Every finding on record at Kenedy Health & Rehabilitation

Based on interview and record review, the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, meet professional standards of quality for 1 of 5 residents (Residents #1) reviewed for following physician orders.The facility failed to obtain a specialty care follow up appointment to the urologist for Resident #1 ordered post hospitalization on 1/7/26 after the insertion of a supra pubic catheter. Resident #1 was transferred to the hospital on 6/23/26 related to a change in condition and was diagnosed with sepsis and a urinary tract infection while at the hospital.These failures could place the residents at risk of not having their individual needs met and of not receiving adequate care and medical interventions to maintain their health and prevent worsening health conditions.The findings included: Record review of Resident #1's face sheet, dated 6/27/26, reflected an [AGE] year-old male admitted to the facility on [DATE], re-admitted on [DATE], and discharged to an acute care hospital on 6/23/26 with diagnoses that included cerebral infarction (an area of brain tissue that has been permanently damaged because its blood supply was blocked; stroke), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or partial loss of strength on one side of the body) following cerebral infarction affecting right dominant side, acute cystitis without hematuria (sudden infection and inflammation of the bladder that does not cause blood in the urine), presence of urogenital implants (a medical device that has been surgically placed in the urinary system), obstructive and reflux uropathy (condition in which the normal flow of urine is impaired because of blockage, backward flow of urine, or both), retention of urine, benign prostatic hyperplasia (a non-cancerous enlarged prostate gland) with lower urinary tract symptoms, gastrostomy status (an active, functioning surgical opening in the stomach which holds a feeding tube), dementia with agitation, and urinary tract infection. Record review of Resident #1's most recent quarterly MDS assessment, dated 5/22/26, reflected the resident was cognitively intact for daily decision-making skills, required substantial/maximal assistance with ADLs and mobility, had an indwelling urinary catheter, and was always incontinent of bowel. Record review of Resident #1's June 2026 Order Summary report, dated 6/27/26, reflected the following:- Cleanse supra pubic catheter site with normal saline, pat dry, cover with drainage sponge twice daily for preventative wound healing with order date 1/8/26 and no end date.- Empty (urine) drainage bag every shift with order date 11/29/25 and no end date.- Ensure catheter strap in place every shit change and as needed with order date 11/29/25 and no end date.- Monitor supra pubic catheter every shift for leakage, blockage, sediment buildup, or low output every shift for preventative with order date 1/8/26 and no end date.- Supra pubic 16 French/10 ml to gravity drainage every day and night shift related to neuromuscular dysfunction of bladder (condition in which the nerves or muscles that control the bladder do not function normally), obstructive and reflux uropathy with order date 1/8/26 and no end date. Record review of Resident #1's comprehensive care plan, with revision date 6/26/26, reflected the resident had an indwelling urinary catheter related to neurogenic bladder (condition in which the bladder does not function normally because of damage to the nerves that control bladder storage and emptying) and on 1/8/26 had a supra pubic catheter with interventions that included to cleanse the supra pubic catheter site. Record review of the hospital records, dated 1/1/26, reflected Resident #1 was seen for acute kidney injury related to urine retention, hyperkalemia (condition in which the level of potassium in the blood is higher than normal), sepsis (the body's response to an infection becomes dysregulated, causing widespread inflammation that can lead to organ dysfunction and if untreated septic shock and death), and obstruction of urinary catheter. Resident #1's hospital record reflected, may need urology consult for potential suprapubic catheter placement. Resident #1's hospital records reflected in part, 1/6 plans for IR SPT (suprapubic tube by Interventional Radiology [IR]) insertion today. Will monitor for output and anticipate discharge this afternoon if no hematuria or complications. Record review of Resident #1's Patient Depart Summary, with disharge date of 1/7/26, revealed, Your suprapubic catheter may need to be changed every 4-6 weeks, or as often as recommended by your health care provider. Record review of Resident #1's clinical record reflected the following:- 2/1/26 Description of the behaviors: Resident #1 pulls on supra pubic catheter tubing- 2/13/26: Resident #1 transferred to the hospital on 2/13/26 at 3:40 p.m. related to unresolving gross hematuria, and low-grade fever- 2/13/26: Resident #1 re-admitted /returned from emergency room via ambulance. Diagnosis urinary tract infection and one new order for antibiotic therapy for 7 days. Family member, MD and DON notified.- 2/15/26: Weekly Summary. Description of behaviors: continues to pull on suprapubic catheter/tubing at insertion site, will attempt to bite/nibble on squishy toy that he keeps in hand. MD and family member aware of the behaviors. Record review of the progress note dated 2/19/26 with time stamp 3:39 p.m., and authored by LVN A reflected in part, call placed to urologist to set up a follow-up appointment at this time. Urology office notified this nurse. Resident #1's current Medicare Part A does not cover appointment. Record review of Resident #1's hospital records, dated 6/23/26, revealed diagnoses of septic shock and a UTI. Further review revealed imaging showed, showed partially decompressed urinary bladder with suprapubic foley catheter in place. There is persistent perivesicular and presacral edema. Enlarged prostate gland. Further review revealed the resident had neurogenic bladder and was referred for consultation related to bilateral hydronephrosis (swelling of the kidneys r/t buildup of urine.) An attempt at a telephone interview on 6/27/26 at 7:01 a.m. with Resident #1 was unsuccessful. The hospital operator indicated they did not have a Resident by that name in the hospital. During an interview on 6/27/26 at 9:30 a.m., the DON stated she submitted an allegation of neglect to State Office related to a social media post she had seen posted by Resident #1's family member on 6/25/26 alleging the facility was not properly treating the resident's urinary tract infection which resulted in the resident having sepsis which resulted in being admitted to the hospital intensive care unit. The DON stated, on 6/23/26 at approximately 3:30 p.m. or 4:00 p.m., Resident #1 was lethargic, or tired, didn't want to get up so we put him in bed, administered fever reducing medication and obtained his vital signs. The DON stated Resident #1's blood pressure began to decrease and the family member and MD were notified. The DON stated that the MD ordered a urinalysis but as the evening progressed Resident #1's condition declined and the MD ordered the resident to be transferred to the hospital for evaluation and treatment on 6/23/26 at approximately 7:30 p.m. The DON stated Resident #1 continued at the hospital but was no longer in the intensive care unit and was awaiting transfer to a regular hospital room. The DON stated, Resident #1 had a long history of chronic urinary tract infections and had been treated in the facility with IV antibiotics. The DON stated, Resident #1 admitted to the facility with an indwelling urinary catheter, but because the resident had a history of pulling on the urine tube and had at times dislodged it, the indwelling urinary catheter was discontinued, and the supra pubic catheter was inserted on 1/7/26 related to trauma. The DON stated, Resident #1 also had a feeding tube and would often pull on the feeding tube as well. The DON stated that when the supra pubic catheter was inserted for Resident #1 on 1/7/26, the resident was discharged from the hospital with a discharge order to follow up with the urologist. The DON stated that when LVN A tried to schedule a follow up appointment with the urologist, the urologist office declined to see Resident #1 because of payor source. The DON stated since then, the nurses had been monitoring the supra pubic site for signs of infection but did not know when the supra pubic catheter was supposed to be changed out. The DON stated she believed the supra pubic catheter would have to be changed out 6 weeks after placement and stated Resident #1 had the same supra pubic catheter since 1/7/26 when it was originally inserted. The DON stated there was no sure way of knowing specifically since the supra pubic catheter had not been changed since its placement on 1/7/26 and up until Resident #1 was sent to the hospital on 6/23/26 that it would have contributed to a urinary tract infection and sepsis. The DON stated Resident #1 had a history of neurogenic bladder, blockage and severe benign prostatic hyperplasia which contributed to the resident's susceptibility to urinary tract infections and sepsis. The DON stated, we were trying to get him (Resident #1) to see a urologist but could not because of the insurance issue. The DON stated she believed the MD had been informed about Resident #1's insurance issue and no follow up with the urologist. The DON stated, the MD visited residents at least once a week. During a telephone interview on 6/27/26 at 10:42 a.m., Resident #1's family member stated the resident was admitted to the hospital on [DATE] related to having a low-grade fever and low blood pressure reading. Resident #1's family member stated the resident was improving and was no longer in the intensive care unit. Resident #1's family member stated the resident had chronic urinary problems and had been diagnosed with sepsis and urinary tract infections in the past that were treated with IV antibiotics. Resident #1's family member stated the resident used to have an indwelling urinary catheter, but it was taken out and replaced with a supra pubic catheter that she believed was supposed to be changed at least every 4 to 6 weeks. Resident #1's family member stated the resident was supposed to see the urologist to have the catheter changed out, and maybe they (the facility) can't do that there and had been told by the facility they could not get the resident an appointment with the urologist because of issues with his insurance. Resident #1's family member stated the facility staff were working on an appointment with the urologist, whoever does the referrals or the appointments. During an interview on 6/27/26 at 11:14 a.m., the Regional Compliance Nurse stated Resident #1 had a supra pubic catheter inserted January 2026 related to complications from the indwelling urinary catheter. The Regional Compliance Nurse stated the DON informed her the surgeon who initially inserted Resident #1's supra pubic catheter refused to see the resident for a follow up due to payment. The Regional Compliance Nurse stated, once the refusal by the urologist for appointment was known, the facility nurses were supposed to monitor the resident for signs and symptoms of infection, change the supra pubic dressing twice a day and wait until the resident could be seen by the urologist. The Regional Compliance Nurse stated Resident #1 should have been sent for a follow up to the urologist despite his payor source and the facility should have paid the bill. The Regional Compliance Nurse stated, our job is to take care of the patient, and we can pay for it (the urologist follow-up appointment) and then get reimbursed later. The Regional Compliance Nurse stated she did not believe the DON understood that the facility was able to do that. The Regional Compliance Nurse stated she was unsure if the MD was made aware that Resident #1 did not go back to the urologist to get the supra pubic catheter changed out. The DON stated that the facility nurses could change out a supra pubic catheter once an order was obtained and stated the floor nurse who admitted the resident to the facility from the hospital should have followed up. The Regional Compliance Nurse stated LVN A documented on Resident #1's medical record on 2/19/26 that a follow up appointment was attempted but the urologist refused to see the resident due to payment. During an interview on 6/27/26 at 11:38 a.m., LVN A stated she recalled Resident #1 admitted to the hospital either in December 2025 or January 2026 related to the indwelling urinary catheter clogging and because of chronic issues, and therefore the indwelling urinary catheter was replaced with a supra pubic catheter. LVN A stated when Resident #1 was discharged from the hospital there were orders on the discharge from the hospital to schedule a follow up appointment with the urologist who inserted the supra pubic catheter. LVN A stated, she called the urologist office and was told the resident was not pulling up coverage meaning the resident was not covered by insurance. LVN A stated she then made a progress note in Resident #1's medical record and let my boss know. LVN A stated she believed she made Resident #1's family member aware, and made the MDS Coordinator, the DON and the ADON aware. LVN A stated she recalled being told by either the MDS Coordinator, the DON or the ADON that the BOM would take care of it. LVN A stated she did not notify the MD about the situation and was not sure if she should have. LVN A stated, I only message him (MD) for medical emergencies. LVN A stated Resident #1's supra pubic catheter was checked twice a day, per shift, and made sure the catheter bag was emptied. During a telephone interview on 6/27/26 at 11:53 a.m., the MD stated he visited with Resident #1 at least once a month. The MD stated he recalled Resident #1 had a supra pubic catheter put in and generally it is changed every 4-6 weeks. The MD stated, if the urologist was ok with it, there would have been an order to indicate whether the supra pubic catheter should be changed out or not. The MD stated he could not recall if the facility nurses had made him aware the urologist did not see the resident for a follow up related to insurance issues. The MD stated, when a resident had an indwelling urinary catheter or a supra pubic catheter, there was always a risk for urinary tract infections. The MD stated, depending on the resident and what the urologist wanted, not having changed out Resident #1's supra pubic catheter since it was inserted and the resident was now in the hospital related to a urinary tract infection would not have made a difference. The MD stated, just changing out a catheter routinely puts the resident at risk of sepsis infection. The MD stated, I don't know where the ball was dropped, and the facility would have normally went with another urologist and the nurses in the facility could change out the supra pubic catheter. The MD stated, it would have been ideal that I be notified. During a follow up interview on 6/27/26 at 12:37 p.m., LVN A stated there was a physician's order that indicated the size of the supra pubic catheter inserted for Resident #1 but there was no order for changing it out. LVN A stated there should have been orders to change out the supra pubic catheter but since an appointment to the urologist was not scheduled there were no instructions on when to change it out. LVN A stated from experience, residents with urinary catheters typically have them changed out every 3 or 4 months. LVN A stated if a urinary catheter was not changed out per physician's orders, then the catheter can wear down but was not sure how that would affect the resident. During a follow-up telephone interview on 6/27/26 at 12:53 p.m., the MD stated for Resident #1 he would have relied on the urologist to send orders to the facility for changing out the supra pubic catheter. The MD stated he usually signed off on orders once a month but did not recall seeing an order for changing out the supra pubic catheter for Resident #1 and stated it would have been something the nurses would have called to his attention. The MD stated, when it is brought to my attention, we take care of it. The MD re-iterated, ideally a supra pubic catheter should be changed every 6 to 8 weeks; two months. During an interview on 6/27/26 at 1:04 p.m., the ADON stated she was not sure if she received notification from the nurses about Resident #1 not being able to see the urologist for a follow-up after having a supra pubic catheter inserted, but it may have been mentioned during the morning meeting. The ADON stated, we probably should have let the doctor know and let the doctor decide what needed to be done. The ADON stated there should have been orders in place for changing out Resident #1's supra pubic catheter but did not know what the policy and procedure was for the facility. During an interview on 6/27/26 at 1:24 p.m., the MDS nurse stated the IDT was aware Resident #1 needed to get an appointment with the urologist, including the DON and ADON. The MDS nurse stated she was aware when a resident discharged from the hospital there were discharge orders for Resident #1 to follow up with the urologist. The MDS nurse stated, she did not handle the resident's financial situation because she was not the BOM but she was aware there was some difficulty getting proper documents to apply for financial assistance. The MDS nurse stated she was not aware there was documentation about Resident #1 not able to see the urologist until she reviewed the resident's medical record to determine when he had gone back to the urologist for follow-up. The MDS nurse stated, Resident #1 should have been sent to the urologist for follow-up despite his payor source because we have to follow discharge instructions from the hospital surgeon/doctor. The MDS nurse stated, we follow doctors orders and the floor nurse was responsible for obtaining those orders. The MDS nurse stated, without the physician's orders to change out the supra pubic catheter there could be adverse effects. The MDS nurse stated, I was not aware the resident (Resident #1) never made it to the urologist for a follow-up. An attempt at a telephone interview on 6/27/26 at 1:41 p.m. was made with the BOM. A voicemail message was left requesting call-back. During an interview on 6/27/26 at 2:03 p.m., RN B stated she was aware Resident #1 had chronic issues with urinary tract infections and the resident pulled on the catheter tubing causing trauma. RN B stated she was not aware there were orders for Resident #1 to follow-up with the urologist and the floor nurses who admitted the resident to the facility post hospitalization were responsible for obtaining the orders. RN B stated, catheter care included monitoring for infection, emptying the catheter urine bag, and instruction on when to change out the catheter, and assumed that was just standard procedure for infection control. An attempt at a telephone interview with the Urologist on 6/27/26 at 4:32 p.m. was unsuccessful. A voicemail message was left requesting call-back. During a follow-up interview on 6/27/26 at 4:36 p.m., the DON stated the floor nurses could change out a supra pubic catheter in the facility. The DON stated the MD had seen Resident #1 since he had the supra pubic catheter had been inserted but the MD never gave orders to change it out. The DON stated, urinary catheters, including supra pubic catheters, were changed out if there was blockage or leakage per facility policy. The DON stated, not to say the MD would never write that order, it's just that during this time it was not indicated to change it (the supra pubic catheter) out. That is what I assume. During an interview on 6/27/26 at 4:51 p.m. LVN C stated there were residents in the facility who had indwelling urinary catheters and one resident who had a supra pubic catheter. LVN C stated that the nursing staff in the facility could change out supra pubic catheters. LVN C stated she was aware from Resident #1's discharge hospital orders that the resident was supposed to go back to the urologist for a follow-up appointment but was not sure if the appointment was made. LVN C stated to change out a supra pubic catheter there had to be a physician's orders in place. LVN C stated, if there was no physician's order to change out the supra pubic catheter, then we would have called the doctor to get an order. During an interview on 6/28/26 at 10:25 a.m., RN D stated, for residents with indwelling urinary catheters, including supra pubic catheters, care included an order that indicated the size of the catheter, monitoring for infection and patency, and orders to have the catheter changed out in case of dislodgement or as needed. RN D stated there were residents in the facility with catheters and had orders to change them out monthly, every two months, or as needed, it just depends on the individual resident. During an interview on 6/28/26 at 10:41 a.m., LVN E, who was also the Treatment Nurse stated, for urinary catheters, including supra pubic catheters care, you do what the doctor's orders say. LVN E stated the nurse should be contacting the doctor to obtain orders for changing out the catheter and notification should be made to the doctor when the catheter had sediment, there was poor urine output, the urine looked cloudy, or the catheter was clogged. LVN E stated, if the urologist refused to see the resident because of payor source, the appointment should have been paid for by the facility because the follow up to the urologist was a doctor's order, and that is following doctor's orders. During an interview on 6/28/26 at 11:03 a.m., the Administrator stated he was aware Resident #1 was not seen for a follow-up appointment by the urologist due to payment issues and, we realize that was an issue now. The Administrator stated medical payment to the specialist was the responsibility of the facility and the appointment should have been expedited regardless. The Administrator stated the facility priority should have been to notify the doctor when Resident #1 did not get the appointment to the urologist because say he has an infection; it could get worse and you want to address it immediately. During a telephone interview on 6/28/26 at 3:27 p.m., the BOM stated she was not directly involved in scheduling appointments and could not recall the exact specifics with the urology follow-up appointment for Resident #1. The BOM stated she worked on securing benefits for Resident #1 but, the Administrator should have stepped in and arranged for payment (to the urologist). He (Resident #1) is a resident of the facility, and we are responsible for him. Record review of the facility document titled, Catheter Care, undated reflected in part, .Review the resident's plan of care daily for changes.Change the catheter and drainage system as needed unless ordered otherwise by the physician. Record review of the facility document titled, Appointments, undated reflected in part, .The facility will assist with outside facility resident appointments to ensure the resident attends any scheduled appointments.If unable to maintain the appointment time, notify the resident, responsible party, location of appointment, and ordering physician. Record review of the facility document titled, Notifying the Physician of Change in Status, undated reflected in part, Abnormal lab, x-ray and other diagnostic reports require physician notification.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen.The facility failed to ensure a bag of biscuits was properly sealed in the reach in freezer.This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included:Observation on 12/02/2025 at 11:35 AM in the reach-in freezer in the kitchen revealed a clear plastic bag of frozen biscuits. The bag was closed at the top with two knots and there was an opening between the knots, exposing the contents of the bag to the ambient air in the freezer and potential contamination by pathogens and bacteria and a deterioration in food quality.During an interview on 12/02/2025 at 11:36 AM, the DFN stated the bag of biscuits was not sealed properly and should have been. Staff was trained on how to properly store food in the freezer and she would conduct additional training. The DFN stated food stored in the freezer should be completely sealed to ensure it did not deteriorate.Record review of the facility's policy IC 00-5.0 Food Safety, Dietary Policy & Procedures Manual 2012, revealed, 2. Food is to be wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated and stored properly.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 3-302 Preventing food and ingredient contamination. 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) Food shall be protected from cross contamination by: (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings. (6) Protecting food containers that are received packaged together in a case or overwrap from cuts when the case or overwrap is opened. 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.

Based on interview and record review, the facility failed to ensure each resident's environment was free from accident hazards over which the facility had control and provided supervision and assistive devices to each resident to prevent avoidable accidents for 1 of 6 residents (Resident #3) whose care was reviewed for accidents and hazards, in that: The facility failed to complete quarterly smoking risk assessments for Resident #3.This deficient practice could affect residents who used tobacco and could result in avoidable accidents from improper supervision during tobacco use. The findings included:Record review of Resident #3's face sheet, dated 12/05/2025, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia with agitation (a common behavioral symptom, appearing as increased restlessness, irritability, yelling, or physical aggression, often stemming from unmet needs, confusion, or environmental triggers), chronic obstructive pulmonary disease (a progressive lung disease that blocks airflow, causing breathing difficulties, persistent cough, wheezing, and chest tightness), and Parkinson's disease (a progressive brain disorder causing dopamine-producing cells to die, leading to movement issues like tremor, stiffness, slow movement, balance problems, and speech changes).Record review of Resident #3's annual MDS dated [DATE] revealed a BIMS score of 5, indicating severe cognitive impairment. Section J1300. Current Tobacco Use revealed the code 1 for Yes was marked.Record review of Resident #3's comprehensive care plan, updated 09/16/2025, revealed a focus area noting Resident #3 is a smoker and the resident also vapes with supervision, dated 07/04/2025. The goal was the resident will smoke or vape in designated areas without occurrence over the next 90 days. The first intervention was, Perform smoking assessment according to facility policy.Record review of Resident #3's electronic health record revealed his last safe smoking assessment was completed on 04/30/2024. The assessment noted the resident had a history of dropping cigarettes and burning his clothes. He was assessed as requiring direct supervision while smoking and requiring a fire-resistant smoking apron while smoking.During an interview on 12/05/2025 at 2:15 PM the DON stated all residents used vapes instead of smoking at present time. Resident #3 was supervised by the AD when he used his vape, and it was the AD's responsibility to do a smoking assessment on all residents who smoked or used a vape every quarter.During an interview on 12/05/2025 at 2:20 PM, the AD stated she supervised the residents who smoked and used a vape, and Resident #3 used a vape. The AD stated she was responsible for completing a safe smoking assessment on all residents who used tobacco in any form and must have missed completing assessments on this resident. The AD did not provide a reason the assessment was missed.Record review of the facility's policy, Smoking Policy revised 11/01/2017 revealed, 2. A safe smoking assessment will be done regularly for each resident who smokes. Smoking by residents is classified as unsafe and will be prohibited except when the resident will be directly supervised by facility personnel or visitors who are aware of the resident's limitations with smoking. The resident must be within direct view of the smoking supervisor, in reasonably close proximity of the supervisor, and the supervisor must be able to respond quickly in the event of an emergency. 5. Smoking or using an e-cigarette/vape is prohibited in any area flammable liquids, combustible gas, or oxygen are used or stored and in any other hazardous locations.

Based on interview and record review, the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 18 residents (Residents #7) reviewed for care plans, in that: The facility failed to revise Resident #7's comprehensive care plan to reflect the resident's change in hearing status.This deficient practice could place residents with a decline at risk of receiving proper care. The findings included: Record review of Resident #7's electronic face sheet dated 12/05/2025 revealed the resident was an [AGE] year-old male with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), chronic obstructive pulmonary disease (a progressive lung disease that blocks airflow, causing breathing difficulties, persistent cough (often with mucus), wheezing, and chest tightness) and chronic atrial fibrillation (a fast, irregular heartbeat that's long-lasting or constant, causing symptoms like palpitations, fatigue, shortness of breath, dizziness, and weakness, significantly raising stroke risk).Record review of Resident #7's Significant Change MDS dated [DATE] revealed a BIMS score of 07/15, indicating severe cognitive impairment. Section B - Hearing, Speech, and Vision revealed the code 1 was checked, indicating the resident had minimal difficulty with his ability to hear (difficulty in some environments, such as when a person speaks softly or the setting is noisy).Record review of Resident #7's comprehensive care plan, updated 10/24/2025, revealed there was no focus area addressing communication or the resident's hearing deficiency.During an interview on 12/05/2025 at 1:30 PM, MDS LVN C stated Resident #7's comprehensive care plan should have addressed his hearing difficulty, and it was omitted in error. MDS LVN C stated it was important to include this information in the comprehensive care plan so staff would know how to adjust their methods when communicating with the resident.During an interview on 12/05/2025 at 1:35 PM, the DON stated the Resident #7's hearing difficulty was not noted in his comprehensive care plan and should have been so that appropriate accommodations could be made for this deficiency.Record review of the facility's policy GP MC 03-18.0, undated, revealed, The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.Review of the CMS RAI Version 3.0 Manual dated October 2019 revealed .to evaluate the information gained through both the comprehensive assessment processes in order to identify problems, causes, contributing factors, and risk factors related to the problems .the IDT must evaluate the information gained to develop a care plan that addresses those findings in the context of the resident's goals, preferences, strengths and problems.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's mental, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment, for 1 of 18 residents (Residents #5) reviewed for comprehensive care plans.The facility failed to develop a comprehensive care plan that addressed Resident #5's self-care of his indwelling catheter.This failure could place residents at risk of infections from inadequate care and lack of staff supervision. The findings included:Record review of Resident #5's face sheet dated 12/03/2025 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Chronic respiratory failure with hypercapnia (a condition where patients experience prolonged respiratory issues that lead to an accumulation of carbon dioxide in the blood), retention of urine, and obstructive and reflux uropathy (conditions that impede normal urine flow and can lead to kidney damage, often requiring medical intervention).Record review of Resident #5's admission MDS assessment dated [DATE] revealed in Section C - Cognitive Patterns, a BIMS score of 15/15, indicating the resident was cognitively intact. Section H, Bowel and Bowl, H0100. Appliances, A. Indwelling catheter was checked, indicating Resident #5 had this type of catheter.Record review of Resident #5's comprehensive care plan, updated 12/02/2025, had a focus area indicating, The resident has Indwelling Catheter. Date initiated: 11/04/2025, Revision on: 11/05/2025. The goal was for the resident to remain free from catheter-related trauma through the review date. Target date: 02/22/2026. Interventions included the size of the catheter bag and tubing and bag placement, changing the catheter as ordered by physician, checking tubing for kinks and maintaining drainage bag off the floor, ensuring tubing was anchored to the resident's leg or linens so it was not pulling on the urethra, monitoring/documenting intake and output per facility policy, monitoring/documenting pain or discomfort, and monitoring/recording/reporting to the physician signs and symptoms of UTI. There was no mention in this focus area of the resident's self-maintenance of his catheter and emptying of his drainage bag.During an interview on 12/02/2025 at 2:30 PM, Resident #5 stated he performed 100% of his catheter care himself and had been doing so since his admission. He was happy he was able to ambulate from his bed to the bathroom to empty the drainage bag and has had no issues with his catheter since admission. During an interview on 12/04/2025 at 8:50 AM, the DON stated Resident #5 performed his own catheter care, his comprehensive care plan did not indicate the resident did his own catheter care and should have this information. The DON stated Resident #5 was a private individual who was capable of performing this care, but his ability should have been properly assessed and noted in his care plan.During an interview on 02/04/2025 at 10:22 AM, MDS LVN C stated she should have noted Resident #5's performed his own catheter care in his comprehensive care plan. It was an oversight on her part that it was omitted. MDS LVN C stated it was important this information was included in the care plan for staff awareness.Record review of the facility's policy GP MC 03-18.0 Comprehensive Care Planning, undated, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.Care plans will be person-centered and reflect the resident's goals for admission and desired outcomes. Person-centered care means the facility focuses on the resident as the center of control, and supports each resident in making his or her own choices. Person-centered care includes making an effort to understand what each resident Is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and having an understanding of the resident's life before coming to reside in the nursing home.

Based on interview and record review, the facility failed to notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review for one of one PASRR positive resident (Resident #47) who had a significant change in mental or physical condition.The facility failed to notify the LMHA of Resident #47's significant change in mental and physical status after submitting a significant change MDS on 10/22/2025.This failure could potentially result in PASRR positive residents receiving services of not having their needs evaluated to determine if additional services were required.The findings included:Record review of Resident #47's electronic face sheet dated 12/04/2025 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a chronic mental health condition characterized by symptoms of both schizophrenia and mood disorders, affecting how individuals think, feel, and behave), psychotic disorder with delusions (a severe mental health condition characterized by a loss of touch with reality, often manifesting as delusions) and mild intellectual disabilities. Record review of Resident #47's significant change MDS dated [DATE] revealed a BIMS score of 07/15, indicating severe cognitive impairment. Section GG - Functional Abilities, revealed a decline in the resident's eating, toileting, and walking abilities from his quarterly MDS dated [DATE]. The resident also changed from always continent of bladder and bowel to frequently incontinent of both.Record review of Resident #47's comprehensive care plan revealed the resident was identified as PASRR positive for mental illness and intellectual disability.Record review of Resident #47's EHR revealed the resident was assessed by the Local Mental Health Authority for both MI and IDD on 01/10/2023.During an interview on 12/04/2025 at 1:45 PM, the MDS LVN C stated she did not notify the state mental health authority or state intellectual disability authority promptly after a significant change in Resident #47's physical condition for a review. MDS LVN C stated the lack of contact was an oversight, and it was important the LMHA was notified of the significant change so they could evaluate the resident to see if he required additional services. During an interview on 12/04/2025 at 1:50 PM, the MDS LVN Regional Director stated the LMHA authority was not notified of Resident #47's significant change in condition, and should have been notified so they could assess the resident to determine if additional services were necessary.During an interview on 12/05/2025 at 11:15 AM, the DON stated she was unaware of the requirement to notify the local state mental health or intellectual disability authority when a resident who was PASRR positive had a significant change and a significant change MDS was submitted. The DON stated she contacted the LMHA and was told she just needed to inform them of the resident's election for hospice, discharge to the hospital for over 30 days, or death.Record review of the facility's policy, PASRR Level 1 Screen Policy and Procedure revised 03/06/2013, stated only, Submission by the NF of the MDS SCSA (Significant Change in Status Assessment) Long Term Care Medicaid Information (LTCMI) on the LTC Online Portal will notify the LIDDA that the designated resident has elected hospice care and that a resident review is required and did not address notification of a significant change in mental or physical status.

Based on observation, interview, and record review, the facility failed to establish and maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 5 resident (Resident #53) reviewed for infection control, in that: 1.The facility failed to ensure CNA A washed her hands before starting to provide incontinent care for Resident #53. 2. The facility failed to ensure CNA A sanitized between her fingers while she provided incontinent care for Resident #53. These deficient practices could place residents at-risk for infection due to improper care practices.Record review of Resident #53's face sheet, dated 12/04/2025, revealed an admission date of 11/29/2024. Resident #53 had diagnoses which included: Cerebral infarction (Cerebral infarction is a type of stroke that results from the obstruction of blood flow to the brain), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Depression (mood disorder that causes a persistent feeling of sadness and loss of interest), Hypertension (High blood pressure), Irritant contact dermatitis due to incontinence (Irritant contact dermatitis is a form of skin inflammation caused by contact with substances and/or environmental factors that injure the skin, damaging the skin barrier). Record review of Resident #53's Skilled nurse note, dated 12/03/2025, revealed Resident #53 required reminders, cues, and supervision in planning, organizing, and correcting daily routines and had memory problems. Resident #53 was rarely understood. Record review of Resident #53's Skilled Section GG, dated 11/30/2025, revealed the resident required total care. Record review of Resident #53's care plan, dated 11/30/2025, revealed a problem of the resident has bowel incontinence and an intervention of Provide peri care after each incontinent episode. Observation on 12/04/2025 at 10:47 a.m. revealed CNA A did not change her gloves or sanitize hands after touching Resident #53's bed remote and before providing incontinent care for Resident #53. CNA A did not sanitize between the fingers of her hands between change of gloves. During an interview with CNA A, on 12/05/2025 at 11:00 a.m., she stated she had not sanitized her hands and change gloves before starting the care. CNA A stated she did not know the bed remote was considered dirty and that she had contaminated her gloves. CNA A stated she forgot to sanitize between her fingers while sanitizing her hands but knew how to practice hand hygiene and that it was important to prevent infection for the residents. She stated she received infection control training at least once a year. During an interview with the DON on 12/04/2025 at 11:45 a.m., she stated staff had to wash their hands before starting to provide care for a resident and had to use sanitizer or wash their hands between change of gloves and sanitize between their fingers to prevent the spread of infection. She stated she provided infection control training at least annually and the staff skills were checked annually and as needed. Review of CNA proficiency audit for CNA A revealed she had passed proficiency for incontinent care and infection control on 05/04/2025. Record review of the facility's policy, titled Fundamentals of Infection Control Precautions, dated 03/2024, revealed The following is a list of some situations that require hand hygiene: [ .] after handling soiled equipment or utensils. [ .] Include applying product to the palm of one hand and rubbing hands together, covering all surfaces of hand and fingers, until the hands are dry.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and service to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 (Resident #53) residents reviewed for incontinent care. The facility failed to ensure CNA A thoroughly cleaned Resident #53's buttocks and anal area during incontinent care. This deficient practice could place residents at-risk for infection and/or skin breakdown.The findings were: Record review of Resident #53's face sheet, dated 12/04/2025, revealed an admission date of 11/29/2024. Resident #53 had diagnoses which included: Cerebral infarction (Cerebral infarction is a type of stroke that results from the obstruction of blood flow to the brain), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Depression (mood disorder that causes a persistent feeling of sadness and loss of interest), Hypertension (High blood pressure), Irritant contact dermatitis due to incontinence (Irritant contact dermatitis is a form of skin inflammation caused by contact with substances and/or environmental factors that injure the skin, damaging the skin barrier). Record review of Resident #53's Skilled nurse note, dated 12/03/2025, revealed Resident #53 required reminders, cues, and supervision in planning, organizing, and correcting daily routines and had memory problems. Resident #53 was rarely understood. Record review of Resident #53's Skilled Section GG, dated 11/30/2025, revealed the resident required total care. Record review of Resident #53's care plan, dated 11/30/2025, revealed a problem of the resident has bowel incontinence and an intervention of Provide peri care after each incontinent episode. Observation on 12/04/2025 at 12:47 a.m. revealed while providing incontinent care for Resident #53, CNA A did not clean between the resident's buttock's and did not clean the anal area. During an interview on 12/04/2025 at11:00 a.m., CNA A stated she did not fully separate Resident #53's buttocks to clean the anal area. She thought she had cleaned the buttock enough and did not need to go deeper She stated she received incontinent care training from the DON. During an interview with the DON on 12/04/2025 at 11:45 a.m., she stated that the staff must clean the anal area and in the case of a male resident the underside of the perineal area to prevent skin irritation and prevent infection. She stated she provided incontinent care training to the staff within the year as well as checked their skills Review of CNA proficiency audit for CNA A revealed she had passed proficiency for incontinent care and infection control on 05/04/2025. Record review of the facility's policy titled Perineal care, dated 05/11/2022, revealed, gently perform care to the buttocks and anal area.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 2 shower rooms (Shower room [ROOM NUMBER]) reviewed for accidents and hazards, in that The facility failed to keep hazardous items out of reach of residents in a shower room. This deficient practice could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included: Observation on 08/27/24 at 11:30 a.m., revealed the door of Shower room was left open. Inside the room was a wall cabinet also left unlocked. Inside the cabinet were a razor, 3 bottle of shaving cream and a bottle of Micro kill one wipes. Review of the safety data sheet for micro kill one wipe revealed ACUTE TOXICITY - INHALATION - Category 4 FLAMMABLE LIQUIDS - Category 2 SERIOUS EYE DAMAGE /EYE IRRITATION - Category 2A SPECIFIC TARGET ORGAN TOXICITY (Single Exposure) - Category During an Interview with CNA A on 08/27/24 at 11:40 a.m., CNA A confirmed the door of the shower room and the wall cabinet were kept unlocked. CNA A confirmed the wipes. razor and shaving cream were in the cabinet. CNA A confirmed the cabinet should have been locked to prevent resident to get in contact with hazardous materials. During an interview with the DON on 08/27/24 at 12:05 p.m., the DON confirmed either the door of the shower room or the doors of the wall cabinet should remain locked. The DON confirmed the wipes, razor and shaving cream could be a hazard. The DON confirmed having several residents in the facility who are ambulatory but have mental illness diagnostics and/or dementia who could misuse the hazardous products and hurt themselves or others. Review of the facility policy, titled Hazardous communication program, dated 2003, revealed [ .] The facility will provide adequate and appropriate space and equipment for safe handling and storage of hazardous materials and waste. The storage areas will have the capacity to be secured and meet the provision of the Life Safety Code.

Based on observation, interview, and record review, the facility failed to ensure residents have a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely, for 1 of 2 shower rooms (Shower room [ROOM NUMBER]) and 2 of 26 resident rooms (Rooms #17 and #24) reviewed for safe, clean, and comfortable environment. The facility failed to repair missing and detached floor molding in a resident's room, replace a broken overhead light in a resident's shower room, and repair a scratched standing clothes closet in a resident's room. This deficient practice could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included: During an observation on 08/29/24 from 1:40 p.m. to 1:50 p.m. with the Maintenance Director. revealed the following: a. Resident room [ROOM NUMBER] had a 3.5 ft x 4 inch section of missing floor molding along the bottom surface of the wall adjoining to the floor surface. There was also a 4 x 4 inch section of floor molding in the bedroom proper that was detached from the wall. b. Resident Shower room [ROOM NUMBER] had 1 of 2 overhead lights which measured approximately 3 ft in length that was not working. c. Resident room [ROOM NUMBER] had a standing clothes closet that had an approximate 2 x 2 ft surface area on the front and side that contained multiple scratch marks that were ingrained into the wood surface. During an interview with the Maintenance Director on 08/29/24 at 1:55 p.m., the Maintenance Director stated that he had not been made aware by staff of the noted areas needing to be repaired. The Maintenance Director stated that fixing the noted repairs would promote a more positive home environment for the residents. During an interview with the Administrator on 6/5/24 at 2:00 p.m., the Administrator stated that fixing the floor molding in room [ROOM NUMBER], replacing the broken light in Shower room [ROOM NUMBER], and repairing the scratched clothes closet in room [ROOM NUMBER] would promote a more positive home environment for the residents. Record review of the facility's policy on Preventative Maintenance/Work-Order Request Section AD 03-12.0 dated 2003 stated The facility will repair or replace damaged/broken equipment or building amenities as needed.

Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 18 residents (Resident #8) observed for accuracy of medical records in that: The facility failed to have an appropriate order regarding the maintenance of Resident #8's oxygen concentrator. This deficient practice could place residents at risk for errors in care and treatment. The findings were: Record review of Resident #8's face sheet, dated 08/27/24, revealed Resident #8 was admitted to the facility on [DATE] and, readmitted on [DATE], with diagnoses that included: Dementia (decline in cognitive abilities), Aphasia (unable to comprehend or formulate language), Hypoxia (the body is deprived of adequate oxygen supply), Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood)and, Hypothyroidism (under active thyroid). Record review of Resident #8's quarterly MDS dated [DATE] revealed a BIMS of 6, indicating the resident was severely cognitively impaired. Further review of this MDS revealed in Section O, Special Treatments and Programs, that the resident received oxygen therapy. Review of Resident #8's physician orders for August 2024 revealed the following order: Change or clean the filter of the 02 concentrator every night shift every Sunday started on 4/23/23. Review of Resident #8's Medication and Treatment administration record for August 2024, revealed the staff had signed on Sundays for changing or cleaning the filter as done. Observation of Resident #8's bedroom on 08/27/2024 at 11:20 a.m. revealed no apparent filter on the back air intake grill at the back of the oxygen concentrator. During an interview with the DON on 8/27/2024 at 12:05 p.m., the DON revealed the concentrator did not require a outside filter since it has a filter inside that is change every two years when the manufacturer does the maintenance. The order to change or clean the filter was incorrect. The staff should not have signed the filter [NAME] as done. Record review of facility's policy, titled purpose and requirements medical records, dated 2015, revealed The medical record is a legal document that serves the purpose of: 1. providing an accurate assessment of each resident's condition.

Based on observations, interviews, and record reviews, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 4 residents (Resident #41) reviewed for infection control, in that: CNA C did not change her gloves or wash her hands after providing incontinent care for Resident #41. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #41's face sheet, dated 08/29/2024, revealed an admitted [DATE], with diagnoses which included: Hypothyroidism (under active thyroid), Anxiety disorder (A group of mental illnesses that cause constant fear and worry), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Dementia (decline in cognitive abilities), Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Major depressive disorder(mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure) and, Hypertension (High blood pressure). Record review of Resident #41's Significant change MDS assessment, dated 05/28/2024, revealed Resident #40 has a BIMS score of 12, which indicated mild to moderate cognitive impairment. Resident #40 required limited to extensive assistance with hid ADLs and was indicated to occasionally be incontinent of bladder and frequently incontinent of bowel. Review of Resident #41's care plan, dated 05/06/2024, revealed a problem of The resident has Urinary Tract Infection, with an intervention of Provide incontinence care as needed. Observation on 08/29/24 at 09:17 a.m., revealed, while providing incontinent care for Resident #41, CNA C did not change her gloves or wash her hands after providing incontinent care for Resident #41 and before touching and fastening the clean brief to Resident #41. During an interview on 08/29/2024 at 09:27 a.m. CNA C confirmed she did not change her gloves or wash her hands prior to touch the clean brief. She confirmed she received infection control training with the year. During an interview with the DON on 08/29/2024 at 3:15 p.m., the DON confirmed gloves must be changed after cleaning and before touching clean brief to prevent cross contamination. The DON revealed she was the one training the staff for infection control and that the ADON, weekend RN supervisor and herself would check the staff skills annually and as needed if a problem was noted. Review of facility policy, titled Fundamental of infection control precautions, dated 2019, revealed [ .] the following is a list of some situations that require hand hygiene: [ .] Before and after direct resident contacts (for which hand hygiene is indicated by acceptable professional practice) [ .] after contact with a resident's mucous membranes and body fluids or excretions.

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy; personal privacy includes accommodations, medical treatment, written and telephone communications, and personal care, for 1 of 4 residents (Resident #40) reviewed for privacy, in that: CNAs A and B did not completely close Resident #40's privacy curtain while providing catheter/incontinent care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #40's face sheet, dated 08/30/2024, revealed an admitted [DATE] and, a readmitted [DATE], with diagnoses which included: Dementia (decline in cognitive abilities), Type 2 diabetes mellitus (high level of sugar in the blood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Hypertension (high blood pressure) and, Peripheral vascular disease (abnormal narrowing of arteries reducing blood flow to the arms or legs). Record review of Resident #40's Quarterly MDS assessment, dated 08/20/2024, revealed the resident had a BIMS score of 15, indicating he had no cognitive impairment. Resident #40 was always incontinent of bowel and had a urinary catheter and, required extensive assistance with most of his ADLs. Record review of Resident #40's care plan, dated 11/02/2022, revealed a problem of ADLS: The resident has an ADL Self Care Performance Deficit Limited Mobility -Bilateral Below the Knee Amputation, with an intervention of TOILET USE: the resident is totally dependent on staff for toilet use. Incontinent of bowel - checked every 2 hours and as needed and incontinent/ perineal care rendered per nursing staff as needed Observation on 08/30/24 at 09:23 a.m. revealed CNA A and CNA B did not completely close the privacy curtains while they provided catheter/incontinent care for Resident #40, exposing the resident who could be seen from the room's door. Further observation revealed Resident #40's roommate was sitting on his bed and was ambulatory as indicated by the walker next to him. After finishing cleaning Resident #40, CNA B collected the soiled supply and opened the door to put it in the barrel outside the room while Resident #40 was still fully exposed. During an interview with CNA A and CNA B on 08/30/2024 at 9:30 a.m., CNA A and CNA B stated the privacy curtain was not completely closed while they provided care for Resident #40 but it should have been. CNAs A and B stated Resident #40's roommate was ambulatory and could have stood up and seen Resident #40 exposed during care. CNA B stated opening the room's door while the resident was still exposed. CNAs A and B stated they had received resident rights training within the year. During an interview with the DON on 08/30/2024 at 9:39 a.m., the DON stated privacy must be provided during nursing care and Resident #40's privacy curtains should have been closed completely. The DON confirmed the staff had received training on resident rights within the year and the training was provided by herself, and they also checked the staff skills annually and as needed. The DON further stated that she, ADON, and the weekend RN supervisor did skills spot checks as well. Review of the facility's policy titled Perineal care, dated 5/11/2022, revealed, Procedure content [ .[ 7/ Provide privacy and modesty by closing the door and/or curtain.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #41) reviewed for incontinent care, in that: The facility failed to ensure CNA C thoroughly cleaned Resident #41 while providing incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #41's face sheet, dated 08/29/2024, revealed an admitted [DATE], with diagnoses which included: Hypothyroidism (under active thyroid), Anxiety disorder (A group of mental illnesses that cause constant fear and worry), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Dementia (decline in cognitive abilities), Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Major depressive disorder(mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure) and, Hypertension (High blood pressure). Record review of Resident #41's Significant change MDS assessment, dated 05/28/2024, revealed Resident #41 has a BIMS score of 12, which indicated mild to moderate cognitive impairment. Further review revealed Resident #41 required limited to extensive assistance with ADLs and was indicated to occasionally be incontinent of bladder and frequently incontinent of bowel. Record review of Resident #41's care plan, dated 05/06/2024, revealed a problem of The resident has Urinary Tract Infection, with an intervention of Provide incontinence care as needed. Observation on 08/29/24 at 9:17 a.m. revealed, while providing incontinent care for Resident #41, CNA C did not clean between the buttocks' cheeks or the rectal area of the resident. During an interview on 08/29/2024 at 9:30 a.m. CNA C stated she did not clean between the resident's buttocks' cheeks area. CNA C stated she should have cleaned the rectal area. CNA C stated she had received training for infection control and incontinent care within the last year. During an interview with the DON on 08/29/2024 at 3:15 p.m., the DON stated the buttocks and rectal area had to be cleaned. The DON stated she was the one training the staff for infection control and incontinent care and that the ADON, weekend RN supervisor and herself would check the staff skills annually and as needed if a problem was noted. Record review of facility policy, titled Perineal care, dated 95/11/2022, revealed [ .] Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 3 residents (Resident #8) reviewed for respiratory care. The facility failed to ensure Resident #8's oxygen concentrator was not dirty. That failure could place residents who required respiratory treatments at risk of receiving inadequate respiratory treatments and could result in a decline in health. The findings were: Record review of Resident #8's face sheet, dated 08/27/24, revealed Resident #8 was admitted to the facility on [DATE] and, readmitted on [DATE], with diagnoses that included: Dementia (decline in cognitive abilities), Aphasia (unable to comprehend or formulate language), Hypoxia (the body is deprived of adequate oxygen supply), Schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood)and, Hypothyroidism (under active thyroid). Record review of Resident #8's quarterly MDS dated [DATE] revealed a BIMS of 6, indicating the resident was severely cognitively impaired. Further review of this MDS revealed in Section O, Special Treatments and Programs, that the resident received oxygen therapy. Record review of Resident #8's physician orders for August 2024 revealed the following order: Continuous Oxygen via nasal cannula at 4 Liter Per Minute due to low O 2 saturation every day and night shift for Shortness of Breath related to RESPIRATORY FAILURE, UNSPECIFIED WITH HYPOXIA to begin on 4/19/2023. Observation on 08/27/2024 at 11:20 a.m. revealed Resident #8's oxygen concentrator's intake air grill was partially covered with gray dust and a sticky substance. During an interview on 08/27/2024 at 12:05 p.m., the DON revealed the concentrator did not require a outside filter since it had a filter inside that was changed every two years when the manufacturer does the maintenance. Th eDON the staff should have cleaned the concentrator outside. Record review of facility undated policy, Oxygen Administration,, dated 03/21/23 revealed: oxygen concentrator should be cleaned according to manufacturer recommendations.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and supervision, in that: The facility failed to ensure Resident #1 did not elope from the facility without staff knowing on the evening of 4/8/2024. The noncompliance was identified as PNC. The IJ began on 4/8/2024 and ended on 4/9/2024. The facility had corrected the noncompliance before the survey began. This deficient practice could place residents at-risk of harm, serious injury, or death. The findings included: Record review of Resident #1's admission record, dated 8/7/2024, reflected that Resident #1 was a [AGE] year-old male initially admitted on [DATE], with diagnoses that included unspecified dementia(group of thinking and social symptoms that interferes with daily functioning), paranoid schizophrenia (a disconnection from reality, including hallucinations and delusions with paranoia), and type 2 diabetes mellitus (long-term condition in which the body has trouble controlling blood sugar and using it for energy). Record review of Resident #1's quarterly MDS assessment, dated 6/21/2024, reflected that Resident #1 had a BIMS score of 12, indicating moderate cognitive impairment. Resident #1 was assessed for using a manual wheelchair and was assessed as, Partial/moderate assistance for the ability to walk at least 50 feet and make 2 turns, and for, the ability to walk at least 150 feet in a corridor or similar space. Record review of Resident #1's care plan dated 8/7/2024, reflected Elopement: Actual elopement. Resident left the facility unattended with interventions including, supervise closely and make regular compliance rounds whenever resident is in room. 1 on 1 frequent monitoring, Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes, Distract resident from elopement attempts by offering pleasant diversions, structured activities, food, conversation, television, books with the date initiated 4/8/2024. Record review of Resident #1's elopement assessment from 1/10/2024 reflected Resident #1 as a low wander elopement risk and on 4/9/2024 as an elopement risk. Record review of Resident #1's nursing note, dated 4/8/2024, revealed , Med nurse asked staff for location of [Resident #1] for his 8pm nitro patch as he was not in room. CNAs stated they saw him sitting up front in TV room at approx [7:30-7:45 PM] when they started their round. At approx. 820 PM, all staff began searching, unable to locate res in facility. After all areas inside and perimeter searches, DON, Administrator notified @ approx. [8:46 PM]. 911 called @ [9:03 PM] by DON. [9:06 PM] [Responsible Party], notified and she was grateful for the all and asked for regular updated. [County] Sheriff Deputy, [County] and [municipality] PD, and [County] Fire Dept arrived on scene to search at approx. [9:08 PM]. Located resident at [9:53 PM] next door property sitting in a vehicle. Alert, oriented to person and place, stated he wanted to see his family so he started walking. No injuries or c/o pain or discomfort, taken by ambulance to [Area Hospital] ER for eval. MD, RP notified of his location. Further review reflected a progress note, dated 4/9/2024, reflected that referrals had been sent to 8 facilities after the incident to attempt to relocate the resident to a facility with a specialized locked unit. Record review of Resident #1's Medical Record reflected a tapered observation schedule of the resident, beginning with 1 on 1 observation. Record review reflected that on 8/7/2024, Resident #1 was to be observed every hour by a staff member. Further review reflected Resident #1 had not had any other elopement attempts prior to this event, or since. Interview on 8/6/2024 at 1:04 PM, the DON stated that it was found during their investigation that Resident #1 had exited the facility through the door to the fenced-in patio area. The DON stated that there is a gate on the fenced-in patio area that is secured with magnetic locks, and sometime before the incident on 4/8/2024, the magnetic locks securing the gates had become misaligned due to shifting in the ground, causing the magnetic locks to fail to lock due to the lack of contact . The DON stated this was found during their investigation after the incident. The DON stated that Resident #1 went through those gates and walked next door, approximately 500 feet away, to an unlocked, abandoned mini van in the fence-line of the next-door lot. The DON stated that because she lives 2 minutes away, she was at the facility within 3 minutes of receiving the call that staff were unable to locate Resident #1. The DON stated that due to Resident #1's psych behaviors , no facilities they reached out to with specialized locked units would accept Resident #1. The DON stated that Resident #1 was sent to the emergency room to be evaluated for injury and was returned to the facility with no injury. The DON stated Resident #1 received enhanced monitoring which has slowly tapered down from one-on-one observation to checking on the resident on specific time intervals. The DON stated that residents are evaluated based on wander risk as required and as needed, and any residents who seem to be a high wander risk will be placed on a higher supervision level. Interview on 8/6/2024 at 1:20 PM, Maintenance Director stated that the magnetic locks had all been assessed after the incident with the contracted company who completes maintenance on them. Interview on 8/6/2024 at 4:18 PM, Resident #1 stated he did not remember leaving the facility or why he would have done that . Observation on 8/8/2024 at 11:05 AM revealed CNA C on one-on-one observation with a resident who was not Resident #1. CNA C stated she was on one-on-one observation with the resident because he was wandering and exhibiting exit-seeking behaviors. CNA C stated that residents who are identified as elopement risks are watched more frequently due to the risk of elopement. A record review of an internet-based map accessed on 08/06/2024 as described by the DON revealed Resident #1 was located approximately 500 feet from the facility's patio door. The Administrator was notified on 8/7/2024 at 9:09 AM, a past non-compliance IJ situation had been identified due to the above failure. The facility implemented the following interventions. During an interview and observation on 8/6/2024 at 1:04 PM, the DON stated the facility has begun changing the security code to every door with a security code in the building every month to ensure residents do not learn the code. The DON stated that during their investigation of the event and processes in which to correct what occurred to ensure this did not occur again, the facility had an alarm installed to the patio door, implemented code lock on the patio door which required residents to ask staff to open the patio door for them, fixed the magnetic locks on the gate and ensured all magnetic locks utilized by the facility were maintained and functional. The magnetic lock functions were also changed from automatically locking after 10 seconds of contact to automatically locking after 2 seconds of contact. During the interview, and observation of the patio door being opened was conducted. Staff was seen to open the patio door for residents while an alarm sounded until the resident was outside, and the patio door was closed and locked. The DON stated that along with this, all staff (66 staff) were given in-service trainings on the elopement protocol, the door lock and code change procedures, and elopement drills were held. Record review of facility door code change logs revealed facility measures put in place for door code changes were being utilized, with weekly door lock changes happening and being recorded in a paper log to ensure all doors are changed. Record review of the facilities employee roster dated 4/9/2024 reflected 66 staff employed at the facility at the time of the incident. Record review of the facility's in-service records dated 4/9/2024 revealed 66 of 66 staff members across all departments and work shifts had signed and documented they received the trainings on elopement protocol and the new changes made after Resident #1's elopement. Interview on 8/6/2024 at 3:04 PM, LVN K stated she received training on elopement after Resident #1 eloped in April of 2024. LVN K stated the in-service covered checking doors when they hear alarms go off, doing head count, checking more frequently on Resident #1, and more general elopement items. LVN K stated she felt comfortable with the training and generally does not have any concerns related to risk of residents eloping. Interview on 8/6/2024 at 3:06 PM, MA N stated she received in-servicing on elopement on 4/9/2024 and stated that they have implemented an alarm on the patio door to ensure staff is aware when a resident is going in or out. Interview on 8/6/2024 at 3:13 PM, LVN J stated the in-service they received on 4/9/2024 after the elopement covered things such as the doors at the facility, access codes, checking in on where residents are located, and ensuring elopement does not occur. LVN J stated she was comfortable with the training and felt capable of implementing the elopement policies and procedures, and those to prevent elopements. Joint interview on 8/6/2024 at 3:15 PM, [NAME] V and [NAME] T stated that they were in-serviced on elopement and how to prevent elopements from happening and the new policies on elopement. [NAME] V stated they felt comfortable with preventing elopement and that if a door alarmed they would respond to it, regardless of being kitchen staff. [NAME] T agreed. Interview on 8/6/2024 at 3:20 PM, Housekeeping Staff R stated she had worked at the facility for [AGE] years and felt very comfortable with the residents and preventing elopement. HK R stated she had no concerns with the in-service and would respond to a missing resident appropriately if necessary. Facility policy titled, Elopement Response, dated revised 01/2023, reflected, It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. The Facility Elopement Response Policy then detailed, in order, what to do if staff observe a resident attempting to leave the premises, discover a resident missing from the facility, and what to do during the search and after the search to include updating care plans, making proper notifications, and completing assessments.

Based on observation, interviews and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for one resident (#4) out of 5 residents reviewed for accident hazards in that: LVN A disposed of the lancet she used to check Resident #4's blood glucose level in the regular trash container on the medication cart and not the sharps container. This deficient practice could affect residents and could result in injury. The findings were: Review of Resident #4's electronic face sheet dated 07/19/2023 revealed he was admitted to the facility on [DATE] with diagnoses of dementia (loss of cognitive functioning to such an extent that it interferes with a person's daily life and activities) and type II diabetes mellitus with diabetic chronic kidney disease (the body doesn't use insulin properly and dysfunction of the kidneys can occur). Review of Resident #4's quarterly MDS assessment with an ARD of 04/17/2023 revealed he scored a 09/15 on his BIMS which indicated he was moderately cognitively impaired. Review of Section I, Active Diagnoses revealed he was checked off to have diabetes mellitus. Review of Resident #4's Active Orders As Of: 07/19/2023 revealed NovoLOG Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 151 - 200 = 2 Units; 201 -250 = 4 Units; 251 - 300 = 6 Units; 301 - 350 = 8 Units; 351 - 400 = 10 Units; 401 - 450 = 12 Units; 451- 500 = 14 Units; 501+ If greater than 500, call MD., subcutaneously (fatty tissue just under skin) before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (high sugar level in blood) Active 03/04/2021 . Review of Resident #4's comprehensive care plan with a revision date of 10/07/2021 revealed Focus .potential for hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) r/t diabetes mellitus .Interventions/Tasks .Administer medications for diabetes as ordered. Observation on 07/19/2023 at 12:23 p.m. of LVN A perform an accucheck for Resident #4 revealed she did not discard the used lancet into the sharps container. She disposed of it into the regular trash bin located on the side of her medication cart. Interview on 07/19/2023 at 12:25 p.m. with LVN A revealed she should have discarded the used lancet into the sharps container because someone else could get stuck when emptying the trash and could be injured. She stated she was not thinking about it at the time and just discarded her used supplies together. Interview on 07/20/2023 at 2:00 p.m. with the DON revealed that LVN A should have discarded the lancet she used to check Resident #4's blood sugar into the sharps container on the medication cart and not the trash. She stated that someone handling the trash could stick themselves and get hurt or an infection. She stated staff were trained by nursing management on how to dispose of sharp items such as lancets and needles. Review of the facility policy and procedure titled Discarding of Sharps dated 2003 revealed Definition Sharps .3. All lancets used for finger sticks .Procedure .4. Place used sharps, intact, into sharps container.

Based on observation, interviews and record reviews, the facility failed to ensure all drugs and biologicals are stored locked compartments and permit only authorized personnel to have access to the keys for 1 of 5 residents (Resident #19) reviewed for storage of medications, in that: Resident #19 had what appeared to be and smelled like cough medicine at his bedside in a specimen cup and an empty brown pill container without a label. This deficient practice could place residents at risk of ingesting unknown medications not ordered by their physicians in an unsupervised manner. The findings were: Review of Resident #19's electronic face sheet, dated 07/21/2023, revealed he was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), chronic obstructive pulmonary disease (common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), dysphagia (difficulty in swallowing food or liquid), history of malignant neoplasm of larynx (type of cancer that affects the voice box and can cause symptoms such as hoarseness, difficulty swallowing and breathing problems, and gastrostomy (an opening to the stomach from the abdominal wall, made surgically for the introduction of food). Review of Resident #19's quarterly MDS assessment with an ARD of 05/29/2023 revealed the resident scored a 06/15 on his BIMS, which indicated he was moderately cognitively impaired. Further review of his MDS assessment revealed that 51% or more of his total calories were from enteral feedings. Review of Resident #19's Active Orders As Of: 07/19/2023, revealed, guaiFENesin Oral Liquid 100 MG/5 ML (GuaiFENesin) (to treat cough or cold symptoms) Give 15 ml via G-Tube as needed for Cough /Congestion .Phone Active 05/15/2023 05/15/2023. Further reviewed no order for Resident #19 as NPO. Review of Resident #19's comprehensive care plan, revised on 12/30/2022, revealed, Focus .EATING .refuses to follow NPO recommendation and wants to eat food by mouth when he chooses to - states he will accept enteral nutrition but when he wants a snack or a drink - he will get it. Observation on 07/19/2023 at 1:26 p.m. revealed as LVN A provided Resident #19 a medication via G-tube medication there was one specimen container filled with a light brown syrup and one unlabeled brown pill bottle next to his bed. When Resident #19 was asked what it was, he stated it was cough syrup. The surveyor and LVN A smelled of the liquid and it smelled similar to cough syrup. When asked where the resident obtained the cough syrup, he stated from the nurses. Resident #19 stated he needed the cough syrup to take when he has coughing episodes. LVN A took both containers of the alleged cough syrup out of the room as Resident #19 was highly agitated at this time and started yelling at LVN A and the surveyor. Interview with LVN A on 07/19/2023 at 1:45 p.m., LVN A stated she did not know how Resident #19 obtained the cough syrup, and she had not noticed it before and it should not have been there. LVN A stated the resident could overdose with the medication or choke. Interview with the DON on 07/20/2023 at 2:00 p.m., the DON the medication should not have been at Resident #19's bedside. Review of the facility policy and procedure titled Bedside Storage Of Medications dated 2003 revealed 1. A written order for the bedside storage of medication is placed in the resident's medical record .2. The facility interdisciplinary team must assess that the resident is capable of safely self-administering the medication and the assessment must be documented .5. Nursing staff will monitor the availability and utilization of all medications that are self-administered.

Based on observations, interviews and record reviews, the facility failed to provide an MDS assessment that accurately reflected the resident's status for one resident (#41) of 8 residents reviewed for accurate assessments in that: Resident #41's chronic pain and cardiac pacemaker were not listed as active diagnoses on his MDS assessment. This deficient practice could affect residents who receive MDS assessments and could result in missed care. The findings were: Review of Resident #41's electronic face sheet dated 07/20/2023 revealed he was admitted to the facility on [DATE] with diagnoses of chronic pain (persistent pain that carries on for longer than 12 weeks despite medication and treatment) and presence of cardiac pacemaker(a small, battery-powered device that prevents the heart from beating too slowly). Review of Resident #41's quarterly MDS assessment with an ARD of 06/09/2023 revealed he scored an 11/15 on his BIMS which indicated he was moderately cognitively impaired. He could understand others and be understood. Review of Section I-Active Diagnoses revealed that chronic pain and cardiac pacemaker were not listed. Review of Resident #41's comprehensive care plan dated revised 10/10/2022 Focus .PAIN: has a potential for uncontrolled pain r/t: back pain .Interventions/Tasks .administer analgesics as per physician orders, evaluate the effectiveness of pain interventions .and Focus .IMPLANTABLE DEFIBRILLATOR .Interventions/Tasks .Monitor vital signs as ordered/per facility protocol and record .Notify MD of significant abnormalities. Review of Resident #41's Active Orders As Of: 06/01/2023 revealed he had orders for cardiac pacemaker monitoring each shift and pain medication as needed. Review of Resident #41's MAR for 06/1/23 to 06/30/23 revealed he was initialed off by the nurses for cardiac pacemaker monitoring each shift, and he was provided pain medication as needed. Observation on 07/20/2023 at 08:47 a.m. revealed Resident #41 was up in the hallway waiting to go outside to smoke. Observation on 07/20/23 at 09:30 a.m. revealed Resident #41 was up in his room. He had a t-shirt on and on his left upper chest he had a scar for the cardiac pacemaker. Interview on 07/20/23 at 09:40 a.m. with Resident #41, he stated he had the cardiac pacemaker since he was admitted and the nurses monitor it, he also stated he received pain medication and assessments for his lower back pain. He said the scar was where his cardiac pacemaker was located. Interview on 07/20/2023 at 2:00 p.m. with the DON revealed that Resident #41 was monitored and assessed for pain and his cardiac pacemaker. She stated the MDS nurse was not available for interview, but that she had talked to her, and she agreed that the pain and cardiac pacemaker needed to be coded as Active Diagnoses to accurately reflect Resident #41's care. She stated that the accuracy of the MDS assessment was needed to further develop Resident #41's plan of care and to meet his health needs. Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, October 2019 revealed Section I: ACTIVE DIAGNOSES .the items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring or risk of death.

Based on observations, interviews and record reviews. the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for one resident (#29) of three residents reviewed for oxygen therapy, in that: Resident #29's oxygen was set to 4L/NC instead of 3L/NC as ordered by the physician. This deficient practice could affect residents who receive oxygen therapy and could result in respiratory distress. The findings were: Review of Resident #29's electronic face sheet dated 07/19/2023 revealed he was admitted to the facility on [DATE] with diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities) and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing related problems). Review of Resident #29's annual MDS assessment with an ARD of 05/22/2023 revealed he scored a 15/15 on his BIMS which indicated he was cognitively intact and that he received oxygen therapy while a resident. Review of Resident #29's comprehensive care plan revised date, 06/26/2023 revealed Focus .has Oxygen Therapy .Interventions/Tasks .administer oxygen as ordered by doctor. See current physician orders for oxygen. Review of Resident #29's Active Orders As Of: 07/19/2023 revealed May use oxygen @ 3 l/m via nasal canula every day and night shift related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED . Active 01/13/2023. Review of Resident #29's TAR dated 07/01/2023 - 07/31/2023 revealed that his oxygen saturation level was being checked every day by the nursing staff and his order for 3L/nc of oxygen was being initialed off by the nursing staff. Observation on 07/18/2023 at 10:00 a.m. revealed Resident #29 was in his room sitting on the side of his bed. His oxygen concentrator was set at 4L/min. He had his nasal cannula on, and when asked by the surveyor what rate his oxygen was supposed to be on he responded 3 Liters I think. Observation on 07/19/2023 at 07:55 a.m. of Resident #29 revealed he was in his room eating breakfast. His oxygen concentrator was set on 4L/min. Interview on 07/20/2023 at 1:00 p.m. with LVN A revealed that she and another nurse had gone down the halls and checked the oxygen and made sure they were set to what the doctor had ordered because the surveyors were at the facility. She stated it was important to check the oxygen because too much or too little for a resident could cause respiratory distress. Interview on 07/21/2023 at 09:30 a.m. with LVN B who worked with Resident #29 on 07/18/2023 revealed she did not check his oxygen concentrator to see if it was on the correct amount. She stated she signed it off on his TAR, but she did not check it. She said she realized it was important to check it because it could result in respiratory distress for Resident #29, especially with his breathing issues. Interview on 07/20/2023 at 2:00 p.m. with the DON revealed that the nursing staff should be checking the oxygen rates for residents on oxygen therapy so that they get the amount ordered. She stated that Resident #29 had COPD and it was important that he was on the rate ordered by the physician to prevent respiratory distress. Review of the facility policy and procedure titled Oxygen Administration dated revised February 13, 2007 revealed the resident will maintain oxygenation with safe and effective delivery of prescribed oxygen.