approved for public aid. V5 said he notified V1 (Administrator) and V2 (Business of Manger/BOM) of his billing grievance regarding R1's credit due. V5 said he felt the facility was not responding promptly to his grievance. V5 said he then contacted V3 (Ombudsman) to help him find a resolution with the facility. On 1/28/2025 at 11:00 AM, V3 (Ombudsman) said she contacted V1 and V2 on 12/13/2024 to assist V5 with his grievance but was unsuccessful. V3 said the facility failed to provide V5 with a response to his grievance and stopped responding to her on 12/26/2024. On 1/28/2025 at 8:30 AM, V2 (BOM) said V5 (R1's Family Member) contacted her in October 2024 regarding R1's billing. V2 said she stopped responding to V5's emails after V3 (Ombudsman) became involved in December 2024. V2 said the facility confirmed the total amount that was due to R1's family on 1/01/2025. V2 was unable to provide a reason for why V5 and V3 were not contacted to provide them with an update regarding the grievance and the money owed to R1. R1's [NAME] Statement dated 1/01/2025 showed the facility acknowledged that R1's family was due a refund credit for R1's stay from 4/04/2023 through 2/18/2024. The email correspondence from V5 (R1's Family Member) to the facility, showed a total of 130 days had passed without V5 receiving a resolution to his billing grievance filed on 9/20/2024. The email correspondence from V3 (Ombudsman) to the facility, showed the facility failed to provide a resolution to V5's billing grievance and stopped responding on 12/26/2024. The facility's Grievance policy dated 11/28/2016, said Policy: The facility will make prompt efforts to resolve grievances that the resident may have. Grievances are taken seriously and will be subject to the procedure listed below. Procedure: 1. All residents will be notified of their right to file grievances whether it be orally or written, or anonymously. The resident will have access to contact information of the grievance official of the facility and know a reasonable timeframe for completing the review of the grievance .

Based on interview and record review, the facility failed to ensure the facility had an assessment performed that identifies where Legionella and other opportunistic waterborne pathogens could grow. This applies to all 46 residents that reside in the facility. The findings include: The facility's Long Term care facility application for Medicare and Medicaid (CMS (Centers for Medicare & Medicaid Services)-671 form) dated November 18, 2024 showed that there were 46 residents residing at the facility. On November 20, 2024 at 11:12 AM, V6 (Maintenance Director) stated the facility does not have an assessment for Legionella or other opportunistic water borne pathogens. V6 stated he is not aware of any Legionella assessment being done in the last 3 years that he has been working at the facility. V6 stated, they will be using a specific company to do the facility's assessment for Legionella and other waterborne pathogens. V6 stated that they have not utilized the company yet. V6 stated the facility does not have an assessment that shows where specifically Legionella or other waterborne pathogens can potentially grow. V6 stated that there has not been any testing for Legionella since he has been working at the facility. The facility's Infection Prevention & Control - Legionnaires Disease policy dated November 1, 2018 showed the following: Procedure: the water management program is maintained by the Maintenance and Environmental Services staff. Facility plan: Identifies building water systems for which Legionella control measures are needed- Utilizing the facility layout to describe the building water systems using text. b. Assesses how much risk the hazardous conditions in those water systems pose-developing a building flow diagram per the CDC toolkit. c. Control measures will be applied as needed to reduce the hazardous conditions, whenever possible to prevent Legionella growth and spread.

Based on observation, interview, and record review the facility failed to label and date medications once opened to determine the expiration date. The facility failed to remove expired medications, and remove or dispose narcotic medications that were in a broken sealed container. In addition, the facility failed to store suppository medications in a sanitary manner. This applies to 8 residents (R3, R8, R16, R19, R29, R30, R40, R41) reviewed for medication storage and labeling in the sample of 12. The findings include: On November 18, 2024, from 3:27 PM through 3:58 PM, observation of medication carts and medication rooms' refrigerator were conducted with V15 and V16 (Both Nurses). 1. R40's Latanoprost 0.005% (ophthalmic solution) label showed that it was opened on September 20, 2024, and expired on November 1, 2024. 2. R19's Latanoprost .005% (ophthalmic solution) label showed that it was opened on September 22, 2024, and expired on November 3, 2024. 3. R8's Latanoprost 0.005% (ophthalmic solution) opened on July 8, 2024. Pharmacy recommendation showed to discard 6 weeks after it was opened. 4. R16's Breo Ellipta (inhaler) was opened and not dated. Pharmacy recommendation showed to discard 6 weeks after opening of foil tray. 5. R41's Fluticasone Furoate/Vilanterol Ellipta (inhaler) was opened and not dated. Pharmacy recommendation showed to discard 6 weeks after opening of foil tray. 6. R30's Tramadol 50 mg tablet blister pack/container had a seal broken and taped over for tablets number 34 and 35. 7. R3's Hydrocodone Acetaminophen 7.5/325 mg tablet blister pack/container had a seal broken and taped over for tablets number 1, 2, 3, 7, 9, and 10. 8. R29's Lorazepam 0.5 mg tablet blister pack/container had a seal broken and taped over for tablets number 1. 9. There was a vial of Tuberculin Purified Protein in the South medication room refrigerator which shows that it was opened on September 26, 2024. The pharmacy guidelines show to discard this medication 30 days after it was opened. 10. There was a vial of Tuberculin Purified Protein in the North medication room refrigerator which showed that it was opened on July 1, 2024. The pharmacy guidelines show to discard this medication 30 days after it was opened. This same refrigerator stored two boxes of Bisacodyl Suppositories and one box of Tylenol Suppositories. The box containers of these suppositories were drenched with water which came from the leaking freezer. There was a puddle of water on the base floor of the refrigerator where they stored these suppositories. On November 21, 2024, at 10:33 AM, V2 (Director of Nursing) stated that if a narcotic medication container is already broken or the medication was already removed from its container and the resident refused to take the narcotic medication, the staff nurse should discard or waste it with the presence of another nurse as a witnessed to prevent potential diversion of this medications. On November 21, 2024 at 1:52 PM, V20 (Registered Pharmacist) stated that their controlled medication policy shows that once the narcotic medication is removed from its container, but the patient refused to take it, the controlled medication should not be returned to its container and should be destroyed, with a witness. The facility's Storage of Medications policy and procedure with revised dated of April 2007, shows: Policy Interpretation: 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview and record review the facility failed to prepare the green peas to pureed consistency for residents on pureed diets. This applies to 5 of 5 residents (R3, R6, R13, R17, R23) reviewed for pureed diet in the sample of 12. The findings include: On November 19, 2024 at 10:30 AM, the pureed green peas preparation done by V5 (cook) was observed in the facility kitchen. V5 stated that she was preparing for five residents who are on pureed diets. According to V5, the green peas were frozen, and she had cooked it. V5 placed eight scoops of 4 ounces (total of 32 ounces) green peas inside the food processor, added 4 ounces of butter and pureed the mixture for about three minutes. V5 then opened the food processor and transferred the processed green peas inside a small metal pan. According to V5, she was done processing the green peas and she will place the small metal pan inside the warmer because the processed green peas was ready to be served to the residents on pureed diet. V5 was asked why she did not test the processed green peas to make sure it was the right consistency. V5 did not respond. On tasting the processed green peas, lots of fibrous casings (pea pods) was visible in the mixture. The fibrous casings were unable to be chewed and got stuck in the throat when swallowed. During this time V4 (Dietary Manager) was notified of the concern with regards to the consistency of the processed green peas and V4 tasted the product. V4 agreed that the green peas still had lots of fibrous casings. V4 stated that the pureed product should be pudding-like consistency and should be smooth without the need to chew. The facility's diet list as of November 19, 2024 showed that R3, R6, R13, R17 and R23 were on pureed diet consistency. On November 20, 2024 at 1:23 PM, V7 (Registered Dietitian) stated that for pureed food, the expected and appropriate consistency should be pudding-like, without chunks, clumps or fibrous casings and should be smooth. V7 added that if the processed food did not reach the pureed consistency, it should not be served to the residents on pureed diet, to prevent choking or swallowing problem. The facility's recipe for pureed green peas showed in-part, 2. Place in food processor and process until fine in consistency. Review of the facility policy and procedure regarding pureed/dysphagia diet dated 2010 showed, Food will be provided in a form designed to meet individual needs. The texture of the food may be altered to pureed consistency. Pureed/dysphagia diets will be served as ordered by the physician. The same policy under procedure showed in-part, Whole food will be pureed in a blender or a food processor to a semi-solid consistency (i.e. (for example), the consistency of pudding-like).

Based interview and record review the facility failed to utilize the McGeer Criteria from March 2024 through November 19, 2024 for residents with suspected infections based on their policy. This applies to 9 of 9 residents (R1, R5, R6, R7, R11, R12, R20, R37, R46) reviewed for antibiotic stewardship in the sample of 12. The findings include: On November 20, 2024 at 11:38 AM, V3 (Infection Preventionist/Assistant Director of Nursing) stated that the facility is using the McGeer Criteria to ensure residents are not prescribed unnecessary antibiotics. V3 stated that in March of 2024, she stopped utilizing the McGeer Criteria. Surveyor reviewed the facility's infection tracking binder and there were McGeer Criteria filled out for residents in January and February of 2024, but there were no McGeer Criteria for residents for the remainder of the year (from March 2024 to present). V3 stated there was no McGeer Criteria documentation stating whether residents who were prescribed antibiotics from March 2024 to present, either met or did not meet standards for antibiotic utilization. V3 stated, she wears a lot of hats and she is not able to get everything done. V3 stated infection control has suffered because of this. Review of the facility's infection prevention and control monthly log from March through November 19, 2024 showed that R1, R5, R6, R7, R11, R12, R20, R37, and R46 had used antibiotic therapy at a given time for suspected/confirmed infections. The facility's Antibiotic Stewardship Protocol dated April 2016 showed the following: Action, a. The facility utilizes McGeer Criteria to improve the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection.

Based on interview and record review the facility failed to provide dementia training for the CNAs (Certified Nurse Assistants) working in the facility and who were required to care for residents with dementia. This applies to 26 of 26 residents (R1, R3, R4, R6, R8, R11, R12, R14, R15, R16, R19, R20, R21, R23, R24, R26, R27, R28, R33, R36, R38, R40, R42, R44, R45 and R46) identified by the facility as having a diagnosis of dementia. The findings include: On November 20, 2024, at 10:03 AM, V9 (CNA (Certified Nursing Assistant) Supervisor) said that as the CNA Supervisor she does the CNAs annual evaluations and does the in-services for the CNAs. V9 said when needed, she will do re-education along with return demonstration on skills provided to the residents. V9 said she does not do dementia training and cannot remember having attended a training on dementia. V9 said V8 (Community Relations Coordinator) does dementia, resident rights, abuse and neglect trainings. The facility trainings are all done as in-services and the documentation is the sign in sheet. On November 20, 2024, at 10:56 AM, V2 (Director of Nursing) said she started working at this facility in April 2024. V2 said they have not done dementia training since she has been here. V2 pulled the in-service binder to see if she could locate a dementia training and provided the surveyor with an in-service V8 did on June 6, 2024. The in-service sign in sheet showed; In a facility that practices Person-Centered Care, listening skills and customer service are important skills. This is a reminder to let the resident finish their thought, sentence, or paragraph, before you offer a solution to them. Let them finish, do not cut them off when they are trying to tell you something. If you don't do it right the first time, you will have to find the time to fix it the second time! We are here to serve the needs of residents. Many of our residents' struggle with symptoms that are overwhelming to them and make their lives difficult, painful, or frustrating. Be conscious that as a staff member, you always have the power to leave, whereas the resident may not. Please remember that you can change your perspective of your job and the work you do here, where as the resident may not be able to do so. V2 was not able to provide any documentation to show dementia training had been provided to the CNAs. On November 20, 2024, 2:25 PM, V8 said she does not do dementia training for the staff. On November 20, 2024, at 1:12 PM, V10 (CNA) said she has worked here since September 2024, and had taken care of residents with dementia at the facility. V10 stated that she was not given dementia training during her orientation. On November 20, 2024, at 1:20 PM, V11 (CNA) said she has worked at this facility for [AGE] years, [AGE] years as a CNA, and had taken care of residents with dementia at the facility. V11 said she has not had dementia training and cannot remember when she had dementia training last. On November 20, 2024, at 1:42 PM, V12 CNA) said she has been working at this facility for five months, and had taken care of residents with dementia at the facility. She was able to explain her orientation process but said she did not have dementia training. On November 20, 2024, at 1:47 PM, V13 CNA) said she has been working at the facility for about five months, and had taken care of residents with dementia at the facility. V13 stated that she did not get dementia training with orientation. The facility provided list of residents with diagnosis of dementia. The list identified 26 residents which included R1, R3, R4, R6, R8, R11, R12, R14, R15, R16, R19, R20, R21, R23, R24, R26, R27, R28, R33, R36, R38, R40, R42, R44, R45 and R46.

Based on observation interview and record review, the facility failed to assess a resident's wound during a course of treatment and document the status of the wound weekly and revise the care plan interventions for wound care. This applies to 1 of 2 residents (R5) reviewed wound care in the sample of 12. The findings include: R5's electronic medical record showed a [AGE] year old female admitted to the facility on [DATE] with diagnoses that include Osteoarthritis, Congestive Heart Failure, Obesity, Difficulty Walking, Weakness, Cognitive communication deficit, Type 2 Diabetes, and Diarrhea. R5's annual Minimum Data Sheet dated August 12, 2024 showed her to be cognitively intact. On November 18, 2024 11:23 AM, R5 was observed to be alert and oriented and stated that the facility took her air mattress and she has buttocks pain. Later, on November 19, 2024 1:40 PM, R5 stated her bottom hurts and she has an open wound on her bottom. R5 stated it has been there for a couple months. V19 (Wound Care Doctor) note dated November 20, 2024 showed R5 presented with moisture associated and excoriations and possible concomitant candida to sacrum with scattered openings in the fragile inflamed skin. V19 then prescribed an antifungal treatment for R5's wound. On November 19, 2024 at 1:43 PM V12 (Certified Nursing Assistant/CNA) confirmed that R5 has a wound to her sacrum and V14 (Licensed Practical Nurse/LPN) stated that R5 has wound on her sacrum ant they are treating it with medi-honey and calcium alginate. V14 also stated that the wound was noted on October 23, 2024. Nursing progress notes document that V18 (LPN-Nurse) obtained orders for wound care for R5 on October 23, 2024. R5 has an order dated October 23, 2024 that showed the following: Sacrum: Cleanse with wound cleanser, apply calcium alginate with medi-honey, and cover with border foam. Two times a day for opening in the sacral area. V16 (Nurse) stated on November 20, 2025 at 9:43AM, that V16 has provided wound care to R5 in the past. R5 skin care plan showed she was at risk for impaired skin integrity related to bowel and bladder incontinence, need for assist with repositioning and impaired mobility. R5's skin goal was for her skin to remain intact, free of redness, blisters, or discoloration through the next review date. The skin care plan was not updated to reflect R5's sacral wound and had not been updated since August 23, 2023. On November 20, 2024 at 9:19 AM, V2 (Director of Nursing/DON) stated, R5 does not have a wound. V2 was unable to provide any assessment or documentation of R5's wound on November 20, 2024. V2 stated she was not aware that R5 had a wound and V2 could not locate a wound assessment. V2 stated when a wound is found it should be care planned, put on the wound care system that the wound care doctor can see, assessed and documented, and the resident should be seen by the wound care doctor. V2 stated the wound care doctor has not seen R5 nor are they currently seeing R5. V2 stated that wounds should be in their Wound care system and then they flow into electronic medical record. The wound care system is what V19 (Wound Care Physician) checks when she comes in to see residents that have wounds. V2 confirmed that R5's name does not appear anywhere on the October 2024 or November 2024 list to be seen by V19. R5 was observed on November 20, 2024 with a wound to her sacrum about the size of a silver dollar. The wound bed was red and missing a layer of skin. R5 stated that the area hurt when touched. V2 stated she is waiting for the wound care doctor to see R5. V19 (Wound Care Physician) assessed R5 later and charted R5's wound as moisture associated excoriation. The facility's Pressure Ulcer/Injury Risk Assessment Policy dated July 2017 showed the following: Steps in the procedure 4. Conduct a comprehensive skin assessment with every risk assessment. b. once inspection of skin is completed document the findings on a facility-approved skin assessment tool. c. if a new skin alterations noted, initiate a (Pressure or non-pressure) form related to the type of alteration in skin. 5. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessment, the condition of the skin, the residents stated wishes and goals. Documentation: The following information should be recorded in the resident's medical record utilizing facility forms: 1. The type of assessment(s) conducted. 5. The condition of the resident's skin (ie., the size and location of any red or tender areas identified. The Facility's Pressure Ulcer/Skin Breakdown- Clinical Protocol policy dated April 2018 showed the following 2. The nurse shall describe and document/report the following: a. Full assessment of the pressure sore including, location, stage, length, width, and depth, presence of exudates or necrotic tissue. 3. The physician will assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc) of an ulcer.

Based on interview and record review, the facility's Arbitration Agreement failed to have the required language in the Arbitration Agreement Contract. This applies to all 46 residents residing at the facility. The findings include: The facility's Long Term care facility application for Medicare and Medicaid (CMS (Centers for Medicare & Medicaid Services)-671 form) dated November 18, 2024 showed that there were 46 residents residing at the facility. On November 20, 2024, at 2:02 PM, V8 (Community Relations Coordinator) said when there is a new admission, she sit downs and goes paragraph by paragraph through the contract with the resident and/or their representative. There have been situations where V8 said she has gone over the contract paragraph by paragraph over the phone with a resident's representative who was not able to come into the facility. On November 20, 2024, at 12:18 PM, facility provided their undated admission packet titled, Contract Between Resident and [facility name] which included the arbitration agreement. Under Section X. Miscellaneous Provisions N. Mediation/Arbitration asked the resident and or their representative to enter into mediation for all claims, disputed, and controversies arising in relation to the performance, interpretation, applications, or enforcement of this contract, including but not limited to the breach thereof, or relating to care and treatment of any other dispute relating to the resident's residency The mediator will be selected in good faith by both parties .Should the parties fail to reach a resolution of the claim, dispute, or controversy by way of mediation, the dispute shall be arbitrated in accordance with the American Arbitration Association (AAA) 'Commercial Dispute Resolution Procedures' . The facility contract was lacking the language that showed that neither the resident nor their representative are required to sign the agreement for arbitration as a condition of admission to, or as a requirement to continue to receive care at the facility. It was also lacking the language that showed the resident or their representative have the right to rescind the agreement within 30 day calendar days of signing the contract. On November 20, 2024, at 2:25 PM, V8 said she has re-read the agreement and the contract does not have the required language in it. V8 said this will be addressed.

Based on observation, interview, and record review the facility failed to safely transfer a resident using a wheelchair. This applies to 1 of 4 residents (R1) reviewed for accident hazards in the sample of 4. The findings include: On 5/18/24 at 9:20 AM, R1 stated, she was being transported from her room to the DR (dining room) on 5/13/24 by V3 (Activity Aide) in her wheelchair, to go for Bingo. R1 stated, she felt her wheelchair was not moving smoothly and she toppled over and fell to the ground. R1 stated, she hit her head and it was bleeding. There was a pair of foot pedals for wheelchair in the room. R1 stated, the foot-pedals are never put on her wheelchair. R1 stated, she usually propels herself and sometimes, the staff helps her. On 5/18/24 at 11:45 AM, V6 (Maintenance Director) stated, he saw R1's foot caught in the front wheel of the wheelchair and then R1 tipped forward and fell to the floor. V6 stated, after R1's fall, he checked the wheelchair and there was nothing wrong with the wheels or the break of the wheelchair. On 5/18/24 at 11:55 AM, V3 (Activity Aide) stated, she was transporting R1 in her wheelchair from her room to the DR on 5/13/24 around 2:00 PM. V3 stated, the wheelchair did not have foot pedals, so she asked R1 to hold her feet up. V3 stated, she did not see that R1 put her foot down and her foot got caught under the front wheel of the wheelchair and she fell forward. V3 stated, she called the nurse, who assessed R1, and sent her out to the ER (emergency room ). On 5/18/24 at 12:20 PM, V8 (CNA-Certified Nursing Assistant) stated, while transporting residents in their wheelchairs to avoid falls, either residents must hold their feet up or use foot pedals so that their feet does not get caught in the wheels. V8 stated, it is the responsibility of the transporter to ensure that the resident is holding their feet up and is safe. On 5/18/24 at 1:45 PM, V4 (LPN-Licensed Practical Nurse) stated, while transporting residents in their wheelchairs to avoid falls, either residents must hold their feet up or use foot pedals so that their feet does not get caught in the wheels. On 5/18/24 at 1:11 PM, V2 (DON-Director of Nursing) stated, when residents are being transported by staff in their wheelchair, either use the foot pedals or ask the resident to hold their feet up. V2 stated, it is the responsibility of the transporter to ensure the resident's feet are not touching the floor. V2 stated, R1 was sent to the ER via ambulance and R1 returned to the facility the same day. V2 stated, R1 had a laceration with no sutures. On 5/18/24 at 12:48 PM, V1 (Administrator) stated, she heard overhead page for nurses to come and when she arrived at the scene, the nurses were assessing R1 and R1 was bleeding from her forehead. V1 stated, 911 was called and R1 sent to the hospital. V1 stated, R1 sustained a laceration and no sutures were needed. R1's face sheet showed R1 is admitted to the facility on [DATE]. R1's MDS (Minimum Data Set) dated 4/15/24 showed R1 had no cognitive impairment. R1's fall risk assessment dated [DATE] showed R1 is at High Risk for Falls. R1's Progress Notes dated 5/13/24 at 4:07 PM showed, around 2:00 PM, R1's left leg got caught in the wheelchair and R1 fell to the floor and sustained a laceration on the forehead. R1 was sent out to the hospital. R1 returned to the facility the same day with no sutures or fracture. Facility Policy on Assistive Devices and Equipment revised on July 2017 did not include any safety measures to be followed while transporting residents on wheelchairs.

Based on observation, interview, and record review, the facility failed to ensure the sanitization of the kitchen, and discard and store food items to prevent the transmission of food borne illness. This applies to all residents that reside in the facility. Findings include: The facility's [DATE] CMS-671 Form showed 50 residents live in the facility. 1. On [DATE] at 11:23 AM, quality assurance checks of red sanitization buckets and the three-compartment sink was conducted with V6 Dietary Manager. Sanitizing Bucket #1 strip tested at zero ppm (parts per million). Sanitizing Bucket #2 was dumped and refilled by V8 Dietary Aid before V6 tested sanitizer concentration. Bucket #2 with sanitizer strip tested at zero ppm. Sanitizing Bucket #3 strip tested at zero ppm. The three-compartment sanitizing sink tested at zero ppm. V6 Dietary manager stated staff should be changing the sanitization bucket several times during meal preparation and the person that changes should be checking it. Staff have not been checking the sanitization bucket or documenting it- ultimately, it's my responsibility. On [DATE], V6 stated I realized the sanitizing bucket and sink weren't at the proper level during the initial tour. Testing the sanitizing buckets should be done when you replace the water with sanitizer. V6 stated the three-compartment sink should be tested three times per day, or when it gets dirty and is refilled, or if the water gets hotter than 75 degrees because the higher temperature makes the sanitizer less effective. The buckets and sink should be tested to assure the correct level of sanitization is being used. V6 stated if you don't have enough sanitizer, it would not effectively sanitize, and can cause infection control issues with cross contamination and food borne illness. If you have too much sanitizer it's ineffective and can contaminate the item you are trying to sanitize, and potentially get residents sick and cause harm to the residents. V6 stated we should have been documenting the testing. If we had been doing the testing, we would have known there was a problem before Tuesday. A company came out to check the dish machine. I should have run the machine and then do a check of the sanitizer after the final rinse. V6 stated we should be doing it three times a day with breakfast lunch and dinner. 2. On [DATE] at 10:31 AM, the facility kitchen tour was conducted with V6 Dietary Manager and the following were noted: Dry Storage- Opened red food color 16oz (ounces) dated [DATE] Opened malt vinegar 12 oz - no opened-on date or use by date. Opened yellow food color 32 oz dated [DATE] Opened green food color 16oz- no open on date, use by date or manufacturer date. Opened red food color 32 oz opened on [DATE] V6 Dietary Manager stated items should be good for one year after opening. Two bottles of chocolate syrup 24oz expired on ,d+[DATE] Eight bottles of raspberry syrup15.1 oz expired [DATE] Open lime juice 1 gallon and in dry storage label says refrigerator after opening. Double bagged ground black crumbs. Bag opened by V6 identified as chocolate cookie crumbs sundaes. Corn starch in large clear bin covered by a metal baking pan not secured to bin- no use by or manufacturer expiration date. Opened whey protein powder (10lb) opened in a zippered storage bag- no open on date, use by date or manufacturer expiration date. Walk-in cooler- 8 Green peppers with mold and soft spots. Canadian bacon 32oz opened package wrapped in plastic wrap-- opened on [DATE]. V6 Dietary manager stated the Canadian bacon should have been used within in four days after opening. We keep dented cans on top of the organizer of in use other cans in dry storage. Reach-in cooler- Opened mayonnaise 128 oz opened [DATE] Opened cream cheese 11lbs opened [DATE] Walk in freezer- large bag of garlic bread -- writing on bag illegible Reach-in freezer- Two bags of pro apple muffin batter no volume amount listed on bags. Manufacture use by date of [DATE]. On [DATE] at 8:45 AM, V6 Dietary Manager stated food coloring is good for one year after opening according to our standard, and vinegar should have an open on date and use by date once it is open. The manufacturer's expiration date is the expiration date. Expired and should be discarded it's not used and serving expired food items can cause food borne illnesses. Foods that say refrigerate after opening should be refrigerated because they can spoil, become contaminated, and causes food borne illness. Dry items like the cornstarch should be labeled with the contents, when it came in, and when it expires. Items should be covered with a tight-fitting lid so rodents and bugs don't get in it, or spoil, which can allow harmful bacteria to grow. V6 stated I don't believe the cornstarch had an expiration date. Food transferred to another container should have a label that includes what it is, when it came in, when it expires or a use by date. Opened items that have manufacturers label should have the date it came in, and if open, when it was opened, when expires, or the use by date. Fresh items with mold and soft spots should be disposed of. V6 stated the Canadian bacon that turned gray should have been disposed of to prevent food borne illness because it could be spoiled. The Canadian bacon should have been used in 4 to 6 days. Labels that are illegible if unopened should go by manufacturer use-by date. The dented cans can be discarded or set aside for the food service company to take back. the dented cans should not be stored where our regular cans are because a staff members may use them and it may increase the risk of food borne illness like botulism. Salad dressing should be used within 30 days of opening and using it past the date increases the risk of contamination and risk of food borne illness increases also. Cream cheese icing should be used 30 days after opening. The garlic bread should be labeled legibly since it was taken out of the original container, and staff should have transferred the label information from the manufacturer label or the received date and use-by date since it was open and it should be good for 30 days after opening. The apple muffin batter was no longer good and should have been disposed of, even if it's in the freezer, because we need to follow the manufacturer original use-by date. The facility policy Storage of Dry goods / Foods dated 2010, states foods stored in bins will be removed from original packaging and bins will be labeled with item and date unpacked. Open products will be labeled and tightly covered to protect against contamination including from insects and rodents. The facility policy Labeling and Date Marking Foods dated 2014, states to decrease the risk of food borne illness and to provide the highest quality of food for the residents prepared and packaged foods may be marked with the date received, the date opened and or the date by which the item should be discarded. The facility undated recommendation chart for opened items list mayonnaise is good for two months refrigerated after opened. The facility policy Sanitizing Solution for Wiping Cloths dated 2015 states using an appropriate test strip, the strength of the sanitizing solution will be tested each time the sanitization buckets are changed. The facility did not provide a policy for the three-compartment sink.

Based on observation, interview and record review, the facility failed to ensure lint was removed from the facility's dryers, posing a fire hazard. This applies to all residents residing in the facility, and all staff and the public that come to the facility. The findings include: On 01/17/24 at 3:48 PM, the facility's three dryers had lint in the bottom of the dryers. In dryer 1, there was approximately a one inch layer of lint on the bottom and on all 4 sides of the lint basket. Dryer 1 was empty. In dryers 2 & 3, there was lint approximately 1 inch thick on the top of the lint screens and there was a pile under both the screens that were about 10 inches high and about 10 inches wide. Both of these dryers were with clothes in them. On 1/17/24 at 3:51 pm, V16 (Laundry staff) said that she cleans the dryers once a day at the end of her day, and she will be cleaning the lint out of these dryers at the end of this day. V16 said that she does about 20 to 30 loads a day. V16 said she does not keep a log when she cleans the lint from the machines. V12 (Maintenance Director) said that if the dryers were running with the lint in them, it would be a fire hazard. V12 said that the facility does not have a policy on removing lint from the dryers. V12 said that he does not keep a log on the maintenance of the dryers, and the lint should be cleaned from the dryer after every load. The facility [brand name] Dryer manual #1 (no date) showed on page 27 rules for safe operation - always keep lint screen clean. The facility [brand name] Dryer manual #2 showed on page 29 rules for safe operation of dryer always keep lint screen clean. The facility's ADC (American Dryer Corp) dryer manual (no date) showed on page 42, Warning lint from most fabrics is highly combustible. The accumulation of lint can create a potential fire hazard, suggested cleaning schedule every third or fourth load.

Based on interview and record review the facility failed to respond to a potential abuse allegation by not thoroughly investigating and not reporting the allegation to the State Survey Agency. This applies to 1 of 1 (R9) reviewed for abuse in the sample of 27. The findings include: The EMR (Electronic Medical Record) showed R9 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, anxiety, delusional disorder, hallucinations, schizoaffective disorder, and dementia. R9's MDS (Minimum Data Sheet) dated 11/02/2023 showed she had short and long-term memory problems and required the use of a manual wheelchair with partial to moderate staff assistance. The EMR showed R31 was admitted to the facility on [DATE], with multiple diagnoses including parkinsonism, anxiety, amd depression. R31's MDS dated [DATE] showed she was cognitively intact. On 1/17/2024 at 10:33 AM, R31 was participating in the facility's resident council group meeting and shared a concern from two months ago where she observed V4 (Agency Certified Nurse Assistant/CNA) pushing R9 into the dining room table. R31 said she was concerned with the manner V4 treated R9. R31 said she notified V1 (Administrator) the following day and was told V4 would not be returning to the facility. On 1/17/204 at 12:50 PM, V1 said R31 informed her of her concern regarding V4 (Agency CNA) and R9 a few months ago. V1 said she did a quick verbal follow-up but did not do a grievance form investigation. V1 said she did not consider R31's concern as abuse. V1 continued to say V4 said he was frustrated because he had to keep pushing R9 back into the dining room table. V1 said she called the staffing agency and asked for V4 not to return to the facility. On 1/18/2024 at 11:15 AM, R31 said V5 (Social Worker) told her on 1/17/2024 the facility had contacted the staffing agency and asked for V4 not to return to the facility. R31 continued to say she had reported R9's incident because she was concerned the incident was possibly abuse of an elderly person. The facility's document, titled Grievance/Complaint Report dated 1/17/2024 (during the survey) showed R31's grievance/complaint of her concern regarding observing an agency CNA speaking sternly and pushing another resident into the table two months ago. The form continued to show V1 was notified of R31's concern two months ago and the staffing agency was contacted to have the identified agency CNA not return to the facility. The form also showed the grievance was not resolved and is still in process. The facility's policy, titled Resident Care Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Known Origin, and Social Media with a revised date of 3/15/2018, showed Abuse and Neglect Prohibited: This facility, for the protection of the residents, utilizes the seven stages of the CMS [NAME] abuse prohibition protocol .I, identification of possible incidents or allegations which need investigation; I, Investigation of incidents and allegations .Investigating Abuse 1. After an initial report of suspected abuse or neglect is sent to IDPH, the Administrator or designee shall investigate all alleged incidents of abuse or neglect .

Based on observation, interview, and record review, the facility failed to ensure residents receive assistance for grooming and hygeine cares. This applies to 1 of 3 residents (R30) reviewed for grooming needs. The findings include: On 1/16/24 at 11:08 AM, R30 was sitting in the wheelchair in her room. R30 had several white hairs on her upper lip and chin. R30 said she does not like the hair on her chin and upper lip and would like it off. R30 said someone was supposed to do it, but they never did. On 1/17/23 at 8:46 AM, hair was still noted on her upper lip and chin. R30's MDS (Minimum Data Se) dated 11/3/23 shows that R30's cognition is moderately impaired and R30 needs moderate assistance with personal hygiene. R30's current care plan shows that R30 is at risk for ADL self-care performance deficit and needs extensive assist of 1 staff participation with personal hygiene. On 1/18/24 at 3:38 PM, V3 (ADON/Assistant Director of Nursing) said CNAs (Certified Nurse Aides) were responsible for assisting residents with ADL care. V3 said R30 does not have a history of refusing care, she should not have hair on her chin or upper lip. The facility's Supporting Activities of Daily Living (ADL) policy (reviewed 12/5/23) states that residents who are unable to carry out activities of daily living independently will receive services necessary to maintain good nutrition, grooming, personal hygiene and oral care.

Based on observation, interview, and record review, the facility failed to secure hazardous chemicals. This applies to 4 of 10 residents (R2, R43, R4, R10) reviewed for safe environment. Findings include: 1. On 01/16/24 at 10:54 AM, one 32 oz spray bottle of bleach was found in R2 and R43's shared bathroom. R43's 11/6/23 MDS (Minimum Data Set) showed that his mental status is severely impaired. R2's EHR (Electronic Health Record) showed diagnoses including dementia, schizoaffective disorder bipolar type, neurocognitive disorder, and major depressive disorder. On 01/16/24 at 11:14 AM, V11 (Housekeeping staff) said she had cleaned R2 & R43's shared bathroom and left the bottle of bleach in there. 2. On 01/16/24 at 11:02 AM, a 32 oz. spray bottle of odor eliminator was found in R4 and R10's shared bathroom. R10's EHR showed diagnoses including schizoaffective disorder, major depressive disorder, and far sightedness. R4's EHR showed diagnosis including dementia with agitation, mild cognitive impairment and age-related cognitive decline. On 01/16/24 at 11:19 AM, V11 was shone the bottle of odor eliminator, and V11 removed the bottle from the shared bathroom. V11 said that the bottle must have been left from the CNAs because she did not use the product. V11 said that bleach and the order eliminator should be locked in a storge area because it is a safety issue for the residents. V11 said that if a resident gets a hold of one of the bottles of chemicals they could get hurt. On 01/18/24 at 2:01 PM, V2 DON (Director of Nurses) said that the bottles of bleach and odor eliminator should not have been left in the residents' rooms because of safety purposes. If a resident has an altered mental status and they get a hold of them, they can hurt themselves or others with it by possibly drinking it or spraying in their eyes or someone else's. The facility's Chemical use policy (no date) showed that all housekeeping staff shall ensure that any chemicals used, such as cleaning, sterilizing, antibacterial, general cleaning . will always be in the housekeeper's control, in locked housekeeping cart and/or behind locked doors.

Based on observation, interview, and record review, the facility failed to ensure sanitary storage/containment of respiratory equipment when not in use. This applies to 1 of 2 residents (R49) reviewed for respiratory equipment in a sample of 27. The findings include: On 1/16/24 at 11:19 AM, R49's oxygen tubing and nasal cannula were observed on the floor. On 1/17/24 at 11:02 AM, R49 was sitting in his wheelchair receiving nebulizer treatment. R49's oxygen tubing and nasal cannula were again on the floor. R49 said he uses the oxygen. R49's EMR (Electronic Medical Records) shows R49's diagnosis which includes Chronic Obstructive Pulmonary Disease (COPD). R49's January 2024 Physician Order Sheet showed that R49 had an order to administer oxygen 2-4 liters via nasal cannula as needed maintain oxygen over 92% every shift related to COPD. On 1/17/24 at 3:44 PM, V3 (ADON/Assistant Director of Nursing) said if oxygen is not in use, the oxygen tubing and nasal cannula should be contained in a bag and not on the floor for infection control reasons. The facility's Oxygen Tubing Storage Policy and Procedure policy (updated 1/2/24) states that oxygen tubing will be stored when not in use in a plastic bag.

Based on observation, interview, and record review, the facility failed to administer correct dose of insulin medication. This applies to 1 of 3 residents (R39) reviewed for insulin medication administration in a sample of 27. The findings include: On 1/17/24 at 8:13 AM during medication pass, V7 (Agency RN/Registered Nurse) went to R39's room and to administer the scheduled dose of insulin. V7 said that R39 has an order to receive 50 units of Lantus (insulin). V7 administered the dose of insulin to R39's right upper arm. When V7 was done administering the insulin, some insulin remained in the insulin pen. Surveyor asked V7 for the insulin pen; there were still 2 units of insulin left in the pen and the pen's dial was at 2 with R39 not receiving the full prescribed dose. V7 said that dial should be at 0. R39's EMR (Electronic Medical Records) shows diagnoses which includes Type 2 Diabetes Mellitus with unspecified diabetic retinopathy and macular edema, and Type 2 diabetes mellitus with diabetic neuropathy. R39's POS (Physician Order Sheet) shows the following order for Insulin Glargine subcutaneous solution pen injector 100 unit/ml inject 50 units subcutaneously in the morning. R39's current are plans shows that R39 has Diabetes Mellitus with intervention to administer Diabetes medication as ordered by the doctor. On 1/17/24 at 3:47 PM, V3 (ADON/Assistant Director of Nursing) said the nurse should administer the required dose because the resident needs to right dose to help digest their food, and to keep insulin levels in the normal range. The facility's Administering Medications (revised 12/2012) policy states that medications must be administered in accordance with the orders .

Based on interview and record review, the facility failed to prevent an injury for 1 of 3 residents reviewed for falls and injuries. As a result of this failure, R1 sustained a rib fracture, and L2 spine fracture. Findings include: R1 is an [AGE] year-old Spanish-speaking male admitted on [DATE] having severely impaired cognitive functioning with a Brief Interview for Mental Status (BIMS) score of 03. R1 was admitted with an admitting diagnosis that included Dementia. Record review on clinical progress note dated 4/15/22 document that R1 was repeatedly tried to leave the facility during the night by opening the emergency door and sounding an alarm. R1 was aggressive and became more annoyed and angry when staff tried to redirect. R1 became extremely combative towards staff and was swinging on staff. The facility called 911 and transferred R1 to a local hospital. On 5/5/22 at 6:40 PM, V4 (R1's Daughter) stated, On 4/16/22, I visited (R1), and he was walking around and had no complaints of pain. On 4/17/22, I didn't visit. When I visited on 4/18/22 at 8 AM he was complaining of rib and back pain. He was in severe pain, and he said he had a fall while the staff was scuffling him to bring him back to his room the previous day. On 5/7/22 at 12:40 PM V8 (Agency CNA for R1 on 4/16/22 Night shift) stated, On 4/16/22 night shift, R1 was so violent. We were afraid as he was tall and was swinging his arms. We followed him trying to redirect him back. He moved to the sheltered side. We carried him back to his room by having the male CNA grab both arms, I held his one leg, and the other female CNA held his other leg. I don't know their names. He had a fall that happened in the hallway while we tried bringing him back, and he didn't report any pain at that time. On 5/7/22 at 11:40 AM, V2 stated (Director of Nursing), We don't know R1 had fallen. I would have notified of any unusual incidents. As I was not notified of any unusual incidents, I don't think any restraint use or fall during the 4/16/22 night shift. A record review of the fallen log and clinical progress note indicates any fall that happened to R1 during his two-week stay. On 5/6/22 at 11:00 AM, V1 (Administrator) stated, We use restraint appropriately, but nothing recently. We never used any restraint on R1. Record review on hospital record dated 4/18/22 documents that R1 was admitted with complaints of rib pain and may have been injured during a scuffle at the nursing home when the patient was combative as per EMS (Emergency Medical Service). Record review on hospital X-ray of the right rib dated 4/18/22 document a nondisplaced fracture of 10th right rib. CT (Computerized Tomography) of the chest/abdomen/pelvis dated 4/19/22 documents acute L2 compression fracture. MRI (Magnetic Resonance Imaging) of the lumbar spine dated 4/20/22 documents acute L2 (lumbar vertebra) fracture and suspected L3 fracture. On 5/10/22 at 9:40 AM, V9 (R1's attending physician) stated, I can't remember if they called me on 4/16/22 when R1 was being combative and trying to escape from the facility during the night shift. R1 might have had a fall causing his rib and L2 fractures. On 5/6/22 at 11:00 AM, V1 (Administrator) stated, residents should be monitored from fall/injury.