Every finding on record at Kingdom Care Senior Living

Based on observation, interview and record review, the facility staff failed to store and serve food at temperatures adequate to prevent food-borne illness and in a manner to prevent contamination and outdated use. Facility staff also failed to allow mechanically washed dishes to air-dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. These failures have the potential to affect all residents. The facility census was 27.1. Review of the facility's policy titled Record of Food Temperatures, undated, showed it is the policy of the facility to record food temperatures to ensure food is at the proper serving temperatures. Review showed potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit (dF). Review showed the policy directed staff to measure and record temperatures for each food product and milk at all meals. Observation on 04/13/26 at 10:51 A.M., showed an unidentified Dietary Aide (DA) prepared the salad bar for the lunch meal. Observation showed the DA placed multiple food items in bowls which were placed on ice in the salad bar. Observation on 04/13/26 at 12:06 P.M., showed residents in the dining room consumed food items from the salad bar. Observation showed: -The temperature of the tuna salad on the salad bar measured 44 dF;-The temperature of the potato salad on the salad bar measured 49 dF;-The temperature of the ranch salad dressing on the salad bar measured 45 dF. During an interview on 04/13/26 at 12:40 P.M., [NAME] E said he/she is responsible to ensure food items in the salad bar are kept at a temperature below 40 d. The cook said he/she checks the salad bar temperatures sometimes, but he/she does not document the temperatures because he/she does not have a temperature log. The cook said he/she would normally wrap unused salad bar items and serve them again the following day. Observation on 04/14/26 at 12:05 P.M., showed residents in the dining room consumed food items from the salad bar. Observation showed: -The temperature of the tuna salad on the salad bar measured 48 dF;-The temperature of the boiled eggs on the salad bar measured 55 dF;-The temperature of the potato salad on the salad bar measured 49 degrees F. During an interview on 04/14/26 at 12:55 P.M., the dietary manager (DM) said he/she is responsible to ensure kitchen staff follow safe practices related to food temperatures and food items on the salad bar should maintain a temperature of 41 dF or below. The DM said the items on the salad bar are prepared on Mondays and any unused items are discarded on Thursdays. The DM said kitchen staff do not check the temperatures of the salad bar items during meal service and they do not keep logs of salad bar food temperatures. During an interview on 04/15/2026 at 11:34 A.M., the administrator said the cook and DM are responsible to maintain the temperature of food items on the salad bar at 40 dF or lower and staff should check and record the temperatures of the food items. The administrator said he/she did not know staff did not check the salad bar food temperatures and staff used the same food items on the salad bar over multiple days. 2. Review of the facility's policy titled Date Marking for Food Safety, undated, showed the policy directed staff to clearly mark ready-to-eat and time/temperature controlled foods to indicate the date or day by which the food shall be consumed or discarded. The head cook or designee shall be responsible for checking the refrigerator daily for food items that are expiring and shall discard accordingly. Prepared foods that are delivered to the nursing units shall be discarded within two hours if not consumed and not be refrigerated as the time/temperature controls cannot be verified. Observations on 4/12/26 at 9:29 A.M., showed the kitchen contained: -Two pieces of French toast wrapped in undated plastic wrap;-An undated container of peas;-Opened and undated beef patties wrapped in plastic wrap;-Opened and undated chicken patties wrapped in plastic wrap;-An opened and undated package of hotdogs wrapped in plastic wrap;-An undated container of prunes;-An undated container of mashed potatoes;-An opened and undated dry yeast package;-An undated container of cooked green beans. Observation on 4/12/26 at 10:21 A.M., showed the refrigerator in the dining room kitchenette contained: -An undated and unlabeled pitcher of yellow liquid;-An opened and undated 1/4 full jug of milk;-Two undated and unlabeled Styrofoam to-go containers of prepared food;-Two undated and unlabeled bowls of unidentifiable food;-An opened and undated container of cranberry juice;-An undated Styrofoam plate of vegetables and a potato;-Two undated red plates of vegetables and a potato. Observation on 04/13/26 at 10:19 A.M., showed the walk-in refrigerator contained a one-gallon container of lime juice dated 7/23/25. Observation showed the lime juice had a use by date of 01/28/26. Observation on 04/13/26 at 10:23 A.M., showed the refrigerator in the dining room kitchenette contained three undated pitchers of drinks and three wrapped and undated plates of meat and mixed vegetables. Observation showed the dining room kitchenette also contained undated plastic bins of crisped rice, cheerios and bran flakes cereal removed from their original containers, an undated loaf of bread opened to air, and an opened and undated bag of potato chips wrapped in plastic wrap. Observation showed the bag of potato chips had a manufacturer's use-by date of November 2025. Observation on 04/14/26 at 10:36 A.M., showed the refrigerator in the dining room kitchenette contained two undated and unlabeled bowls of a bread-like substance and three undated Styrofoam plates of meat, beets and a bowl of spiral pasta. Observation on 04/14/26 at 10:52 A.M., showed the walk-in freezer contained undated boxes of crescent and dinner rolls opened to the air. During an interview on 04/13/26 at 12:24 P.M., DA I said open food items should be dated by whomever wrapped or stored the items. The DA said he/she tries to check dates when he/she works but he/she did not realize there were items that were not dated or past their use-by dates. During an interview on 04/14/26 at 12:55 P.M., the DM said he/she is responsible to ensure kitchen staff follow safe practices related to food storage and the kitchen staff are expected to label and date all food items. The DM said all food items should also be stored covered or sealed, and items past their best by or use by dates should be discarded. The DM said he/she did not know about any food storage issues. During an interview on 04/15/2026 at 11:34 A.M., the administrator said the DM is responsible to ensure food is stored correctly. The administrator said the DM should ensure foods are labeled, dated, covered completely and discarded by their use by dates and he/she did not know about any issues with the food storage. 3. Review of the facility provided policies showed they did not contain a policy related to dish drying or storage. Observation on 04/13/26 at 10:15 A.M., showed five large metal food service pans stacked together wet on a kitchen shelf. Observation on 04/13/26 at 10:38 A.M., showed four stacks of clear plastic cups stacked together wet inside a cabinet in the dining room kitchenette. Observation also showed wet red plastic coffee cups stored inverted inside a cabinet directly on the surface of the cabinet which did not allow air flow beneath to dry them. During an interview on 04/13/26 at 12:40 P.M., [NAME] E said he/she washed the dishes this morning and he/she put away the dishes before they were completely dry because he/she was in a hurry and he/she knew dishes were to be air-dried before they are put away. During an interview on 04/14/26 at 12:55 P.M., the DM said he/she is responsible to ensure kitchen staff follow safe practices related to dish washing and storage, and staff should allow dishes to air-dry before they are put away. The DM said he/she did not know about any dish storage issues. During an interview on 04/15/26 at 11:34 A.M., the administrator said the DM and kitchen staff are responsible to ensure dishes are dry before they are put away and he/she did not know about any dish storage issues.

Based on record review and interview, facility staff failed to document a thorough facility-wide assessment to include specific staffing needs for each resident unit in the facility and consider specific staffing needs for each shift, such as day, evening, night or include active involvement in the process from direct care staff, including but not limited to: Registered Nurses (RN), Licensed Practical Nurses (LPN), Nurse Aides (NA), and representatives of the direct care staff, if applicable, and/or solicit and consider input received from residents, resident representatives, and family members. The facility census was 27.1. Review of the facility's Facility Assessment policy, dated October 2018, showed the residents, representatives and family members may be asked to participate in the review of the care and services provided to meet the needs of our residents. The policy did not contain documentation or assessment of staffing needs of each unit or shift. Review of the Facility Assessment, dated 04/01/26, showed the workforce profile includes the following direct care staff type of RN's, LPNs, and Certified Nurse Aides (CNA). To ensure thoroughness, individuals involved in the facility assessment should include other individuals including direct care staff. Review of the assessment did not contain documentation on how the facility assessed or will staff each unit of the facility or shift and did not contain documentation a resident, resident representative, family member or direct care staff were involved in the assessment process. 2.Observation on 04/12/26 at 9:00 A.M., showed the facility with resident rooms on two separate halls in the facility. During an interview on 04/14/16 at 4:15 P.M., the Administrator said he/she is responsible for completion and review of the facility assessment. He/She said all staffing data should be a part of the assessment to include hours, days, and type of staff. The administrator said he/she does not include input from direct care staff or residents and/or resident representatives. He/She is new to the facility and did not include it during his/her initial review in January. During an interview on 04/15/26 at 10:58 A.M., LPN A said he/she does not participate or have input in the facility assessment. During an interview on 04/15/26 at 11:23 A.M., the Director of Nursing (DON) said he/she does not participate in the review of the facility assessment but is still new to the building. He/She said he/she is not familiar with the facility assessment. During an interview on 04/15/26 at 12:16 P.M., RN H said he/she does not participate or have input in the facility assessment review.

Based on observation, interview and record review, facility staff failed to develop and implement a person-centered comprehensive care plan for four (Resident #1, # 9, #17, and #23) of twelve sampled residents. The facility census was 27.1. Review of the facility's Comprehensive Care Plan policy, dated March 2022, showed: -The care plan interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment;-The comprehensive, person-centered care plan:-Includes measurable objectives and timeframes;-Describes services to be furnished to attain or maintain the residents highest practicable physical, mental and psychosocial well-being;-Includes resident stated goals and outcomes;-Builds on resident strengths;-Reflects current recognized standards of practice for problem areas and conditions. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/15/26, showed staff assessed the resident as cognitively intact. Review of the resident's care plan, dated 02/04/26, showed the care plan did not contain bed rail use. Observation 04/13/26 at 9:00A.M., showed the resident in bed with bed rails in the upright position on both sides of the bed. During interview on 04/13/26 at 9:00A.M., the resident said he/she uses the bed rails for bed mobility. 3. Review of Resident #9's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact;-Required set up and clean-up assistance for shower/tub hygiene and transfers.Review of the resident's care plan, dated 04/01/26, showed the resident required partial to moderate assistance from one staff with bathing. The care plan did not include shower preferences. During an interview on 04/13/26 at 10:32 A.M., the resident said he/she likes to receive a shower once a week on Tuesdays. 4. Review of Resident #17's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively Intact;-Required partial to moderate assistance of staff with toileting and showering/bathing;-Occasionally incontinent of urine; -Always continent of bowel. Review of the resident's care plan, dated 02/19/26, showed the care plan did not contain bed rail use. Observation 04/13/2026 9:00 A.M., showed the resident in bed with bed rails up on both sides. 5. Review of Resident #23's Significant Change in Status Assessment (SCSA), dated 02/12/26, showed staff assessed the resident as: -Cognitively impaired;-Felt it was very important to listen to music he/she enjoys;-Felt it was somewhat important to participate in group activities, favorite activities, go outside when the weather is nice, and religious activities. Review of the resident's care plan, dated 04/01/26, showed:-Likes one on one activities;-Enjoys spending time with daughter who comes to visit often;-Offer to participate in all activities;-The care plan does not indicate or give direction for residents' preference to go outside and/or religious activities. 6. During an interview on 04/15/26 at 12:16 P.M., the MDS Coordinator said he/she is responsible for the care plans with oversight of the corporate nurse and he/she is working to get all the care plans updated as they become due or as a change is reported to him/her. He/she said care plans should include all aspects of the residents' care based on the resident assessment and preferences. The MDS coordinator said he/she has only been in the role since February and is still learning the job. During an interview on 04/15/26 at 11:23 A.M., the Director of Nursing (DON) said the MDS nurse is responsible for the initial care plan and the care plan should reflect the residents' care, needs and preferences. The DON said he/she is new to the DON position and still learning about MDS assessments and care plans.

Based on observation, interview, and record review, facility staff failed to review and revise the comprehensive care plan for five residents (Resident #2, #8, #13, #19, and #23) out of twelve sampled resident care plans. The facility census was 27.1. Review of the facility's Comprehensive, Care Plan policy, dated March 2022, showed: -The care plan interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment; -The comprehensive, person-centered care plan: -Includes measurable objectives and timeframes; -Describes services to be furnished to attain or maintain the residents highest practicable physical, mental and psychosocial well-being; -Includes resident stated goals and outcomes; -Builds on resident strengths; -Reflects current recognized standards of practice for problem areas and conditions. -Assessments are on-going and care plans are revised as information about the resident condition changes; -The Interdisciplinary team (IDT) revise and updates the care plan: -When the resident has a significant change in resident condition; -When a desired outcome is not met; -When readmitted from a hospital stay; -At least quarterly in conjunction with the quarterly assessment. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/18/26, showed staff assessed resident as: -Cognitively intact; -Occasionally incontinent of urine; -Diagnosis of chronic kidney disease. Review of the resident's care plan, dated 04/01/26, did not address the resident's indwelling urinary catheter. Observation on 4/14/26 at 12:00 P.M., showed the resident had an indwelling urinary catheter. The resident said the nurse flushed his/her catheter twice a day. During an interview on 04/15/26 at 12:44 P.M., Licensed Practical Nurse (LPN) A said the catheter should be on the care plan, but the MDS Coordinator is new. 3. Review of Resident #8's Significant Change in Status (SCSA) MDS, a federally mandated assessment tool, dated 03/23/26, showed staff assessed the resident as: -Severely cognitively impaired; -Diagnoses of stroke and polyneuropathy (a malfunction of nerves throughout the body); -Received hospice care. Review of the resident's Physician Order Set (POS) showed an order dated 03/26/26 to admit to hospice. Review of the resident's care plan, dated 01/22/26, showed the care plan did not address hospice care. 4. Review of Resident #13's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderately cognitively impaired; -Did not have weight loss or require a specialized diet. Review of Dietary Notes, dated 12/18/25, showed a recommendation for a nutritional shake daily to help maintain weight. Review of the resident's care plan, dated 08/9/25, showed weight loss and nutritional needs were not addressed. During an interview on 04/15/26 at 9:00 A.M., the Director of Nursing (DON) said nutritional supplements and weight loss should be included on the care plan. 5. Review of Resident #19's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Continent of bladder and bowel; -Required partial to moderate assistance from staff for toilet hygiene and transfers; -Diagnosis of renal insufficiency. Review of the resident's care plan, dated 04/01/26, showed the care plan did not contain direction or guidance for the residents toileting needs. During an interview on 04/12/26 at 10:27 A.M., the resident said he/she has occasional bowel incontinence and needs staff assistance for cleansing. 6. Review of Resident #23's SCSA MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Received hospice; -Had not fallen since admission/entry, re-entry or prior assessment; -Diagnosis of dementia. Review of the resident's nurse's notes dated 01/01/26 through 04/13/26 showed staff documented the resident had a fall from his/her wheelchair on 01/03/26. Review of the resident's census record showed the resident admitted to hospice services on 02/14/26. Review of the resident's care plan, dated 04/01/26, showed the care plan did not contain documentation of a fall review when the resident fell on [DATE] or election to hospice services. 7. During an interview on 04/15/26 at 12:16 P.M., the MDS Coordinator said he/she is responsible for the care plans with oversight of the corporate nurse. He/She said he/she is working on getting all the care plans updated as they become due or as a change is reported to him/her. Care plans should include all aspects of the residents' care based on the assessment of the resident and resident preferences. The coordinator said he/she has only been in the role since February and is a brand new MDS Coordinator still learning the job. During an interview on 04/15/26 at 11:23 A.M., the DON said the MDS nurse is responsible for the initial care plan and the care plan should reflect the residents' care, needs and preferences. He/She said he/she is new to the DON position and still learning MDS assessments and care plans. During an interview on 04/15/26 at 9:30 A.M., the Administrator said the MDS Coordinator and nurses are responsible for reviewing and revising care plans. Care plans are to include fall interventions, admission to hospice service, medications, treatments, bowel and bladder incontinence. He/She said nurses should be referring to the care plans to direct care.

Based on observation, interview and record review, facility staff failed to provide an environment free from accident hazards, when staff failed to lock medication carts when unattended and not in use and store chemicals when not in use. The facility census was 27.1. Review of the facility's Medication Storage policy, dated 2026, showed: -All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls;-Only authorized personnel will have access to the keys to locked compartments;-During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. 2.Observation on 04/12/26 at 9:15 A.M., showed one unlocked and unattended treatment cart and one unlocked unattended medication cart at the nurse's station. Observation showed residents and staff walked by carts. Observation on 04/12/26 at 7:38 A.M., showed an unlocked treatment cart at the nurse station. Registered Nurse (RN) C had his/her back to the cart. Residents and staff passed by the cart. The RN took the medication cart to the dining hallway and left the treatment cart unlocked and unattended. Housekeeping staff were in the area and residents passed the unattended, unlocked cart. Observation on 04/13/26 at 3:38 P.M., showed the medication cart by the nurse station, unlocked and unattended. During an interview on 04/12/26 at 8:06 A.M., RN C said he/she normally locks the cart and did not realize the treatment cart was left unlocked. He/She said residents, staff or visitors could get into the unlocked cart and take things that could hurt them. During an interview on 04/15/26 at 11:23 A.M., the Director of Nursing (DON) said the staff assigned the medication and treatment carts are responsible for ensuring the carts are locked when unattended and unsupervised to keep the contents secure from residents, staff and visitors so they don't get hurt. During an interview on 04/15/26 at 1:45 P.M., the Administrator said he/she is always reminding staff to keep the carts locked. The carts should be locked when unattended for safety. 3. Review of the facility's Environmental Services Safety Procedures policy, dated 2025, showed staff will ensure equipment (e.g., cords, ladders, or chemicals) is properly stored and not left unattended in areas that are accessible to residents. When not in use, equipment will be stored in a locking closet, cabinet or storage area for safety. 4.Observation on 04/12/26 at 10:21 A.M., showed an unlocked, unattended cabinet in the kitchenette area of the main dining room contained a bottle of a disinfectant cleaner and two bottles of multipurpose cleanser. Observation on 04/13/26 at 10:41 A.M., showed an unlocked unattended cabinet in the kitchenette area of the main dining room contained a bottle of a disinfectant cleaner and two bottles of multipurpose cleanser. Observation on 04/14/26 at 10:37 A.M., showed an unlocked unattended cabinet in the kitchenette area of the main dining room contained a bottle of a disinfectant cleaner and two bottles of multipurpose cleanser. During an interview on 04/14/26 at 12:55 P.M., the Dietary Manager (DM) said he/she is responsible for ensuring cleaning chemicals in the kitchenette are secure. The DM said the cleaning sprays should be locked up. The DM said he/she did not know the cleaning sprays were not locked up.

Based on record review and interview, facility staff failed to educate and offer Coronavirus disease 2019 (COVID-19), a respiratory disease that can cause severe illness, immunizations to residents as required for four residents (Residents #8, #13, #15, and #25) of five sampled residents. The facility census was 27.1. Review of the facility's policy COVID-19 Vaccination dated 2025, showed the facility will educate and offer the COVID-19 vaccine to residents, resident representatives and staff and maintain documentation of each. A copy of the Vaccine Information Statement will be given to staff, residents and resident representatives prior to administration. Review of Resident #8's medical record showed the record did not contain documentation of education, administration or refusal of the COVID-19 vaccination for the 2025-2026 season. Review of Resident #13's medical record showed the record did not contain documentation of education, administration or refusal of the COVID-19 vaccination for the 2025-2026 season.Review of Resident #15's medical record showed the record did not contain documentation of education, administration or refusal of the COVID-19 vaccination for the 2025-2026 season. Review of Resident #25's medical record showed the record did not contain documentation of education, administration or refusal of the COVID-19 vaccination for the 2025-2026 season. During an interview on 04/13/2026 at 10:00 A.M., the Infection Preventionist (IP) said he/she is new to the position, and the facility recently underwent a change of ownership. He/She said documentation may not have been uploaded into the computer system since the facility transitioned to a new electronic medical record on April 1st. The IP said he/she is responsible for the immunization program. During an interview on 04/15/26 at 9:30 A.M., the Administrator said he/she expects all residents be offered COVID-19 vaccination according to policy. He/She said the corporate transition and relocation of staff has made compliance challenging.

Based on interview and record review, facility staff failed to perform a significant change in status (SCSA) Minimum Data Set (MDS) assessment, a federally mandated assessment tool, for two (Resident #8 and #23) of three residents who elected hospice services and one (Resident #19) of four sampled residents who had a change in activities of daily living. The facility census was 27.1. Review of the facility's MDS 3.0 Completion policy, dated 2025, showed:-The facility conducts periodic comprehensive, accurate, and standardized assessment of each resident's functional capacity using the Resident Assessment Instrument (RAI) manual specified by the state;-A SCSA is a comprehensive assessment completed within 14 days of the identification of a status change that meets the requirements outlined in Chapter Two of the RAI manual;-A SCSA is a major decline or improvement in a resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, impacts more than one area of the resident's health status, and requires interdisciplinary (IDT) review and/or revision of the care plan;-A SCSA is required when a resident enrolls in a hospice program or changes hospice providers and remains in the facility, or a resident in the facility receiving hospice services discontinues those services and remains in the facility. 2. Review of Resident #8's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Cognitively impaired;-Received hospice services;-Diagnosis of dementia.Review of the census record showed the resident admitted to hospice services on 03/25/26.Review of the medical record showed the record did not contain a completed SCSA when the resident admitted to hospice services. During an interview on 04/15/26 at 12:16 P.M., the MDS Coordinator said he/she has only been in the role since February and is a new MDS Coordinator. He/She is still learning and was not aware a SCSA was not completed.3. Review of Resident #23's SCSA, dated 02/12/26, showed staff assessed the resident as follows:-Cognitively impaired;-Received hospice services;-Diagnosis of dementia.Review of the census record showed the resident admitted to hospice services on 02/14/26.During an interview on 04/15/26 at 12:16 P.M., the MDS Coordinator said he/she was not aware a SCSA was not completed.4. Review of Resident #19's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Cognitively intact;-Required supervision/touch assistance for toileting;-Independent transfers;-Occasionally incontinent of bowel.Review of the Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Cognitively intact;-Required partial to moderate assistance from staff with toileting needs and transfers;-No incontinence.During an interview on 04/12/26 at 10:27 A.M., the resident said he/she had occasional bowel incontinence and needed assistance from staff to get cleaned up. He/She said he/she can transfer independently sometimes but needs help other times.5. During an interview on 04/15/26 at 12:16 P.M., the MDS Coordinator said residents newly admitted to hospice or discontinuing services should have a new MDS assessment completed. He/She said residents who have had a change of status should have a new MDS completed within 14 days of observing the change. He/She said he/she is responsible for ensuring the assessments are completed and the corporate nurse checks his/her work. During an interview on 04/15/26 at 11:23 A.M., the Director of Nursing (DON) said the MDS Coordinator is responsible to ensure MDS assessments are completed timely and include a change of status if necessary. The DON said he/she is not familiar with the MDS process, is a new DON, and is still learning.

Based on observation, interview and record review, facility staff failed to obtain orders for an indwelling urinary catheter and catheter care for one resident (Resident #2) out of one sampled resident, failed to obtain an order for hospice for one (Resident #23) out of three sampled residents, and failed to notify the physician when one (Resident #17) of four sampled residents did not receive his/her medication as ordered. The facility census was 27.1. Review of the facility's Indwelling Catheter Care policy, undated, showed ff an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to insertion, ongoing care and catheter removal protocols that adhere to professional standards of professional and infection prevention and control procedures. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/18/26, showed staff assessed the resident as: -Cognitively Intact; -Occasionally incontinent of urine; -Always continent of bowel. Review of the resident's Physician Order Summary (POS), dated March 2026, showed an order dated 03/18/26 to change the resident's urinary catheter every month on the 19th. The POS did not contain a catheter size, balloon size or orders for catheter care. Observation on 04/11/26 at 10:30 A.M., showed the resident his/her recliner in his/her room with a urinary catheter in place. During an interview on 04/11/26 at10:30 A.M., the resident said a nurse flushes his/her catheter twice a day. During an interview on 04/15/26 at 12:44 P.M., Licensed Practical Nurse (LPN) A said the nurses are responsible for changing the resident's indwelling urinary catheter. The LPN said he/she did not know the resident did not have orders for the indwelling catheter size/balloon size or catheter care. 3. Review of the facility's Hospice Program, dated July 2017, showed the program did not include direction or guidance for a physician order for such services. 4. Review of Resident #23's Significant Change in Status Assessment (SCSA) MDS, dated [DATE], showed staff assessed the resident as cognitively impaired, received hospice services, and had a diagnosis of dementia. Review of the resident's POS, dated April 2026, showed the POS did not contain an order for hospice. During an interview on 04/14/26 at 10:58 A.M., LPN A said residents should have a hospice order in the medical record when a resident elects hospice services. LPN A said he/she did not know the resident did not have an order. It is the nurse's responsibility to ensure the orders are obtained and documented. During an interview on 04/14/26 at 11:23 A.M., the Director of Nursing (DON) said the nurses should obtain an order from the physician when the resident and/or family elects hospice services. He/She was not aware there was not an order. 5. Review of the facility's Medication Orders policy, dated 2025, showed if using electronic medication records, input the medication order according to the electronic health record (EHR) instructions. Transcribe the newly prescribed medications on the Medication Administration Record (MAR) in the electronic record. Review of the facility's Notification of Changes policy, dated 2025, showed the facility must consult with the physician when there is a change requiring such notification. The policy did not contain direction or guidance regarding omission of medications. Review of the facility's Charting and Documentation policy, dated July 2017, showed documentation of procedures and treatments will include care-specific details including notification of family, physician or other staff, if indicated. 6. Review of Resident #17's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's POS, dated March 2026, showed the physician ordered Tirzepatide (a weight reduction medication) 2.5 milligrams (mg)/0.5 milliliters (ml) on 02/08/26, Inject once a week on Mondays. The order was discontinued on 03/16/26 and reordered on 03/23/26. Review of the nurse notes, dated 01/14/26 through 04/14/26 showed: -On 2/23/26 - trizepatide, prior authorization needed;-On 03/02/26 - trizepatide, did not contain documentation why the medication was not administered;-On 03/09/26 - trizepatide, prior authorization needed;-03/23/26 - trizepatide, prior authorization needed;-03/30/26 - trizepatide, omission;-04/06/26 - trizepatide, prior authorization awaiting;-04/13/26 - trizepatide, omission. Review of the resident's MAR, dated March 2026, showed staff documented showed staff documented for the trizepatide:-03/02/26 a code of 11 (the MAR did not contain a key to indicate what 11 meant) on the MAR;-03/09/26, 03/23, and 3/30/26 a code of nine (the MAR did not contain a key to indicate what nine meant) on the MAR;-03/16/26 did not contain an entry. Review of the MAR, dated April 2026, showed staff documented on 04/06/26 and 04/13/26 a code of OT (other, see progress note) for the resident's trizepatide. Review of the residents progress notes did not contain documentation staff notified the physician the medication had not been administered or a follow up had been conducted for prior authorization. During an interview on 04/14/26 at 8:58 A.M., a family member said the resident needs to lose weight so he/she can have hip surgery. When the resident switched insurances the trizepatide has not been given. He/She is concerned the resident will not lose the needed weight to get his/her hip surgery. During an interview on 04/14/26 at 9:58 A.M., the pharmacy said a denial was sent to the facility on [DATE] for a Trizepatide order received on 03/13/26. He/She said the resident transferred to this pharmacy in February. He/She said the order received on 03/13/26 required prior authorization before the pharmacy could send it to the facility. When prior authorization is needed, the form is sent to the facility and the physician's office for follow-up. The pharmacy reviews the prior authorization folder every one to two weeks for follow-up. During an interview on 04/14/26 at 10:20 A.M., the Primary Care Physician's office said he/she would expect the facility to notify him/her if medication is unavailable so a modification can be made to the treatment plan. He/She was not notified about the medication omission and would expect to if the resident's goal is to lose weight for surgery. During an interview on 04/14/26 at 10:58 A.M., LPN A said since the resident's payor source changed the facility has had an issue obtaining prior authorization for the medication. He/She said he/she did not receive a denial until today for the trizepatide. He/She said he/she had been in contact with the physician a while back about this, he/she had not recently reached out. He/She said when a resident is out of a medication or unable to obtain a medication, the physician should be notified. He/She was recently given additional duties and did not follow up on the trizepatide. During an interview on 04/14/26 at 11:23 A.M., the DON said he/she was not aware of any issues with the resident's medications. He/She said if a resident is out of a medication or cannot obtain it, staff should notify the physician and the DON. He/She said it's the nurses responsibility to ensure prior authorizations are obtained timely.

Based on observation, interviews and record review, facility staff failed to ensure arrangements were made for nephrology (services that provide care for kidney related conditions) services outside of the facility for one resident (Resident #35) of one sampled resident with kidney disease. The facility census was 27.1. Review of the facility's admission Agreement, undated, showed if a resident chose a physician who does not have privileges at the facility, the resident must travel, at their own expense, to the healthcare provider to receive services from that provider. The agreement did not contain direction or guidance on assistance to set up transportation for ordered services or assistance in set up for the appointments. Review of Resident #35's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/01/26, showed staff assessed the resident as: -Cognitively intact;-Always incontinent of bladder;-Diagnosis of impaired kidney function. Review of the resident's nurse's notes, dated 01/01/26 through 03/31/26, showed staff documented: -02/08/26: Order received for a nephrology appointment;-02/09/26: Called and left voicemail for family concerning order for nephrology consult, awaiting a call back;-02/09/26: Spoke with family, would like to have an update on appointment date/time so they can go with the residents;-03/23/26: Spoke with family concerning appointment for nephrology to be scheduled, family states these appointments must be scheduled out 30 days due to needing to request off from work;-The notes did not contain documentation to show staff attempted to schedule the nephrology appointment, as ordered, from the date of the original order on 02/08/26 to when the resident discharged from the facility on 03/30/26. Review of the Physician Progress Notes showed: -02/10/26, nephrology consult requested;-02/19/26, nephrology appointment requested;-03/23/26, nephrology appointment requested. Review of the Physician Order Set (POS), dated February 2026 through March 2026, showed the physician ordered a nephrology consult on 02/08/26. Review of an email attached to the medical record, dated 02/20/26, showed the physician requested staff to schedule a nephrology appointment. During an interview on 03/25/26 at 8:00 A.M., a family member of the resident said he/she reminded staff a nephrology appointment was ordered in February and still had not been set-up. He/She said blood work completed 02/08/26 showed the resident was in Stage Four Kidney failure. The facility originally had a urology appointment set up for the resident but the family was told by staff to cancel it and just have the resident see the nephrologist. Review of the Resident Roster, dated 04/12/26, did not show the resident as admitted to the facility. During an interview on 04/15/26 at 10:58 A.M., Licensed Practical Nurse (LPN) A said he/she is responsible for scheduling appointments but during that time another staff member was assigned to set up appointments. He/She said the employee responsible does not work at the facility any longer. He/She said the employee told the family to cancel the urology appointment and just go to the nephrologist. The LPN is not sure why the appointment was not set up timely for the resident but would expect the appointment set up even if it was for a future date and attempts documented. He/She said he/she believes the appointment was set up prior to the residents discharge to another facility but could not confirm it. During an interview 04/15/26 at 11:36 A.M., the Director of Nursing (DON) he/she did not work for the facility during the timeframe but would expect the nursing staff to set up appointments within a day or two of getting the order and communicating that to the families. He/She said attempts to set up appointments, dates of appointments, any transportation needs, and family contact should be documented in the resident record. #2961796

Based on observation, interview and record review, the facility staff failed to provide a clean, comfortable and homelike environment for residents, when staff failed to maintain one of one shower rooms free of an excessive buildup of foreign material. This failure has the potential to affect all residents. The facility census was 27.F1. Review of the facility's policy titled Safe and Homelike Environment, dated 2025, showed housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Review showed the policy did not contain specific guidance related to the resident shower room. Observation on 04/14/26 during the Life Safety Code tour showed the facility equipped with one shower room for use by all residents. Observation showed the spa tub contained a large amount of brown discoloration that extended from the faucet all the way down the tub to the drain area. Observation showed all three walls of the shower, the shower grab bar, and the shower caddy contained a large amount of a thick white substance. Observation also showed the outer edges of the shower floor contained a large buildup of white and off-white substances. During an interview on 04/14/26 at 12:10 P.M., Housekeeper H said staff clean the shower daily. The housekeeper said the thick white substance, which had been in the shower for quite some time, was limescale buildup and he/she thought maintenance staff had some kind of chemical to remove it. During an interview on 04/15/26 at 8:30 A.M., the housekeeping supervisor said nursing staff are responsible to clean the tub and shower after each use. The supervisor said housekeeping staff tried to clean the shower and tub a few months ago but they could not remove all of the buildup. The supervisor said he/she thought if the tub and shower were deep cleaned more regularly the buildup would not be so bad, but he/she never discussed this with the nursing or maintenance staff. The supervisor said he/she would expect the tub and shower to be clean and free of excessive limescale. During an interview on 04/15/26 at 10:09 A.M., the maintenance director said nursing staff are responsible to clean the tub and shower daily and housekeeping staff also deep clean the shower and tub but he/she did not know how often. The maintenance director said he/she is responsible to remove the scale buildup on the tub and shower. The maintenance director said he/she has known the tub and shower needed the limescale removed for about two or three months, but he/she got busy with other things and had not addressed it. During an interview on 04/15/26 at 11:34 A.M., the administrator said housekeeping is responsible to keep the tub and shower clean and free of limescale buildup. The administrator said he/she just found out about the issues and the shower room should not be in that condition.

Based on interview and record review, facility staff failed to conduct and document an annual facility-wide assessment to determine what resources are necessary to care for facility residents competently during both day-to-day operations and emergencies as required. The facility census was 26. 1. Review of the facility's Facility Assessment Report, dated July 2024, showed the assessment did not contain information on staffing for day-to-day operations and emergencies as required. During an interview on 1/6/25 at 10:02 A.M., Licensed practical Nuse (LPN) A said he/she is responsible for the nursing staff schedule. He/She said he/she schedules a consistent schedule based on the census and not according to resident acuity. He/She said he/she does not know what the facility assessment directs for staffing. During an interview on 1/6/25 at 11:01 A.M., the corporate director of finance said the previous administrator left abruptly and he/she at the facility to help until a new administrator is hired. He/She said the July 2024 is the only facility assessment the facility has and he/she does not know how often it needs to be updated. He/She said he/she does not know why the previous administrator did not keep up with the facility assessment. He/She said LPN A does the staffing schedule. During an interview on 1/21/26 at 9:09 A.M., The corporate administrator said the facility has been without a director of nursing (DON) since 12/16/25. He/She said they had one hired for start date of 1/5/26 but he/she let them know 12/29/25 that he/she had taken a different position. He/She said there are adds out on indeed and multiple other places to hire a DON. He/She said the Assistant DON who is a Registered Nurse (RN) returned to work on 1/19/26 and will be placed in the role of DON until one is hired. He/She said the facility has a new administrator that starts on 1/26/25. Complaint #2708397

Based on interview and record review, facility staff failed to prevent the commingling of nine residents (Resident #6, #7, #8, #9, #10, #11, #12, #13, and #14) personal funds with the facility operating funds out of 13 sampled residents. The facility census was 28.1.Review of the facility's admission assessment, revised 09/12/25, showed:-The facility must establish and maintain a system that assures a full and complete separate accounting, according to generally accepted accounting principles;-The system must preclude any commingling of resident funds with facility funds or with funds any other person other than the resident;-The individual financial record must be available to the resident through quarterly statements and upon request;-The facility must refund the resident or the resident representative any and all funds due to the resident within 30 days from the date of the resident's discharge. 2.Review of the facility-maintained Accounts Receivable (AR) Aging report, dated 12/17/25, showed the following residents with personal funds held in the facility operating account:Resident Amount Held in Operating Account #6 $1097.89 #7 $3316.00 #8 $8445.00 #9 $1840.00#10 $3698.83#11 $1075.00#12 $1342.04#13 $564.49#14 $1380.00Total $22,759.25During an interview on 12/17/25 at 10:25 A.M., the administrator said he/she reviews the facility's AR Aging report monthly when he/she prints the billing statements to send out to the resident or their responsible party. The administrator said if he/she notices a credit owed to a resident he/she will email the Director of Operations (DOO) and the Director of Accounts Payable/Accounts Receivable ([NAME]/AP) to advise them of the credit owed and request a refund be issued at that time. The administrator said he/she cannot issue a refund from the facility or update the AR Aging report. The administrator said resident refunds and updating the AR Aging report are only completed at the corporate level. The administrator said he/she is aware the facility has multiple credits on their AR Aging report and knows refunds are owed to those residents. The administrator said he/she has emailed the DOO and [NAME]/AP multiple times to request the refunds be issued. The administrator said he/she knows all refunds should be issued within 30 days of the resident's discharge date , but he/she is not able to do that as he/she must go through the corporate office to get those completed. The administrator said the DOO is responsible to review the accounts receivable aging report each month, approve credits to be refunded, and notify [NAME]/AP to issue the check. The administrator said the DOO is supposed to ensure the facility gets a copy of the refund check but he/she said those are not sent to the facility so he/she can't track what is refunded timely. The administrator said he/she is aware the facility has credits more than 30 days old that need to be refunded, and he/she said the only reason he/she knows they aren't refunded within 30 days is due to the DOO not approving the refunds timely. The administrator said the facility does not have written permission to hold the resident money after discharge. During an interview on 12/17/25 at 9:45 A.M., the DOO said he/she is responsible to review the facility AR Aging report monthly and ensure all credits are refunded timely. The DOO said refunds are to be issued within 30 days of a resident discharge. The DOO said he/she is the person who makes the decision of when a resident refund is issued. The DOO said once he/she approves the resident refund he/she notifies [NAME]/AP who is responsible to cut the check. The DOO said [NAME]/AP does not issue any checks without his/her approval. The DOO said [NAME]/AP is responsible to update the AR Aging report once he/she issues the refund check. The DOO said he/she is aware [NAME]/AP has not updated the AR Aging report timely. The DOO said they do not send a copy of refund checks to the facility either. The DOO said he/she is aware the facility has outstanding credit balances due to the residents and he/she is aware they have not been issued within the 30-day timeframe. The DOO said he/she does not approve to issue a resident refund timely because sometimes we financially can't do it. The DOO said the facility does not have written permission to hold these credits in the facility operating account. The DOO said the administrator has communicated with him/her regarding approval of resident refunds frequently. Complaint #2695026

Based on observation, interview and record review, facility staff failed to provide a clean, safe, and comfortable home-like environment when staff failed to adequately maintain doors and keep walls in resident rooms free of gouges in the drywall and scrapes in the paint. The facility census was 26. 1. Review of the facility's policy titled Quality of Life-Homelike Environment, dated May 2017, showed residents are provided with safe, clean, comfortable and homelike environment. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting, to include clean, sanitary and orderly environment. 2. Review of the facility's policy titled Maintenance Service, dated December 2009, showed the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include maintaining the building in compliance with current federal, state, and local lows, regulations, and guidelines. The building should be maintained in good repair. The Maintenance Director is responsible for developing and maintaining a maintenance schedule. A copy of the maintenance schedule shall be provided to each department director so that appropriate scheduling can be made without interruption of services to the residents. The Maintenance Director is responsible for maintaining Work Order Requests. 3. Observation on 09/09/24 at 10:51 A.M., showed resident occupied room [ROOM NUMBER] drywall and paint peeled from the floor to the ceiling, an unpainted patched circular area, behind the sink in the bathroom had unpainted patched drywall, and the bathroom door contained black scrape marks on the lower quarter of the door. 4. Observation on 09/09/24 at 11:01 A.M., showed occupied room [ROOM NUMBER] a hole in the drywall had been patched with drywall mud and had not been painted. Drywall behind headboard of bed is damaged and missing paint. The wall beneath the thermostat in the room had a hole in the drywall and areas of chipped paint. The dresser in the room and door to the bathroom had chunks of wood and the finish missing. The heater in the restroom leaned out of the wall and base trim is off the wall behind the toilet. 5. Observation on 09/09/24 at 11:33 A.M. showed in occupied room [ROOM NUMBER] the wall behind bed A had unpainted drywall. 6. Observation on 09/09/24 at 12:05 P.M. showed in occupied room [ROOM NUMBER] two visible unpainted patches of drywall on the right side of the bed. 7. Observation on 09/09/24 at 2:15 P.M., showed in occupied room [ROOM NUMBER] the wall behind and alongside bed A and the wall behind and alongside bed B had several areas of unpainted drywall. To the left of the window on the far wall of the room there are black marks on the lower portion of the wall. The back corner of the room had decorative bricks stacked two high underneath the head of bed B. 8. Observation on 09/09/24 at 2:15 P.M., showed in occupied room [ROOM NUMBER] the wall to the left side of the window had several areas of unpainted drywall. The wall on the right side of the room behind bed B and recliner has several gouges and areas of unpainted drywall. 9. Observation on 09/09/24 at 2:42 P.M., showed in occupied room [ROOM NUMBER] damage to drywall and paint scraped off of the wall behind the headboard of a bed. 10. Observation on 09/09/24 at 2:51 P.M., showed in occupied room [ROOM NUMBER] the wall to the left of the entrance alongside bed A had several areas of unpainted drywall. 11. Observation on 09/10/24 at 9:34 A.M., showed in occupied room [ROOM NUMBER] had damaged drywall and paint under wall thermostat and above chair in room. 12. Observation on 09/10/24 at 10:05 A.M., showed in occupied room [ROOM NUMBER] had missing paint and damaged drywall on wall beside bed and on wall beside window. During an interview on 09/12/24 at 10:47 A.M., Certified Nurse Aide (CNA) J said staff are supposed to tell the nurse if they see something that needs fixed. The CNA said staff should report damaged walls and doors to the nurse and the nurse should put a work order in the computer for maintenance. The CNA said he/she is usually too busy trying to take care of the residents to look at cosmetic stuff. During an interview on 09/12/24 at 10:49 A.M., Registered Nurse (RN) H said staff should tell him/her if there is damage to walls and doors and he/she will send an email to the Maintenance Director. The RN said he/she has noticed damage to walls, walls with drywall mud on them and unpainted. The RN said he/she did not send a maintenance request when he/she noticed because he/she is uncertain if someone else had already reported it. During an interview on 09/12/24 at 10:54 A.M., the Maintenance Director said staff are supposed to send him/her a work order if something needs repaired. He/She said if repairs are needed in a resident room he/she has to have a work order before entering the room. The Maintenance Director said he/she tries to respond to concerns within 24 hours. The Maintenance Director said he/she doesn't think he/she has gotten any work orders for walls or doors in resident rooms this week. The Maintenance Director said the aides are rough and tear up the walls with the beds. The Maintenance Director said he/she doesn't have a set schedule to paint the patched drywall damage. During an interview on 09/12/24 at 11:03 A.M., the administrator said staff is supposed to notify maintenance when they see damage to walls and doors. The administrator said aides should tell the nurses and the nurses should email maintenance. The Administrator said they put paper requests at the nurses station, so even aides could fill out a maintenance request. The administrator said he/she has not noticed drywall repairs that had not been painted. The administrator said he/she has educated staff on reporting maintenance issues. 45489 50361

Based on observation, interview, and record review, facility staff failed to implement Enhanced Barrier Precautions (EBP) to prevent the spread of bacteria and other infection causing contaminants during the provision of care for two residents (Residents #9 and #28) of a sample of two residents. The facility census was 26. 1. Review of the facility's titled Enhanced Barrier Precautions, undated, showed EBP are an infection control intervention designed to reduce the transmission of Multidrug-Resistant Organisms (MDROs) in nursing homes. EBP expands upon Standard Precautions by requiring the use of gowns and gloves during specific high-contact resident care activities. High-contact resident care activities are activities that have been demonstrated to result in the transfer of MDROs to hands or clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. Example of high-contact care activities include, but are not limited to dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of catheter, feeding tube, etc. The Infection Preventionist ensures that regular audits of staff adherences to EBP guidelines are conducted. Any deviations from protocol should prompt additional training and education efforts. 2. Review of Resident #9's Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/02/24, showed staff assessed the resident had a severe cognitive impairment and required a feeding tube. Review of the resident's Physician Order Sheet (POS), dated September 2024, showed an order for enteral feedings every shift by feeding tube. Observation on 09/09/24 at 11:53 A.M., showed the resident received his/her tube feeding in his/her room. Observation showed outside the resident room did not contain an EBP sign posted outside the resident's room or Personal Protective Equipment (PPE) station observed inside or outside the resident's room. Observation on 09/09/24 at 3:15 P.M., showed the resident's feeding tube leaked and ran down the front of the resident's shirt. Licensed Practical Nurse (LPN) D entered the resident's room and fixed the resident's tube feeding. The LPN did not wear a gown when he/she assisted the resident with the his/her tube feeding. Observation on 09/10/24 at 10:16 A.M., showed Certified Nurse Aide (CNA) E entered the resident's room. The CNA assisted the resident out of bed and did not wear a gown. Observation on 09/12/24 at 7:54 A.M., showed LPN M administered the resident's medications through his/her feeding tube. LPN M did not wear a gown when he/she administered the resident's medications. Observation on 09/12/24 at 8:18 A.M., showed CNA I showered and transferred the resident. The CNA did not have a gown on. Observation showed Registered Nurse (RN) H started the resident's tube feeding and did not have a gown on. The resident's room did not have an EBP sign on the door. 3. Review of Resident #28's Discharge Assessment MDS, dated [DATE], showed staff assessed the resident admitted to the facility on [DATE] and required a feeding tube. Review of the resident's POS, dated September 2024, showed an order for enteral feeding, continuously of Jevity 1.2 Calories. Observation on 09/09/24 at 10:55 A.M. showed the resident received his/her tube feeding in his/her room. Observation showed outside the resident room did not contain an EBP sign posted outside the resident's room or PPE station observed inside or outside the resident's room. Observation on 09/10/24 at 8:53 A.M. showed the resident received his/her tube feeding in his/her room. There is no EBP sign posted outside the resident's room or PPE station observed inside or outside the resident's room. Observation on 09/12/24 at 8:21 A.M., showed Certified Medication Technician (CMT) J entered the resident's room and assisted the resident with perineal care. The CMT did not wear a gown when he/she provided care to the resident. 4. During an interview on 09/12/24 at 10:03 A.M., CNA I said he/she does not remember receiving training on EBP and had not used a gown when caring for residents with a catheter or feeding tube. During an interview on 09/12/24 at 10:07 A.M., RN H said he/she does not know what EBP is. The RN said he/she does not think there is any residents on EBP. The RN said he/she would not know what residents should be on EBP, because he/she doesn't even know what the definition of EBP is. The RN said he/she does not wear a gown when providing care for resident #9 and #28. The RN said the two resident's do not have gowns or signs for EBP outside their rooms. The RN said the aides do not wear gowns when providing the two resident's care. During an interview on 09/12/24 at 10:08 A.M., CMT J said he/she guessed he/she did not receive education for EBP use. The CMT said he/she did not know EBP should be used during care for residents with feeding tubes and catheters. During an interview on 09/12/24 at 10:25 A.M., CNA E said he/she used gloves when providing care for residents with feeding tubes, but he/she does not wear a gown. The CNA said he/she does not know what EBP are. The CNA said he/she hasn't seen any signs posted. During an interview on 09/12/24 at 10:25 A.M., the Director of Nursing (DON) said he/she is not familiar with EBP and the facility is not following it. The DON said it could be an infection control concern if staff is transferring germs from resident to resident. During an interview on 09/12/24 at 10:29 A.M. the administrator said he/she is not familiar with EBP, and the facility does not have any residents on EBP. The administrator said he/she currently does not have any EBP signs posted outside any resident doors. The administrator said he/she does not know why EBP signage is not posted outside the resident doors. The administrator said he/she can not say why staff are not wearing gowns, honestly. The administrator said it is his/her and the DON's responsibility to ensure staff are are wearing gowns with residents on EBP, we did not set equipment out for the staff to use. During an interview on 09/12/24 at 1:19 P.M., the Administrator said the Infection Preventionist is responsible for updating staff training when new requirements come out to be used. The administrator said they were aware of EBP for multi drug resistant organisms, but did not know it also applied to feeding tubes or catheters, intravenous access devices, and wounds. 45489

Based on observation, interview, and record review, facility staff failed to update the care plans for meal assistance for two residents (Resident #3 and #24) and for bed rail usage for one resident (Resident #3) of 19 sampled residents. The facility census was 26. 1. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centers dated, December 2016 says; -The interdisciplinary team should develop and implement a comprehensive, person-centered care plan for each resident, -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment, -Care plans will include the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 2. Review of Resident #3's care plan dated, 10/14/23, showed staff documented the resident independent with meals after setup assistance, and required assistance from two staff member for bed mobility. Review showed the care plan did not contain documentation in regard to the resident's side rail use and meal assistance. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/24/24, showed the resident required set-up assistance for eating and has upper extremity impairment of one side. Review of the resident's physician orders, dated 09/2024, showed an order may use a transfer bar to the bed for self-positioning. Observation on 09/09/24 at 10:42 A.M., showed the resident had a partial contracture of his/her right hand and used his/her left hand to eat finger foods. Observation on 09/09/24 at 12:16 P.M., showed the resident in the dining room for the noon meal. Observation showed the resident struggled to use a fork with his/her left hand and could not obtain a bite of food. Observation on 09/09/24 at 12:29 P.M., showed the dietary director approached the resident in the dining room and offered him/her a bite. The resident took the bite and the dietary director walked away. Observation on 09/09/24 at 12:35 P.M., Certified Nurse Aide (CNA) I approached resident and asked if he/she is okay but did not offer to assistance the resident with his/her meal. During an interview on 09/09/24 at 12:50 P.M., the resident said he/she is hungry and had a hard time eating because of his/her left hand. The resident said he/she is right-handed but is not able to use the right hand to eat. Observation on 09/09/24 at 2:50 P.M., showed two quarter bed rails up on both sides of the resident's bed. Observation on 09/11/24 at 12:22 P.M., showed dietary staff served the resident lunch and placed the silverware on the right-hand side of the plate. The resident struggled to reach across his/her plate for the silverware. Staff brought drinks to the resident and placed the drinks on the right-hand side of the resident's plate out of the resident's reach. During an interview on 09/12/24 at 9:55 A.M., CNA I said staff are supposed to supervise the resident during meals and offer assistance as needed. The CNA said he/she knows the resident has limited use of his/her right hand and is right-handed. CNA I said the resident is usually pretty good at using his/her left hand. CNA I said staff should not place silverware or drinks on the resident's right side. CNA I said the resident uses the bed rails to hold on when being turned from side to side. The CNA said this should be on the resident's care plan. During an interview on 09/12/24 at 10:21 A.M., Registered nurse (RN) H said mealtime assistance needs should be on the care plan but the RN does not have time to look at the care plans so he/she did not know if it is on the resident's care plan. RN H said the resident has days when he/she required more assistance and that is why he/she is sat in the assisted dining room. RN H said staff should offer to help the resident if he/she is struggling. RN H said staff know the resident does not use his/her right hand due to a contracture and that the resident is right handed. RN H said staff should not put the resident's items like drinks or silverware on his/her right side because it puts the items out of the resident's reach. RN H said the resident uses the bed rails to help turn in bed with staff assistance. RN H said the resident can not use the bed rails independently and they should be care planned. During an interview on 09/12/24 at 10:48 A.M., the Director of Nursing (DON) said the MDS coordinator is responsible for care plan development but he/she is out on leave, so the DON has been updating the care plan. The DON said the resident's meal time assistance needs should be care planned and he/she did not know why it had not been. The DON said the bed rails are called positioning rails and the resident uses the rails with staff assistance while turning. The DON said this should be in the resident's care plan. 3. Review of Resident #24's quarterly MDS, dated [DATE] shows staff assessed the resident choked and coughed while he/she ate. Review of the resident's care plan, dated 05/29/24, showed staff documented the resident is independent with eating. The care plan did not contain intervention for the residents choking concerns. Review of the resident's nutrition assessment, dated 07/22/24, showed the resident required nectar thick liquids with supervised assistance meals. Observation on 09/09/24 at 12:26 P.M., showed dietary staff served the resident his/her meal and fed the resident. Observation on 09/11/24 at 11:28 A.M., showed dietary staff served the resident drinks without additional staff present in the dining room. Staff served a meal enhancement shake in the original container. Observation showed the resident coughed and choked while he/she drank the shake. Dietary staff took the drink and thickened it in a separate glass. The resident continued to drink nectar thick fluids and coughed and choked. Dietary staff served the resident his/her meal without additional staff present and the resident coughed and choked while he/she tried to eat his/her meal. During an interview on 09/12/24 at 10:01 A.M., CNA I said the resident receives nectar thick liquids because he/she has difficulty swallowing. The CNA said the resident should not be along in the dining room without supervision while eating or drinking. The CNA said the resident could choke if left unsupervised. The CNA said the resident's swallowing issues and need for supervision should be on his/her care plan. During an interview on 09/12/24 at 10:27 A.M., RN H said the resident has swallowing issues and is working with speech therapy. The resident requires nectar thick liquids. RN H said there should be a nursing staff member present in the dining room if the resident is eating or drinking. The RN said if nursing staff is not present the resident could choke while eating or drinking. The RN said the resident's swallowing issues and need for supervision should be on his/her care plan. During an interview on 09/12/24 at 10:54 A.M., the DON said the resident does have occasional issues with swallowing and requires nectar thick liquids. The DON said nursing staff should be in the dining room if the resident has food or drinks. The DON said if nursing staff is not present in the dining room the resident could choke on their food or drinks. The DON said the resident's swallowing issues and need for supervision should be on his/her care plan. During an interview on 09/12/24 at 11:33 A.M., the administrator said there should be a care plan for the resident's swallowing issues and interventions staff are implementing. The administrator said nursing staff should always be in the dining room if the resident is eating or drinking.

Based on observation, interview, and record review, facility staff failed to obtain a physician's order for and failed to update the plan of care for one resident (Resident #23) out of two sampled residents who received oxygen therapy. The facility census was 26. 1. Review of the facility's policy titled, Oxygen Administration, dated October 2010, showed staff are directed to verify there is a physician's order. Review the physician's order or facility protocol for oxygen administration. Review the care plan to assess for any special needs of the resident. 2. Review of Resident #23's admission Minimum Data set (MDS), a federally mandated assessment tool, dated 07/07/24, showed staff assessed the resident used oxygen. Review of the resident's Physician Orders Sheet (POS), dated September 2024, showed it did not contain an order for oxygen. Review of the resident's care plan, dated 07/07/24, showed staff documented the resident used oxygen continuously. Review showed staff documented the resident is unable to propel self and manage the oxygen concentrator. Review of the resident's progress notes, dated July 2024, showed staff documented: -On 07/2/24: Resident in a recliner with oxygen set at three liters (L) via nasal cannula (NC); -On 07/3/24: Residents oxygen saturation (the percentage of hemoglobin in the blood that is saturated with oxygen compared to the total amount of hemoglobin in the blood) is 95% on three liters of oxygen via NC; -07/28/24: Residents oxygen saturation is 97% on three liters of oxygen via NC. Observation on 09/09/24 at 11:30 A.M., showed the resident in the dining room and oxygen at five liters via NC. Observation on 09/11/24 at 10:52 A.M., showed the resident with four liters of 4L of oxygen via NC. Observation on 09/12/24 at 10:06 A.M., showed the resident four liters of oxygen via NC. During an interview on 09/12/24 at 9:58 A.M., Certified Nurse Aide (CNA) I said the resident receives continuous oxygen at two to three liters per minute. He/she said all nursing staff is responsible for checking the oxygen setting but the nurse is responsible for adjusting it. CNA I said when the resident is transported within the facility they take the concentrator with him/her. CNA I said oxygen use should be on the resident's care plan. He/she said they would go to the nurse for instruction if it is not on the care plan. During an interview on 09/12/24 at 10:25 A.M., Registered Nurse (RN) H said the resident receives three to four liters per minute of oxygen when at rest. RN H said there should be an order for oxygen, and it should also be in the resident's care plan. During an interview on 09/12/24 at 10:51 A.M., the Director of Nursing (DON) said the resident's oxygen concentrator should be set at two liters per minute when resident is at rest. He/she said staff should find this on the resident's care plan as well as physician's orders. He/She said he/she did not know the resident's oxygen had been set at four or five liters per minute. The DON said the resident's oxygen is only for comfort and when he/she is not ambulating for transport, he/she does not need it. The DON he/she is responsible for ensuring oxygen is listed on the physician's orders and the care plan since the Assistant Director of Nursing is out on leave. During an interview on 09/12/24 at 11:31 A.M., the administrator said oxygen use should have a physician's order and it should be on the care plan. The administrator said there was some confusion and changes with the resident's oxygen when he/she first admitted .

Based on observation, interview, and record review, facility staff failed to post the required nurse staffing information, which included the total number of staff and the actual hours worked, by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and on a daily basis. The facility census was 26. 1. Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, dated August 2022, showed staff were directed to do the following: -Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents; -Within two hours of the beginning of each shift, the number of licensed nurses (Registered Nurses (RN), Licensed Practical Nurses (LPN) and the number of unlicensed nursing personnel (Certified Nurse Aides (CNA) and Nurse Aides (NA) directly responsible for resident care is posted in a prominent location accessible to resident and visitors and in a clear and readable format; -The information on the form shall include the following: -Twenty-four hour shift scheduled operated by the facility; -Type (RN, LPN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift who are paid by the facility; -The actual time worked during that shift for each category and type of nursing staff; -Total number of licensed and non-licensed nursing staff working for the posted shift; -Within two hours of the beginning of each shift, the charge nurse or designee computes the number of direct care staff and completes the Nurse Staffing Information form; the charge nurse completes the form and posts the staffing information in the location(s) designated by the administrator. 2. Observation on 09/09/24 at 11:09 A.M., showed the daily nurse staff posting did not include the number of licensed staff or the total number of hours worked for the evening shift (3 P.M. to 11 P.M.) and night shift (11 P.M. to 7 A.M.). Observation on 09/10/24 at 8:45 A.M., showed the daily nurse staff posting did not include the number of licensed staff or the total number of hours worked for all three shifts. Observation on 09/11/24 at 8:02 A.M., showed the daily nurse staff posting listed only licensed staff for the day shift (7 A.M. to 3 P.M.), and did not include the total number of hours worked for the day shift or staff and total number of hours worked for the two remaining shifts. Observation on 09/12/24 at 12:47 P.M., showed the daily nurse staff posting did not include licensed staff or the total hours worked for all three shifts. 3. During an interview on 09/12/24 at 7:56 A.M., Licensed Practical Nurse (LPN) L said he/she puts the form out every night, and each shift charge nurse fills out staffing numbers and hours per shift. LPN L said he/she did not know the form is not being filled and staff just forget. LPN L said he/she turns the forms in to the Administrator each night. He/she was not sure who is responsible for ensuring the forms are completed, but they are given to the Administrators office. During an interview on 09/12/24 at 10:35 A.M. the Director of Nursing (DON) said the daily nurse staff posting should be completed during report, and should have licensed staff and total hours for all shifts. The DON did not know the form is not being filled out. He/She said the oncoming charge nurse is responsible to fill it out at the beginning of each shift, he/she said it has always been filled out for each shift separately, and staff will need education about filling it out completely. He/she said the forms are turned in to the office at night and he/she believes the administrator is responsible for reviewing. During an interview on 09/12/24 at 1:19 P.M., the administrator said daily nurse staff posting should have the census, the number of staff, and the hours worked for each shift. The charge nurse on the floor is responsible for filling out the form for the whole day. The administrator did not know the form is not being filled out during the day. The administrator said the DON should be monitoring when doing floor rounds to ensure the forms are completed accurately for the whole day.

Based on interview and record review, facility staff failed to check the Certified Nurse Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse and/or neglect) as directed in their policy. The facility census was 29. 1. Review of the facility's policy, titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, showed staff were directed to conduct employee background checks and not knowingly employ or otherwise engage any individual who has a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of resident or misappropriation of resident property. 2. Review of Housekeeper A's employee file showed: -Hire date of 08/10/23; -The file did not contain documentation of the Nurse Aide registry check. 3. Review of Dietary Aide (DA) B's employee file showed: -Hire date of 04/07/23; -The file did not contain documentation of the Nurse Aide registry check. 4. Review of Staff C's employee file showed: -Hire date of 03/06/23; -The file did not contain documentation of the Nurse Aide registry check. 5. Review of Certified Nurse Aide (CNA) D's employee file showed: -Hire date of 08/08/23; -The file did not contain documentation of the Nurse Aide registry check. 6. During an interview on 09/13/23 at 11:31 A.M., the Administrator said he/she was in charge of all background checks for new employees. He/She said he/she only checked the Nurse Aide registry if the employee was a Nurse Aide or a CNA.

Based on interview and record review, the facility staff, failed to update and revise care plans with the interdisciplinary team (IDT) for three residents (Resident #1, #2, and #8). The facility census was 29. 1. Review of the facility's policies showed staff did not provide a policy for care plan meetings. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated, showed staff assessed the resident as: -Moderate cognitive impairment; -Required limited one person assistance for bed mobility, transfers, toileting, and personal hygiene; -Diagnosis of Depression (a depressed mood or loss if pleasure or interest in activities for long periods of time). Review of the resident's care plan signature sheet, dated 06/16/23, showed the sheet did not consist of an IDT team. Review of the resident's medical record showed the record did not contain documentation of the IDT team was invited or attended a care plan meeting. 3. Review of Resident #2's Quarterly MDS, dated [DATE], showed facility staff assessed the resident as: -Severe cognitive impairment; -Required extensive two plus person physical assistance for bed mobility and dressing; -Required total assistance from two staff for transfers; -Diagnosis of dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). Review of the resident's care plan signature sheet, dated 06/15/23, showed the sheet did not consist of an IDT team. Review of the resident's medical record showed the record did not contain documentation of the IDT team was invited or attended a care plan meeting. 4. Review of Resident #8's significant change MDS, dated [DATE], showed facility staff assessed the resident as: -Cognitively intact; -Required limited one person assistance for bed mobility, toileting, personal hygiene; -Required extensive two plus person physical assistance for transfers and dressing; -Diagnosis of traumatic brain injury (an injury that affects how the brain works). Review of the resident's care plan signature sheet, dated 07/19/23, showed it did not consist of an IDT team. Review of the resident's medical record showed the record did not contain documentation of the IDT team invited or attended a care plan meeting. 5. During an interview on 09/13/23 at 02:52 P.M., licensed practical nurse (LPN) H said the MDS coordinator was responsible for scheduling and inviting people to the resident's care plan meetings. He/She said he/she used to be the MDS coordinator and knew that the MDS coordinator, DON, Social services director, dietitian, activities director, physician, family, resident, and resident representative should all be invited to the care plan meetings. During an interview on 09/13/23 at 03:00 P.M., the MDS coordinator said he/she was responsible for scheduling and inviting people to the care plan meetings. He/She said he/she invites the resident, resident representative, and Director of nursing (DON). He/She said depending on the circumstances he/she may invite social services and the administrator. He/She said the physician does not attend the care plan meetings but issues can be addressed through email for his/her input. During an interview on 09/13/23 at 03:19 P.M., the DON said it is the MDS coordinator's responsibility to plan and invite people to attend the residents' care plan meetings. He/She said the MDS coordinator invites different people to attend based on the resident's care needs. He/She said the resident's primary contact or representative, the resident, the MDS coordinator and himself/herself usually attend. He/She said sometimes social services and the administrator attend if needed. He/She said the physician does not attend but can be consulted if needed. During an interview on 09/13/23 at 04:36 P.M., the Administrator said the MDS coordinator is responsible for inviting people to the resident's care plan meetings. He/She said the DON, assistant director of nursing (ADON), the resident's family and the resident are invited to the meetings. He/She said sometimes social services and himself/herself will be invited depending on the situation. He/She said the physician is not invited unless the resident or the residents family requests. He/She said all the people who attend the meeting sign the care plan meeting sheet and it is uploaded into the resident's electronic medical record. 47193

Based on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when staff failed to ensure safe propulsion for three residents (Resident #4, #8, #12, and #15) in wheelchairs in a manner to prevent accidents. The facility census was 29. 1. Review of the facility's Manual Wheelchair safety and Maintenance policy, undated, showed the following: -No pedals-No push; -Always propel a resident in a forward position; -Always ensure leg rests and foot pedals are in the correct position and in use when propelling a resident in a wheelchair. 2. Review of Resident #4's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/03/23, showed staff assessed the resident as: -Severe cognitive impairment; -Diagnoses of Renal insufficiency (poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys caused by renal artery disease.), Dementia (loss of cognitive functioning thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities.) and Depression (depressed mood or loss of pleasure or interest in activities for long periods of time); -Limited Assistance one person physical assist for locomotion on and off the unit; -Wheelchair use. Observation on 09/11/23 at 12:14 P.M., showed Certified Nursing assistance (CNA) I propelled the resident in his/her wheelchair from his/her room to the dining room without foot pedals. The resident's foot wear skimmed the floor. 3. Review of Resident #8's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of diabetes (body doesn't make enough insulin or can't use it as well as it should), other fracture (partial or complete break in the bone), traumatic brain injury (TBI), atrial fibrilation (type of arrhythmia, or abnormal heartbeat) and depression; -Limited assistance one person physical assist; -Walker and wheelchair in use. Observation on 09/11/23 at 10:23 A.M., showed CNA L propelled the resident down the hall to the scale without foot pedals. The resident's foot wear skimmed the floor. Observation on 09/11/23 at 11:50 A.M., showed CNA L grabbed the residents cup holder on his/her wheelchair and pulled the resident to the dining room. The resident's foot wear skimmed the floor. 4. Review of Resident #12's annual MDS, dated [DATE], showed facility staff assessed the resident as: -Sever cognitive impairment; -Required extensive two plus person assist with bed mobility, transfers, dressing, and toileting; -Uses a wheelchair; -Diagnosis of stroke (can occur when blood flow to the brain is blocked or there is sudden bleeding in the brain) and hemiplegia (paralysis of one side of the body). Observation on 09/12/23 at 11:34 A.M., showed nurse aide (NA) J propelled the resident down the hall from his/her room to the dining room with only the right foot pedal on. Further observation showed the resident's left foot skimmed the floor. 5. Review of Resident #15's Admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact. -Cognitively intact; -Diagnosis of absence of the right leg below the knee and cancer. Observation on 09/12/23 at 10:44 A.M., showed CNA L propelled the resident to the scale without foot pedals. Further observation showed CNA L pushed the resident up the scale ramp and then after he/she obtained the resident's weight he/she pulled the resident backwards down the ramp to the other side of the hall without foot pedals. 6. During an interview on 09/13/23 at 2:37 P.M., Nurse Aide J said you should always propel residents with pedals, so they don't fall out. He/She said it might happen because coworkers can be careless, because staff have been educated on it in the past. During an interview on 09/13/23 at 2:37 P.M., certified medication technician (CMT)/(CNA) K said the facility policy is No pedals No push. He/She said staff should always push residents forward never back. He/She said staff are instructed to not use pedals when weighing residents on the scale. He/She said staff should push residents up on the scale and pull them backwards off or push backward on to the scale and pull forward off the scale. During an interview on 09/13/23 at 2:52 P.M., licensed practical nurse (LPN) H said, No pedals no push. He/She said staff should not push residents fast and never push or pull backwards with wheelchair bound residents. He/She said the resident's feet could hit floor and the resident could fall out on their head, they could break their legs or ankles. During an interview on 09/13/23 at 3:19 P.M., the Director of Nursing (DON) said his/her [NAME] is no pedals no push. He/She said staff should not pull ? forward or pulled backwards in their wheelchairs. He/She said using the scale to weigh residents who are wheel chair bound can be tough. He/She said staff are expected to push the resident up onto the scale without foot pedals and then pull them back off the scale backward or push the resident backwards onto the scale and pull the resident forward off the scale. He/She said the risk factors for pushing residents improperly in wheelchairs are the risk for them falling, toppling out of the chair causing injury to the residents or themselves. During an interview on 09/13/23 at 4:36 P.M., the administrator said she expects staff to always use pedals when pushing residents. He/She said staff should always push residents forward with wheels on the ground. He/She said residents who are wheel chair bound are weighed by taking the pedals off the wheel chair and pushing the resident up onto the scale. He/She said staff should try to push resident up and turn the wheel chair. He/She said staff should not pull the resident backward off the scale. He/She said he/she knows that pushing residents onto the scale was an issue on the last survey and has been a topic that they have had. He/She said improperly pushing residents can result in the resident flying out and getting hurt.