Every finding on record at Lake Montgomery Health and Rehabilitation Center

Based on record review and interview, the facility failed to ensure resident care plans regarding advanced directives were updated for 1 of 4 residents, Resident #1, reviewed for accuracy of care plans.Findings include:Review of Resident #1's admission Data documented the resident was admitted into the facility on [DATE] with an Advanced Directive of Full Code status (if a resident is absent of life the health care team is to use all available and necessary life-saving measures to resuscitate).Review of Resident #1's Care Plan read, Focus: Advanced Directives: Resident has an established CPR [cardiopulmonary resuscitation] (Full Code) order in place. Date Initiated: [DATE]. Created on: [DATE].During an interview on [DATE] at 1:09 PM the DON (Director of Nursing) stated, I see that his [Resident #1] Care Plan was not updated. He came in as a Full Code, and he changed it in October to a DNR [Do Not Resuscitate]. During an interview on [DATE] at 5:14 PM the MDS LPN (Minimum Data Set Licensed Practical Nurse) stated, When the order [for code status] changes we should be updating the care plan, but that didn't happen. It's discussed in morning meetings and then we update the care plans.During an interview on [DATE] at 5:27 PM the Social Worker Director stated, I recall [Resident #1's name]. I attend the morning clinical meetings. We look at advanced directives. If the care plan was not updated, it must have been missed. We all look at it in the clinical meeting. It was just probably missed. Care plans are reviewed and updated through the clinical meetings.Review of the policy and procedure titled Advanced Directives Code Status, with an implementation date of 1/2024 and a revision date of 1/2026 read, Standard: It is the policy of the facility to honor advanced directives, code status and do not resuscitate orders in accordance with state and federal regulations. Guideline: Change of code status/review of code status: Social Services and nursing must document in a progress note that code status was changed as per resident/representative request and orders were obtained. Code status/advanced directives care plan must be updated.

Based on interview and record review, the facility failed to ensure complete and accurate records for 1 of 4 residents, Resident #1, reviewed for medication administration. Findings include:Review of Resident #1's MAR (Medication Administration Record) for 11/01/2025 - 11/30/2025 read, HumaLOG KwikPen (an insulin pen) 100 UNIT/ML (100 units per milliliter) solution pen injector: Inject as per sliding scale: if [blood sugar reading] 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10 Call MD, subcutaneously before meals and at bedtime for DM (diabetes mellites) - Start Date 09/08/2025 0630 (6:30 AM) -D/C (discontinue) Date 12/22/2025 1232 (12:32 PM). Documented for the Hours of 0630 [6:30 AM] dated 11/1/2025, 11/19/2025, and 11/30/2025 the MAR for BS [blood sugar] was documented NA (not applicable). Dated 11/24/2025 the MAR was blank. For the Hours of 1130 (11:30 AM) dated 11/13/2025, 11/16/2025, 11/19/2025, 11/20/2025, 11/25/2025, and 11/27/2025 the MAR was documented as NA. For the Hours of 1630 (4:30 PM) dated 11/25/2025 and 11/26/2025 the MAR documented NA. For the Hours of 2100 (9:00 PM) dated 11/18/2025, 11/24/2025, and 11/30/2025 the MAR was documented as NA. Dated 11/25/2025 the MAR was documented with an X. This resulted in a total of 16 occurrences of the resident having refused and/or the staff did not monitor the resident's blood sugar as ordered by the physician to determine if insulin injections were required. Review of Resident #1's medical record for 11/1/2025 through 11/30/2025 did not contain documentation in the record of the resident's physician having been notified of the medication not having been administered per the resident's refusal and/or staff not administering the medication.Review of Resident #1's MAR for 11/01/2025 through 11/30/2025 read, Lantus SoloStar (an injectable insulin) 100 UNIT/ML solution pen-injector. Inject 15 units subcutaneously at bedtime for DM - Start Date 08/13/2025 2100 (9:00 PM) - D/C Date 12/02/2025 1513 (3:13 PM). Lantus SoloStar was documented dated 11/18/2025, 11/24/2025, 11/25/2025 and 11/30/2025 as a 2. Review of the Chart Codes/Follow Up Codes read, 2 = Drug Refused. This resulted in a total of four doses not having been administered due to the resident's refusal. Review of Resident #1's medical record did not provide documentation the resident's physician was notified of the resident's refusal of the medication.Review of Resident #1's MAR for 12/01/2025 through 12/20/2025 read, Lantus SoloStar 100 UNIT/ML solution pen-injector. Inject 25 units subcutaneously at bedtime for DM - Start Date 12/02/2025 2100 - D/C Date 12/22/2025 1232 [12:32 PM]. The MAR documented 2 dated 12/2/2025, 12/7/2025, 12/10/2025, 12/11/2025, and 12/14/2025. For a total of five doses of the medication not being administered due to the resident's refusal.Review of Resident #1's medical record for 12/01/2025 through 12/20/2025, the record did not contain documentation the resident's physician was notified of the resident's refusal of the medication. Review of Resident #1's MAR for 12/1/2025 through 12/20/2025 read, HumaLOG KwikPen 100 UNIT/ML solution pen-injector Inject as per sliding scale: if 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10 Call MD, subcutaneously before meals and at bedtime for DM - Start Date 09/08/2025 0630 (6:30 AM) - D/C Date 12/22/2025 1232 (12:32 PM). For the Hours of 0630 dated 12/02/2025, 12/03/2025, 12/13/2025, 12/16/2025, and 12/17/2025 the MAR was documented as NA. For the Hours of 1130 dated 12/05/2025, 12/07/2025, 12/08/2025, 12/10/2025, and 12/11/2025 the MAR was documented as NA. For the hours of 1630 dated 12/08/2025 the MAR was documented as NA. For the Hours of 2100 Dated 12/02/2025, 12/10/2025, 12/11/2025, and 12/14/2025 the MAR was documented with an X. This resulted in 15 occurrences of the resident's blood sugar value not being monitored.Review of Resident #1's medical record for 12/01/2025 through 12/20/2025, the record did not contain documentation the resident's physician was notified of the resident's refusal of and/or staff not monitoring the resident's blood sugar value to determine if insulin administration was required. During an interview on 01/29/2026 at 2:37 PM the APRN (Advanced Practice Registered Nurse) stated, I've known him [Resident #1] for quite some time. That was something he [Resident #1] also did at [Name of a different facility], refuse blood sugar monitoring and/or insulin. He was stubborn and fairly independent. I saw him a couple of days prior to him going out. I had just gotten notification from the nurses that he had again refused his insulin. I told him that his wound would not heal. They definitely would notify me. Maybe they didn't document it. I had quite a few conversations. They would call me after he refused. Any time they give a higher dose, they spoke with me. I don't typically have a concern regarding notification of refusal of medications. They notify me pretty often. I am in constant contact with the DON and the unit managers, and the wound care nurse. He would take his insulin if he was feeling bad. During an interview on 01/29/2026 at 3:38 PM Staff B, LPN (Licensed Practical Nurse) stated, Usually he [Resident #1] would take his medications, but on certain days he would refuse his insulin and accu-checks (used to measure blood sugar levels). It was usually on my shift. I would call his doctor. It should be documented when I called. For the most part we called her [Resident #1's Primary Care Physician/Advanced Practice Registered Nurse]. There are probably times, I'm not going to lie, that I didn't document it. From what I'm understanding, when a patient refuses their medications, if it's often, we call the doctor and document it.During an interview on 01/29/2026 at 5:01 PM the DON (Director of Nursing) stated, The expectation is that the nurses notify family and the provider and document it [if a resident refuses medications or treatments].Review of the policy and procedure titled Physician Services, read, Intent: it is the policy of the facility to provide physician services in accordance with state and federal regulations. Procedure: 8. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift.Review of the policy and procedure titled Medication Administration, read, Policy: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy explanation and compliance guidelines: 22. Report and document any adverse side effects or refusals.

Based on interview and record review, the facility failed to ensure the resident's representative was notified of the resident's refusal of medication administration for 1 of 4 residents, Resident #1, reviewed for medication administration.Findings include:Review of Resident #1's admission Data documented the resident was admitted on [DATE] with medical diagnoses to include type 2 diabetes mellitus with foot ulcer; difficulty in walking, not elsewhere classified; and non-pressure chronic ulcer of other part of right foot with necrosis of muscleReview of Resident #1's MDS (Minimum Data Set) Evaluation, quarterly assessment dated [DATE], documented the resident had a BIMS (Brief Inventory of Mental Status) Score of 09 out of 15, which indicated some cognitive impairment.Review of Resident #1's MAR (Medication Administration Record) for 11/01/2025 - 11/30/2025 read, HumaLOG KwikPen (an insulin pen) 100 UNIT/ML (100 units per milliliter) solution pen injector: Inject as per sliding scale: if [blood sugar reading] 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10 Call MD, subcutaneously before meals and at bedtime for DM (diabetes mellites) - Start Date 09/08/2025 0630 (6:30 AM) -D/C (discontinue) Date 12/22/2025 1232 (12:32 PM). Documented for the Hours of 0630 [6:30 AM] dated 11/1/2025, 11/19/2025, and 11/30/2025 the MAR for BS [blood sugar] was documented NA (not applicable). Dated 11/24/2025 the MAR was blank. For the Hours of 1130 (11:30 AM) dated 11/13/2025, 11/16/2025, 11/19/2025, 11/20/2025, 11/25/2025, and 11/27/2025 the MAR was documented as NA. For the Hours of 1630 (4:30 PM) dated 11/25/2025 and 11/26/2025 the MAR documented NA. For the Hours of 2100 (9:00 PM) dated 11/18/2025, 11/24/2025, and 11/30/2025 the MAR was documented as NA. Dated 11/25/2025 the MAR was documented with an X. This resulted in a total of 16 occurrences of the resident having refused and/or the staff did not monitor the resident's blood sugar as ordered by the physician to determine if insulin injections were required. Review of Resident #1's medical record for 11/1/2025 through 11/30/2025 did not contain documentation in the record of the resident's representative having been notified of the medication not having been administered per the resident's refusal and/or staff not administering the medication.Review of Resident #1's MAR for 11/01/2025 through 11/30/2025 read, Lantus SoloStar (an injectable insulin) 100 UNIT/ML solution pen-injector. Inject 15 units subcutaneously at bedtime for DM - Start Date 08/13/2025 2100 (9:00 PM) - D/C Date 12/02/2025 1513 (3:13 PM). Lantus SoloStar was documented dated 11/18/2025, 11/24/2025, 11/25/2025 and 11/30/2025 as a 2. Review of the Chart Codes/Follow Up Codes read, 2 = Drug Refused. This resulted in a total of four doses not having been administered due to the resident's refusal. Review of Resident #1's medical record did not provide documentation the resident's representative was notified of the resident's refusal of the medication.Review of Resident #1's MAR for 12/01/2025 through 12/20/2025 read, Lantus SoloStar 100 UNIT/ML solution pen-injector. Inject 25 units subcutaneously at bedtime for DM - Start Date 12/02/2025 2100 - D/C Date 12/22/2025 1232 [12:32 PM]. The MAR documented 2 dated 12/2/2025, 12/7/2025, 12/10/2025, 12/11/2025, and 12/14/2025. For a total of five doses of the medication not being administered due to the resident's refusal.Review of Resident #1's medical record for 12/01/2025 through 12/20/2025, the record did not contain documentation the resident's representative was notified of the resident's refusal of the medication. Review of Resident #1's MAR for 12/1/2025 through 12/20/2025 read, HumaLOG KwikPen 100 UNIT/ML solution pen-injector Inject as per sliding scale: if 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10 Call MD, subcutaneously before meals and at bedtime for DM - Start Date 09/08/2025 0630 (6:30 AM) - D/C Date 12/22/2025 1232 (12:32 PM). For the Hours of 0630 dated 12/02/2025, 12/03/2025, 12/13/2025, 12/16/2025, and 12/17/2025 the MAR was documented as NA. For the Hours of 1130 dated 12/05/2025, 12/07/2025, 12/08/2025, 12/10/2025, and 12/11/2025 the MAR was documented as NA. For the hours of 1630 dated 12/08/2025 the MAR was documented as NA. For the Hours of 2100 Dated 12/02/2025, 12/10/2025, 12/11/2025, and 12/14/2025 the MAR was documented with an X. This resulted in 15 occurrences of the resident's blood sugar value not being monitored.Review of Resident #1's medical record for 12/01/2025 through 12/20/2025, the record did not contain documentation the resident's representative was notified of the resident's refusal of and/or staff not monitoring the resident's blood sugar value to determine if insulin administration was required. During an interview on 1/29/2026 at 11:52 AM Resident #1's Representaitve stated, I was not aware that he was refusing his blood sugar checks. I was never told that he was not compliant or that he was refusing.During an interview on 1/29/2026 at 3:38 PM Staff B, LPN (Licensed Practical Nurse) stated, From what I'm understanding when a patient refuses their medications, if it's often, we call the doctor. I have called family, but not for him. I didn't notify the family.During an interview on 01/29/2026 at 5:01 PM the Director of Nursing stated, The expectation is that the nurses notify family and the provider and document it [if a resident refuses medications or treatments]. We had discussed him [Resident #1] refusing his insulin in morning meeting.Review of the policy and procedure titled Notification of Changes, with an implementation date of 11/2020 and a revision date of 8/16/2022 read, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: Clinical complications. Additional considerations: 1. Competent individuals: a. The facility must still contact the resident's physician and notify residents representative, if known. c. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally.

Based on record review and interview, the facility failed to ensure resident assessments were accurate for 1 (Resident #19) of 3 residents reviewed for respiratory services.Review of Resident #19 Minimum Data Set (MDS) titled Quarterly dated 7/10/2025 documented resident did not use oxygen therapy.Review of Resident #19 vital task for oxygen saturations documented on 7/8/2025 at 12:53 PM oxygen via nasal cannula, on 7/7/2025 at 6:05 AM oxygen via nasal cannula, 7/5/2025 at 5:16 AM oxygen via nasal cannula, 7/4/2025 at 12:42 AM oxygen via nasal cannula, and 7/3/2025 at 3:38 AM oxygen via nasal cannula.Review of Resident #19 nurses notes dated 7/8/2025 read, O2 [oxygen] sats [saturation]: 97% Method: Oxygen via Nasal Cannula.Review of Resident #19 physician order dated 4/8/2025 read, Oxygen @ [at] 3 litters via nasal cannula for SOB [shortness of breath] no humidification as needed for SOB.During an interview on 7/31/2025 at 1:58 PM with Staff A MDS Licensed Practical Nurse (LPN) stated, [Resident #19's name] Section O for oxygen needs to be updated, the nurses were not documenting on the treatment record but included the information in the nurses note and oxygen saturations vital record for the look back.Review of the facility policy and procedure titled MDS 3.0 Completion with a last review date of 1/31/2025 read, Policy: Resident are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State.

Based on record review and interview, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) was accurately completed for 2 of 6 residents reviewed (Residents #11, and #19). Findings include: 1) Review of Resident #11’s admission record showed the resident was admitted on [DATE] with diagnoses including but not limited to residual schizophrenia (onset date: 3/26/2019), unspecified mood (affective) disorder (onset date: 3/26/2019), adjustment disorder with mixed anxiety and depressed mood (onset date: 3/26/2019), major depressive disorder (onset date: 1/31/2024), generalized anxiety disorder (onset date: 1/31/2024), paranoid schizophrenia (onset date: 3/26/2019), and other specified persistent mood disorders (onset date: 3/26/2019). Review of Resident #11’s PASSR dated 7/10/2025 did not show persistent mood disorder under mental illness or suspected mental illness under Section I: PASSR Screen Decision-Making. Review of Resident #11’s psychiatry subsequent note dated 7/1/2025 read, “Chief complaint: Depression, anxiety, mood disorder, schizophrenia and TD [Tardive Dyskinesia].” Review of Resident #11’s quarterly Minimum Data Set assessment dated [DATE] showed unspecified mood (affective) disorder under Section I- Active Diagnoses. During an interview on 7/31/2025 at 1:45 PM, the Director of Nursing (DON) stated, “[Resident #11’s name] PASSR needed to be updated. I did not know we could add diagnosis in the other section.” 2) Review of Resident #19’s medical record showed the resident was originally admitted on [DATE] and most recently admitted on [DATE] with diagnoses that included but not limited to brief psychotic disorder (onset date: 10/12/2024), major depressive disorder (onset date: 10/12/2024), other specified persistent mood disorders (onset date: 10/12/2024), generalized anxiety disorder (onset date: 10/12/2024), cerebral ischemia, and urinary tract infection. Review of Resident #19’s PASRR dated 10/9/2025 did not show brief psychotic disorder, major depressive disorder, and other specified persistent mood disorders under mental illness or suspected mental illness under Section I: PASSR Screen Decision-Making. Review of Resident #19’s psychiatry subsequent note dated 7/8/2025 read, “Chief complaint: Depression, anxiety, dementia, mood disorder, psychosis, and Parkinson’s disease.” Review of Resident #19’s quarterly Minimum Data Set assessment dated [DATE] showed depression, psychotic, and anxiety as part of the active diagnosis under Section I- Active Diagnoses. During an interview on 7/30/2025 at 2:45 PM, the DON stated, “[Resident #19’s name] PASRR needs to be updated to include the diagnosis that were missing.”

Based on record review and interview, the facility failed to ensure medications were administered as ordered by physician for 2 of 7 residents reviewed for medication management (Residents #5 and #11). Findings include: 1) Review of Resident #5's physician order dated 9/2/2024 read, Metoprolol Tartrate Oral Tablet 50 MG [Milligram] (Metoprolol Tartrate), Give 50 mg by mouth every 12 hours for Beta Blocker. Review of Resident #5's Medication Administration Record (MAR) for June 2025 for administration of Metoprolol Tartrate Tablet 50 mg showed code 4 (vitals outside of parameters for administration) was documented on 6/4/2025 at 9:00 PM for the blood pressure of 115/60 and pulse of 66, on 6/7/2025 at 9:00 PM for the blood pressure of 109/65 and pulse of 80, on 6/8/2025 at 9:00 PM for the blood pressure of 111/69 and pulse of 70, on 6/19/2025 at 9:00 PM for the blood pressure of 107/61 and pulse of 66, and on 6/21/2025 at 9:00 PM for the blood pressure of 111/69 and pulse of 62. Review of Resident #5's MAR for July 2025 for administration of Metoprolol Tartrate Tablet 50 mg showed code 4 was documented on 7/19/2025 at 9:00 AM for the blood pressure of 110/66 and pulse of 60 and at 9:00 PM for the blood pressure of 112/61 and pulse of 59, and on 7/22/2025 for the blood pressure of 105/43 and pulse of 67. During an interview on 7/30/2025 at 8:30 AM, the Director of Nursing (DON) stated, The nurses were holding the medication without an order. If they have questions, they should contact the provider and let him about their concern. During an interview on 7/30/2025 at 4:05 PM, the Medical Doctor #1 stated, Nurses should not be holding medications that do not have parameter. If they have any questions, they need to call me. This was not reported to me. No medical concerns have been reported to be recently in regards to [Resident #5's name] related to his medication. During an interview on 7/31/2025 at 3:55 PM, Staff E, Licensed Practical Nurse (LPN), stated, I held [Resident #5's name] blood pressure medication because it was low. I did not let the provider know. 2) Review of Resident #11's physician order dated 5/8/2025 read, Insulin Glargine Solution 100 UNIT/ML [milliliter], Inject 20 unit subcutaneously two times a day for diabetes if blood sugar is less than 150 hold Lantus. Review of Resident #11's MAR for July 2025 showed Lantus was administered at on 7/2/2025 at 6:00 AM for the blood sugar of 77; on 7/4/2025 at 6:00 AM for the blood sugar of 75 and at 9:00 PM for the blood sugar of 100; on 7/8/2025 at 6:00 AM for the blood sugar of 120; on 7/9/2025 at 6:00 AM for the blood sugar of 78; on 7/11/2025 at 6:00 AM for the blood sugar of 85; on 7/12/2025 at 9:00 PM for the blood sugar of 121; on 7/13/2025 at 9:00 PM for the blood sugar of 121; on 7/18/2025 at 6:00 AM for the blood sugar of 87 and at 9:00 PM for the blood sugar of 98; on 7/22/2025 at 6:00 AM for the blood sugar of 90; and on 7/27/2025 at 6:00 AM for the blood sugar of 112, and at 9:00 PM for the blood sugar of 148. During an interview on 7/30/2025 at 9:54 AM, the DON stated, [The Medical Doctor #2's name] will be taking off the parameters and she actually said [Resident #11's name] A1C [Glycated Hemoglobin] has improved. I also spoke to the medical director and he said no harm was done to the patient. I also spoke to the medical director about [Resident #5's name] blood pressure and there were no concerns with the blood pressure. He was going to discontinue one of the blood pressure medications because he had two. Nurses should always follow doctor's orders. During an interview on 7/30/2025 at 11:11 AM, Staff B, Registered Nurse (RN), stated, Usually long-acting medication is never stop and this order probably was new. I was not reading it. I read the order that shows up on the screen. I feel I should have been more careful and read the order. Also, I should contact the provider if I have any questions about the orders. We should always follow doctor's parameters. It is our obligation. During an interview on 7/30/2025 at 12:21 PM, Staff C, LPN, stated, If he [Resident #11] has parameters to hold medication, I would have definitely held it. I don't recall those days. It might have been an error, because I would hold the medication if he has parameters. During an interview on 7/30/2025 at 12:23 PM, Staff D, RN, stated, I don't recall. I will say this Lantus is a 24-hour insulin that would be my only reason for giving it. That is a terrible mistake. Orders should show the parameters. I know there is parameters for other insulins, and he does have some issues with blood sugar. I should have followed parameters. During an interview on 7/30/2025 at 1:01 PM, the Medical Doctor #1 stated, I have a standard for my parameters. I have not been notified of any medical concerns. I plan to stop [Resident #11's name] insulin depending on the next A1C results. Review of the facility policy and procedure titled Medication Administration with the last review date of 1/31/2025 read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

Based on observation and interview, the facility failed to ensure accurate nurse staffing information was posted on a daily basis. Findings include: During an observation on 7/28/2025 at 9:39 AM, nurse staffing information dated 7/27/2025 was posted immediately after entering the residential area (Photographic evidence obtained). During an interview on 7/29/2025 at 2:39 PM, the Director of Nursing stated, The scheduler is the one responsible for updating the staff posting daily. She arrives around 6 AM and by 8 AM, the posting should be updated. During an interview on 7/31/2025 at 8:19 AM, the Scheduler stated, I will normally update the staff posting when I get to the facility that is around 8 to 8:30 AM. I had it ready in the backroom on Monday [7/28/2025] and was trying to still get the numbers correct during the morning routine. I don't have access to the census. I have to wait on payroll or the Business Office Manager. During an interview on 7/31/2025 at 12:45 PM, the Business Office Manager stated, I had no delays on Monday that I recall that would have not allowed me to provide the census in a timely manner. During an interview on 7/31/2025 at 12:46 PM, the Administrator stated, There is no policy for the posting of the federal staffing, but my expectation would be that by 9:00 AM, it is posted.

Based on record review and interview, the facility failed to provide laboratory services to meet the needs of the residents for 1 of 5 residents reviewed for medication management (Resident #19). Findings include: Review of Resident #19's progress note dated 7/7/2025 at 5:19 PM read, Resident daughter came to nursing reporting that mother is hallucinating, talking to someone that is not there and thinking someone is watching here. Will notify MD [Medical Doctor] and Psych [Psychiatrist]. Review of Resident #19's psychiatry subsequent note dated 7/8/2025 read, Chief complaint: Depression, anxiety, mood disorder, psychosis, and Parkinson's disease. Reason for Today's encounter: Today I saw the patient as it was reported to me that patient is unstable requiring psychiatric assessment. History of present illness . Today I saw the patient as it was reported to me that patient is unstable requiring psychiatric assessment. As per collected information, staff reported increased anxiety. Patient come to front lobby and pray all the time. Dementia is persisting, but no other behaviors noted. Assessment and plan: I feel the symptoms are occurring due to exacerbation of underlying depression and anxiety disorder. The symptoms occur almost daily and causing severe distress. Therefore, I decided to make medication changes to stabilize the symptoms Plan of action: I have decided to continue Buspirone along with Clonazepam for anxiety and Donepezil to treat dementia. Medication rationale and adverse effects: Dry mouth, headache, drowsiness, fatigue, constipation, diarrhea, decreased appetite, increased sweating, dizziness, and insomnia. Review of Resident #19's progress note dated 7/10/2025 at 5:51 PM read, res [Resident] noted to be having conversations with past relatives. md [Medical Doctor] made aware and ua [urine analysis] ordered. vitals at baseline. plan of care continues. Review of Resident #19's physician order dated 7/11/2025 read, UA w [with]/culture and sensitivity STAT [immediately] for lab. Review of Resident #19's progress note dated 7/11/2025 at 8:36 AM read, Resident observed sitting up front by the doors and claims to be waiting on her brother. After speaking to daughter she says her mother prays and that family members talk to her through it. Her brother lives out of state and does not come down to visit. Review of Resident #19's lab result report dated 7/14/2025 showed invalid result for urinalysis w/reflex to culture. Review of Resident #19's progress note dated 7/19/2025 at 12:29 AM read, Behavior Monitoring- Observe for (specify resident's behavior). Document: 'Y' if the resident is exhibiting behaviors. 'N' if resident is not exhibiting behaviors. If 'Y' document in the PN's [progress notes]. every shift. Was a behavior observed? YES. Resident sitting in front lobby believing family is coming. Review of Resident #19's progress note dated 7/20/2025 at 7:35 AM read, Behavior Monitoring- Observe for (specify resident's behavior). Document: 'Y' if the resident is exhibiting behaviors. 'N' if resident is not exhibiting behaviors. If 'Y' document in the PN's. every shift. Was a behavior observed? YES. Resident sat up in front lobby and refused to go to bed, insisted that her brother was coming to pick her up. Review of Resident #19's progress note dated 7/21/2025 at 2:59 PM read, Resident has been sitting up front by the door. She refused to eat or take a shower. MD notified and orders put in regarding her UA. Will continue to monitor. Review of the text message conversation with the Director of Nursing (DON) dated 7/21/2025 at 12:54 PM read, [Resident #19's last name] has been refusing to eat and leave from in front of the front door for the past 3-4 days. She says she is waiting on family members who talk to her through her prayers. Her daughter says she progressed this same way at the last facility before she started attempting to leave. The U/A results show no bacteria seen but elevated WBC [White Blood Cell] leukocytes, and hyaline casts. I am trying to look into the c/s [culture and sensitivity] now. It's shown being ordered but no results are here. The C/S was invalid. We will reorder and it will go out in the morning. Can she get something in the mean time to hold over until the results come back? Review of Resident #19's progress note dated 7/22/2025 at 1:26 PM read, Resident taking antibiotic treatment of UTI [Urinary Tract Infection] started on 7/21/2025. Resident continues sitting front entrance periods of times during the shift, however she has participated in meals and activities today. Resident took a nap in her bed after lunch. No s/s [signs and symptoms] of adverse reactions noted. Review of Resident #19's progress note dated 7/23/2025 at 2:55 PM read, Resident has been sitting up front by the door since I came onto shift at approx. [approximately] 8 am. She is refusing to come to bed or eat claiming she is not hungry. She is getting agitated when asked to lay down. MD notified. Daughter says she will be in after work to try and talk to her. Review of Resident #19's progress note dated 7/24/2025 at 12:11 AM read, Continues on ABT [Antibiotic Therapy] for UTI. No adverse reactions noted. temp [temperature] 97.3. Resting in bed with eyes closes. Review of Resident #19's progress note dated 7/24/2025 at 12:34 AM read, Due to the poor vitals, 911 was called. They assessed her and the resident was discharged to the hospital. Review of Resident #19's progress note dated 7/24/2025 at 1:25 PM read, patient aggressive behavior, attempting to hit at staff and push staff to stand up, educated on unsteadiness and being careful not to fall, patient replies I no fall, behavior inappropriate at this time. notified [Medical Doctor #1's name] that patient has not changed with cipro treatment for uti, asked [Medical Doctor #1's name] for a broad spectrum abt [antibiotics] while we wait for culture due to not noticing a change with patient since treatment started. new order Augmentin 500 mg bid [milligram twice a day] for 7 days. Review of Resident #19 progress note dated 7/24/2025 at 2:09 PM read, Resident was walking to the bathroom and fell from generalized weakness and fatigue. She has not been sleeping or eating well. Daughter and MD have been notified. She then refused to sit down and walk away from the winding saying she was waiting on someone. She then became combative. MD changed antibiotics for uti. No s/s or adverse reactions observed. Review of Resident #19's hospital note dated 7/25/2025 read, In the ED [Emergency Department], CT [Computed Tomography] abdomen pelvic shows no acute findings except for distended bladder, creatinine of 5.7, BUN [Blood Urea Nitrogen] 118, urinalysis with leuko esterase, concerning of mild UTI. Review of Resident #19's lab results with the collection date of 7/24/2025 and report date of 7/28/2025 documented urine culture with no growth after 48 hours. Review of laboratory order history for Resident #19 showed pending status for urinalysis w/reflex to culture on 7/11/2025, and on pending collection status on 7/14/2025 and on final status on 7/24/2024. During an interview on 7/30/2025 at 4:00 PM, the Medical Doctor #1 stated, We were in the process of finding out the reason behind [Resident #19 name] altered mental status since she was having signs of confusion. I gave the order [Urinalysis and culture and sensitivity] as a stat order. It should have been done as stat if not the same day the next day if possible. I ordered a broad-spectrum antibiotic while we were waiting for the results of the labs. From 7/14/2025 to 7/24/2025 is 10 day. The culture and sensitivity should have been done quicker. During an interview on 7/30/2025 at 4:25 PM, the DON stated, [Laboratory's name] comes Tuesday and Thursdays. They first started saying they come every day and now they only come Tuesdays and Thursdays. We have lots of problems with them. They came in on 7/11/2025 and collected the urine. The staff kept calling and they did not have the results. That is why we recollected on 7/14/2025. We have not done a performance improvement plan. The nurses kept calling to find out. Usually, the order will be placed once the urine is collected. During an interview on 7/30/2025 at 4:53 PM, Laboratory Medical Records Representative stated, Per our contract, we will collect STAT orders any day. We are not able to do cultures and sensitivity as a stat order. They have to be ordered as a regular run. The order was a stat order and the urine analysis was drop off at the hospital. Cultures take 72 hours and we are not allowed to leave it at the hospital. We let the nurses know they have to do a new order and collect for regular run. We will communicate this information via the chat when the nurse is placing the order. I see an order placed on 7/14/2025 and no new order or communication with us from the facility until 7/24/2025. During an interview on 7/31/2025 at 8:23 AM, the DON stated, The urine was collected and showed no bacteria, but we were awaiting the culture and sensitivity. [Resident #19's name] was having signs and symptoms and we got psych involved also. We thought it would be psych and they saw her and adjusted her medication. There was no bacteria in the urine. That is why the doctor did not order anything until we called and requested antibiotics to be ordered while we waited for the lab results. During an interview on 7/31/2025 at 10:04 AM, Staff F, Registered Nurse, stated, The culture and sensitivity was collected and it was invalid. On 7/21/2025, I reached out to the provider and started to try to get a urine specimen to send to the lab to get a culture and sensitivity. She shares a bathroom and even though we were trying, we were able to collect it on Wednesday night [7/23/2025] and the lab came that next Thursday morning [7/24/2025]. The urine culture came back with no growth. We reached out to the provider and kept waiting on the lab. Since she had behaviors mixed with UTI, we were trying to figure out what was the underlying cause. She was ordered antibiotics, but not all worked. Review of the facility policy and procedure titled Laboratory Services and Reporting with the last review date of 1/31/2025 read, Policy: The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. Policy Explanation and Compliance Guidelines: 1. The facility must provide or obtain laboratory services to meet the needs of its residents. 2. The facility is responsible for timeliness of the services.

Based on observation, interview, and record review, the facility failed to ensure food was properly stored in 1 of 2 nourishment rooms. Findings include: During an observation of the nourishment room on C Hall on 7/28/2025 at 9:35 AM, there were two unlabeled and undated plastic bags containing unknown food items in the freezer. There was unlabeled and undated cloth lunch box containing unknown food item in the refrigerator drawer. During an interview on 7/28/2025 at 9:37 AM, the Dietary Manager stated the food should have been labeled and dated. Review of the facility policy and procedure titled Use and Storage of Food Brought in by Family or Visitors with the last review date of 1/31/2025 read, Policy: It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the residents. Policy Explanation and Compliance Guidelines. 2. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated.

Based on observation and interview, the facility failed to maintain a clean and homelike environment for residents (Photographic evidence obtained). The findings include: During an observation of laundry room on 4/10/2024 at 2:50 PM with the Maintenance Director, Director of Housekeeping and Laundry, and Staff C, Laundry Assistant, one of the two washing machines was not working. In the washing machine room, there were linen cans with no covers, a large buildup of garbage, debris, and lint behind the washing machines, a window screen propped on the floor next to the working washing machine with a large amount of garbage and debris around it, and on debris and lint on the air conditioning unit. In the lint area of Dryer #1 and Dryer #2, there was a large buildup of dust and lint. In the drum of Dryer #2, there was a large buildup of brown, melted, unidentified matter. Dryer #2's door did not latch. In the bottom of the clean linen cart, there was a buildup of garbage and debris. The carts in the dryer room which held the clean linens were uncovered. During an interview on 4/10/2024 approximately at 2:55 PM, the Director of Housekeeping and Laundry stated the washing machine had been broken for a couple of weeks and it was affecting their ability to keep up with laundry needs. During an interview on 4/10/2024 approximately at 2:57 PM, the Maintenance Director stated there was a window air conditioning unit in the window, preventing the screen from fitting into the window properly, and stated that the facility never cleaned and scraped the dryer drums. During an interview on 4/10/2024 approximately at 3:00 PM, Staff C, Laundry Assistant, stated that the latch was broken. During an observation on 4/10/2024 approximately at 3:10 PM, inside the shower room on the C-Hallway, there was one disinfectant cleaner with bleach spray lying near a stack of towels, a drink, a package of cookies, and a cell phone on the sink counter. The freezer section of the specimen refrigerator located in the dirty utility room of the C-Hallway had a buildup of ice. Three ceiling vents located on the C-Hallway had a buildup of dust, lint, and a black substance. In the Medication Room on the C-Hallway, there were supply boxes stacked on top of the upper cabinets, reaching the ceiling. The wash sink in the soiled room on the B-Hallway was broken. During an interview on 4/10/2024 approximately at 3:15 PM, the Maintenance Director confirmed the findings and was unable to tell how long the wash sink had been broken.

Based on observation, interview, and record review, the facility failed to ensure nutritional interventions were provided in a timely manner for 1 of 6 residents reviewed for nutrition, Resident #4. The findings include: During an interview on 4/8/2024 at 10:27 AM, Resident #4 stated the food at the facility was cold and over seasoned and that she often asked for a substitute which was normally a sandwich. The resident stated she had lost weight since being admitted to the facility. Review of Resident #4's admission record showed the resident was admitted to the facility on [DATE] with diagnoses including diabetes, gastroesophageal reflux disease, and pressure injuries. Review of Resident #4's Minimum Data Set, dated dated dated [DATE] showed a Brief Interview of Mental Status score of 15, which indicated intact cognition. Review of Resident #4's care plan, last reviewed on 1/24/2024, showed the resident was at nutritional risk and was experiencing weight loss despite having a fair to good oral intake. Review of Resident #4's care plan, last reviewed on 3/12/2024, showed the resident was care planned for alteration in skin integrity related to stage 4 pressure ulcer on her sacrum with history of wound infection and is at ongoing risk for further breakdown. Review of Resident #4's weights showed 188 pounds on 10/10/2023, and 150 pounds on 4/9/2024, which indicated the resident had 20.21% weight loss since she was admitted to the facility. Review of Resident #4's Skin and Wound Notes documented by the Wound Nurse Practitioner revealed the post-debridement measurement of the wound was 2.1 x 0.9 x 0.2 centimeters (cm) on 4/9/2024 at 9:18 AM, 2.1 x 1.3 x 0.3 cm on 3/19/2024 at 8:30 AM, and 2.3 x 2.1 x 0.4 cm on 2/20/2024 at 8:27 AM. Review of Resident #4's Nutrition/Dietary Notes dated 11/16/2023 and 2/23/2024 revealed the Registered Dietitian was aware that the resident had lost weight and that her intervention was to provide snacks. Review of Resident #4's meal consumption log documented by the Certified Nursing Assistants revealed the resident ate 50-100% of all meals with the exception of three meals during a 30-day look back period. During observations on 4/8/2024, 4/9/2024, and 4/10/2024, Resident #4 consumed 60-80% of each of her meals. During an interview on 4/10/2024 at 8:45 AM, the Consultant Dietitian stated she was aware that Resident #4 had a significant weight loss and that she had not started supplements for her yet. She stated she saw the weight that had been done on 4/9/24.

Based on interview, document review, and review of facility policy, the facility failed to develop facility-specific policies and procedures with processes required, including a process for requesting an exemption, processes which included all requirements for medical exemptions, tracking temporary delay in vaccinations as well as the facility's contingency plan for staff that are not fully vaccinated. Eighty-seven of 111 staff were up to date on their COVID-19 vaccinations, two had been granted a medical exemptions, eight had been granted non-medical exemptions, and 14 had a temporary delay per the Centers for Disease Control and Prevention (CDC) for a compliance rate of 100%. This had the potential to affect all 69 residents of the facility, staff, and visitors. Findings include: Review of the facility policy titled, COVID-19 Vaccination, dated May 2021, revealed, .All residents and employees who have no medical contraindications or if they have not been immunized will be offered the COVID-19 vaccine to encourage and promote the benefits associated with vaccinations against COVID-19. The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents (or residents' legal representatives) for example, risk factors that have been identified for specific age groups or individuals with risk factors such as allergies or pregnancy .The COVID-19 vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated, or the resident or employee has already been immunized. Before offering COVID-19 vaccine, all residents and staff are provided with education regarding the benefits and risks and potential side effects associated with the vaccine .In situations where COVID-19 vaccination requires multiple doses, the resident, resident representative, or staff member is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects, associated with the COVID-19 vaccine, before requesting consent for administration of any additional doses . In addition, the facility policy revealed, .The facility maintains documentation related to staff COVID-19 vaccination that includes at a minimum .staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine .Staff were offered the COVID-19 vaccine or information on obtaining COVID-l9 vaccine .and the COVID-19 vaccine status of staff and related information as indicated by NHSN .If an employee refuses the vaccine for reasons other than medical contraindication, this shall be documented on the COVID-19 Vaccine Informed Consent document .The facility will maintain surveillance data on COVID-19 vaccine coverage and reported rates of COVID-19 among residents and staff. Surveillance data will be made available to staff as part of educational efforts to improve vaccination rates among employees . The facility's COVID-19 staff vaccination policies did not include specific process by which staff may request an exemption from the COVID-19 Health Care Staff vaccination requirements, including documentation of each staff who requests medical exemption, tracking and secure documentation of delayed staff vaccinations for clinical precautions/considerations, a process for which a contingency plan for staff that are not fully vaccinated for COVID-19, and what actions the facility will take such as a deadline for staff to receive their COVDI-19 vaccination and action if this deadline is not met. During an interview on 12/26/22 at 1:19 PM, the Administrator stated that she was aware that the Staff Vaccination policy was pretty generic and did not contain all of the required components, as required.

Based on interview and record review, the facility failed to notify residents when the amount in the resident's account reached $200 less than the SSI (Social Security Income) resource limit for 3 of 5 residents reviewed, Residents #37, #24, and #72, in a total sample of 40 residents. Findings: Review of Resident #37's Resident Trust Statement from 5/1/2020 to 6/3/2021 revealed an opening balance of $850.00 and an ending balance of $4,910.38. There was no documentation in the residents financial file informing the responsible party that the resident was over Medicaid resource limit. Review of Resident #24's Resident Trust Statement from 6/1/2020 to 6/4/2021 revealed an opening balance of $3511.80 and an ending balance of $8,212.42. There was no documentation in the residents financial file informing the responsible party that the resident was over Medicaid resource limit. Review of Resident #72's Resident Trust Statement from 6/1/2020 to 6/4/2021 revealed an opening balance of $4,146.79 and an ending balance of $7,008.43. There was no documentation in the residents financial file informing the responsible party that the resident was over Medicaid resource limit. During an interview on 6/9/2021 at 11:10 AM, the Business Office Manager stated she did not have any copies of letters in the residents financial file notifying them that they were approaching or were over the Medicaid resource limit. She also stated she did not have any return receipts for letters notifying responsible parties that the residents were over the Medicaid resource limit. Review of the facility policy titled Management of Resident Funds, revised on 2/15/2011, last reviewed on 1/21/2021, reads, The facility will provide written notification to each resident receiving Medicaid funds, or the resident's responsible party in cases where the resident is deemed to be incompetent, when the amount in the resident's account reaches $200.00 less than the maximum amount allowed under the Medicaid Program. The letter mailed to the responsible party must be sent certified with a return receipt. The letter to the resident or the responsible party will be filed in the resident's financial file. Likewise, all other communication with the resident or responsible party concerning spending down the resident's funds will be documented and filed in the financial folder.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 3 residents reviewed for accidents/safety, Resident #68, in a total sample of 40 residents. Findings: During an observation on 6/7/2021 at approximately 11:00 AM, Resident #68 was loudly yelling for help. She was in the bathroom in her room. Staff B, Certified Nursing Assistant (CNA), was in the bathroom with her, attempting to assist her to use the toilet. The resident, who is a double leg [CONDITION(S)], was attempting to transfer herself to the toilet from the wheelchair. The bathroom was small for a wheelchair, staff and this resident to transfer. There was a plastic [MEDICATION(S)] about 4 inches in height, on the toilet seat. Staff A, CNA, joined the group and noted the agitation of the resident. The [MEDICATION(S)] on the toilet seat was broken, where it attached to the toilet. The [MEDICATION(S)] was sliding off the toilet, causing the resident to nearly fall. The resident continued to yell for help. (Photographic evidence obtained) During an interview on 6/7/2021 at approximately 11:05 AM, Staff A, CNA, stated Resident #68 wanted to use the bathroom in the shower room, where she felt safer. She stated the resident almost fell off the toilet in her room a few minutes ago and was quite upset. She verified she was the assigned staff for the resident. She did not answer the question regarding reporting to the nurse or maintenance about the [MEDICATION(S)] being broken on the resident's toilet. During an interview on 6/7/2021 at approximately 11:25 AM, Resident #68 stated she should have the [MEDICATION(S)] on the toilet or she would fall. Observation of the hall shower room on 6/7/2021 at 11:30 AM, across from Resident #68's room, revealed no [MEDICATION(S)] on the toilet. The sink was removed from the wall leaving pipes and joints exposed. During an interview on 6/7/2021 at 1:13 PM, Resident #68 was at the nurse's station, asking for help to be toileted. She stated she wanted to use the shower bathroom but was told it was not ready yet. During an observation of Resident #68 on 6/7/2021 at 1:20 PM, she was yelling for help to go to the bathroom. She loudly stated she did not want to fall again. During an interview on 6/7/2021 at 1:23 PM, Staff A, CNA, stated they needed to try to get the proper [MEDICATION(S)] for the shower room toilet. During an interview on 6/7/2021 at approximately 1:35 PM, Staff C, Licensed Practical Nurse (LPN), stated the toilet in the shower room did not have a [MEDICATION(S)] and could not be used. The toilet [MEDICATION(S)] in Resident #68's bathroom was broken and could not be used. The toilet in the shower room broke over the weekend and it was fixed first thing this morning, but it still needs a [MEDICATION(S)]. The resident did not want to use the toilet in her bathroom because the [MEDICATION(S)] was broken on the toilet and the room was too small for her, the staff and her chair. During an observation of Resident #68 on 6/7/2021 at 1:49 PM with the Staff D, LPN, the resident was not toileted yet and Staff D was still trying to find an appropriate toilet. During an interview on 6/8/2021 at 7:45 AM, the Maintenance Director denied anyone told him they needed a [MEDICATION(S)] for the toilet in the shower room. He denied anyone informed him of the broken [MEDICATION(S)] on the toilet in Resident #68's room. During an interview on 6/8/2021 at 7:45 AM, the Administrator confirmed the lack of a safe toilet. Review of the facility policy titled Safety and Supervision of Residents, revised in July 2017, reads, Individual, Resident-Centered Approach to Safety: . 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Review of the facility policy titled Maintenance Service revised in December 2009, reads. Policy Interpretation and Implementation: . 2. Functions of maintenance personnel include, but are not limited to: . b. Maintain the building in good repair and free from hazards.

Based on observation, interview, and record review, the facility failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Findings: 1. On 6/7/2021 beginning at 9:20 AM, a tour with the Maintenance Director showed a missing sink in the shower room with exposed pipes and joints across Resident #68's room; broken closet door in Residents #24 and #47's room; saturated white towel with beige and brown discolorations, folded underneath the window air conditioner in Residents #57 and #60's room; major cracks in the sagging ceiling drywall, in the hall, outside the room door, and a brown mark on the white ceiling tiles in Resident #62 and #5's room. During an interview on 6/8/2021 at approximately 10:00 AM, the Maintenance Director verified the findings observed on the tour were in need of corrective action. During an interview on 6/8/2021 at approximately 3:00 PM, the Administrator stated he was aware of some of the findings. 2. On 6/8/2021 at 9:12 AM, the bathroom door of Resident #71's room was observed to have chipped wood at top corner and the door was hard to open and close. The door sticks at the upper top corner. (Photographic evidence obtained) During an interview on 6/9/2021 at 11:45 AM, the Maintenance Director confirmed the bathroom door was hard to open and close and stuck at the top corner. Review of the facility policy titled Maintenance Service revised in December 2009, reads. Policy Interpretation and Implementation: . 2. Functions of maintenance personnel include, but are not limited to: . b. Maintain the building in good repair and free from hazards . 8. The Maintenance Director is responsible for maintaining the following records/reports: . b. Work order requests.

Based on record review and interview, the facility failed to ensure the medical records were complete for 2 of 5 residents reviewed for nutrition, Residents #8 and #138, in a total sample of 40 residents. Findings: Review of Resident #8's clinical record revealed the resident was diagnosed with mild protein-calorie malnutrition and vitamin D deficiency. The resident weighed 143.5 pounds on 4/5/2021 and 133 pounds on 5/31/2021 (a 7.32 % weight loss). Further review of Resident #8's clinical record revealed the resident weighed 150 pounds on 12/3/2020 and 133 pounds on 5/31/2021 (an 11.33% weight loss). Review of Resident #8's care plan reads, Problem. Problem Start Date: 10/23/2020. Category: Nutritional Status. Resident at nutritional/hydration risk related to a dx. [diagnosis] of [CONDITION(S)], mild protein/calorie malnutrition. Good po [by mouth] intake this review, and a stable weight. Approach: Encourage a high po intake at all meals and record all findings. Review of Resident #8's Vitals Report from 5/8/2021 through 6/6/2021 for the amount of meals eaten revealed: 6/6/2021: Breakfast: 76% - 100%, Lunch: No data entered, Dinner: 76% - 100%. 5/31/2021: Breakfast: No data entered, Lunch: No data entered, Dinner: 76% - 100%. 5/24/2021: Breakfast: No data entered, Lunch: No data entered, Dinner: 51% - 75%. 5/19/2021: Breakfast: 76% - 100%, Lunch: No data entered, Dinner: 76% - 100%. 5/16/2021: Breakfast: No data entered, Lunch: No data entered, Dinner: 76% - 100%. 5/15/2021: Breakfast: No data entered, Lunch: No data entered, Dinner: No data entered. 5/13/2021: Breakfast: No data entered, Lunch: No data entered, Dinner: 26% - 50%. Review of Resident #138's clinical record revealed the resident weighed 109 pounds on 5/4/2021 and 97.2 pounds on 6/7/2021 (a 10.83% weight loss). Review of Resident #138's care plan reads, Problem. Problem Start Date: 05/07/2021. Category: Nutritional Status. Resident is at nutritional/hydration risk related to dx. [diagnosis] of dementia, diabetes, depressive disorder and a BMI [Body Mass Index] of 14.7. Approach: Encourage a high po [by mouth] intake at all meals and record all food intake. Review of Resident #138's Vital Records from 5/8/2021 through 6/6/2021 for the amount of meals eaten revealed: 6/6/2021: Breakfast: No data entered, Lunch: No data entered, Dinner: 76% - 100%. 5/31/2021: Breakfast: No data entered, Lunch: No data entered, Dinner: 76% - 100%. 5/24/2021: Breakfast: No data entered, Lunch: No data entered, Dinner: 76% - 100%. 5/21/2021: Breakfast: No data entered, Lunch: No data entered, Dinner: 76% - 100%. 5/19/2021: Breakfast: 51% - 75%, Lunch: No data entered, Dinner: 76% - 100%. 5/17/2021: Breakfast: 51% - 75%, Lunch: 51% - 75%, Dinner: No data entered. 5/16/2021: Breakfast: No data entered, Lunch: No data entered, Dinner: 51% - 75%. 5/15/2021: Breakfast: No data entered, Lunch: No data entered, Dinner: No data entered. 5/13/2021: Breakfast: No data entered, Lunch: No data entered, Dinner: 26% - 50%. During an interview on 6/9/2021 at 7:55 AM, Staff E, Registered Nurse (RN), stated that certified nursing assistants were responsible for recording the amounts eaten in the residents' records. She stated the amounts eaten for Resident #8 and Resident #138 were probably not recorded on a document other than the Vitals Report. During an interview on 6/9/2021 at 9:30 AM, the Director of Nursing acknowledged the amounts eaten data recorded in Resident #8's and Resident #138's vital records were incomplete. She verified the meal amount eaten data should be recorded and certified nursing assistants were responsible for recording intake of residents' meals.

Based on observation, interview, and record review, the facility failed to provide proper treatment and care to maintain good foot health for 1 of 3 residents reviewed for Activities of Daily Living (ADL) care, Resident #67, in a total sample of 40 residents. Findings: On 6/7/2021 at 10:25 AM, Resident #67 was observed lying on his bed, fully dressed, and bare feet. His toenails were observed to be long, and the toenails of his great toes were discolored, thick and long. On 6/8/2021 at 9:05 AM, Resident #67 was observed in bed, lying on his back, fully dressed and bare feet. His toenails were observed to be long, and the toenails of his great toes were discolored, thick and long. During an interview on 6/9/2021 at 9:56 AM, the Director of Nursing (DON) confirmed Resident #67 needed his toenails cut. She stated that he was not seen by the podiatrist when he was in on 4/14/2021. She also confirmed the resident had not seen a podiatrist yet. During an interview on 6/9/2021 at 10:14 AM, Staff I, Licensed Practical Nurse (LPN), stated that she was not aware that Resident #67 had long toenails. During an interview on 6/9/2021 at 10:15 AM, Staff C, LPN, Unit Manager, stated that she was just made aware of Resident #67's long toenails. She stated that residents were referred to the podiatrist and if they needed nail care between podiatrist visits, they were sent out to see a podiatrist in the community. Review of Resident #67's care plan reads, Problem. Problem Start Date: 04/12/2021. Category: ADL deficit related to poor decision making, very forgetful, requires redirection and reminders of tasks, potential for having a unkept appearance due to refusing assistance needed. Gait is unsteady but ambulates independently . Approach: . Set up and assist with AM/PM and prn [as needed] hygiene care to include brushing hair, wash face, assist with or provide nail care and shaving to ensure resident is neatly groomed. Review of Resident #67's physician's order dated 3/23/2021 reads, May have consultations for ophthalmology, podiatry, dental and optometry as needed. Review of Resident #67's physician's order dated 5/20/2021 reads May have consultations for ophthalmology, podiatry, dental and optometry as needed. Review of the facility policy titled Foot Care, revised in March 2018, last reviewed on January 21, 2021, reads, Policy Statement: Residents will receive appropriate care and treatment in order to maintain mobility and foot health. Policy Interpretation and Implementation: 1. Residents will be provided with foot care and treatment in accordance with professional standards of practice . 4. Trained staff may provide routine foot care (e.g. toenail clipping) within professional standards of practice for residents without complicating disease processes. Residents with food disorders or medical conditions associated with foot complications will be referred to qualified professionals.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 2 of 3 medication carts, and 1 of 2 medication storage rooms. Findings: On [DATE] at 9:06 AM, an observation of the 100 Hall medication cart showed one [MEDICATION(S)] insulin pen for Resident #52 that was not documented with the date the insulin was opened on the pen or the bag. During an interview on [DATE] at 9:14 AM, Staff I, Licensed Practical Nurse (LPN), stated, I do not know why the [MEDICATION(S)] insulin pen for Resident #52 did not show a date when the insulin was opened. He already had another open insulin pen in the cart. I am aware that the insulin is supposed to have a date to show when the insulin was opened. On [DATE] at 9:55 AM, an observation of the medication cart on the 300 Hall showed two prescription [MEDICATION(S)] tablets with no resident identifier. On [DATE] at 9:55 AM, an observation of the medication storage room showed two intravenous (IV) premixed [MEDICATION(S)] two grams for Resident #88, which expired on [DATE], and two concentrated (needing to be mixed) [MEDICATION(S)] two grams for Resident #88 with a bright yellow sticker that read do not refrigerate in the resident medication refrigerator. On the working stock shelf in the medication storage room, there was an open bottle of Aspercreme with [MEDICATION(S)] that was not documented with the date the medication was opened or with a resident identifier. During an interview on [DATE] at 10:07 AM, Staff G, Registered Nurse (RN), stated, I do not know who the two [MEDICATION(S)] tablets belong to. It is usually given at 6:00 AM. The [MEDICATION(S)] should be in a resident specific drawer. I was not aware that the two pre-mixed [MEDICATION(S)] were in the working stock area of the refrigerator expired on [DATE]. I do not know why the other [MEDICATION(S)] was in the refrigerator when the big yellow sticker clearly read do not refrigerate. I do not know who the bottle of Aspercreme belongs to. Review of the facility policy titled Storage of Medication, revised in [DATE] and last revised on [DATE] reads, Policy Interpretation and Implementation: . 5. Once any medications or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened.

Based on interview and record review, the facility failed to ensure 1 of 6 reviewed staff members, Staff D, was annually trained in abuse, neglect and exploitation as per the facility policy. Findings Include: Review of the facility policy titled Abuse Prohibition/Investigative Policy, revised in November 2016, reads, Training/Education. Training will be provided to all employees through orientation, annual education, and ongoing sessions about: - Appropriate intervention to deal with aggressive and/or catastrophic reactions of residents, - how staff should report their knowledge related to allegations without fear of reprisal, - how to recognize signs of burnout frustration and stress that may lead to abuse, - what constitutes abuse, neglect and misappropriation of resident property, - interacting with resident to maintain and enhance self esteem/self worth, - policies and procedures on protection, identification and reporting abuse, confidentiality and facility grievance process. Review of the facility's Employee Electronic Inservice Record revealed that Staff D, Housekeeping Aide, completed freedom from abuse, neglect and exploitation training on 10/29/2018. During an interview on 08/27/2020 at 4:30 PM, the Director of Operations confirmed that Staff D had not completed abuse, neglect and misappropriation of property training since 10/29/2018. She also confirmed that the training was supposed to be completed annually.

Based on observation, interview and record review, the facility failed to ensure 5 of 6 sampled residents, Residents #1, 2, 4, 5, and 6, who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal and oral hygiene. Findings include: 1. Review of Resident #1's clinical records revealed the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's activities of daily living report dated from 07/15/2020 to 07/21/2020 revealed two partial bed baths were given. On 07/28/2020 at 4:43 PM, during an observation of Resident #1, his hair was oily and matted, and his nails were dirty and overgrown. On 07/28/2020 at 5:44 PM, Resident #1 was observed in his room in a Broda chair wearing a facility gown, with his briefs and legs exposed. The sheet was crumpled to the side of the chair. His hair was unkempt. When he was asked to stick his tongue out, his tongue was crusty and red. His teeth had a dried dark crusty substance. No tray was observed in the room. It was located on the uneaten meal cart located outside of the room. Review of Resident #1's Minimum Data Set (MDS) with assessment reference date of 07/21/2020 revealed a Brief Interview for Mental Status (BIMS) score of 6 (indicating cognitive impairment). Section G revealed the resident required extensive assistance for ADLs including transfers: extensive assistance, two-person assist; dressing: extensive assistance, one-person assist; eating: extensive assistance, one-person support; toileting: extensive assistance, one-person support; personal hygiene: extensive assistance, one-person support; bathing: total dependence. During an interview on 07/29/2020 at 10:50 AM, Staff F, Certified Nursing Assistant (CNA), stated, I was assigned to take care of (Resident #1's name) today. I try to do ADL care for those residents that need it, but there is so much to do with everyone in their rooms all the time and sometimes I just can't get to it. 2. Review of Resident #2's clinical records revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. On 07/28/2020 at 04:30 PM, Resident #2 was observed in his room, sitting in a chair with his right leg elevated. A full leg cast was noted with his toes and forefoot exposed. The skin and nails of the foot were dry with soiled flaking dry skin. His hair was oily and matted. During an interview on 07/28/2020 at 5:10 PM, Resident #2 stated he couldn't recall exactly the last time he had a shower, but that he tried to wash his face and hands in the bathroom sink. Review of Resident #2's ADL report revealed the last recorded bath as 05/16/2020. No baths after that date were documented. Review of Resident #2's MDS revealed a BIMS score of 7 (indicating cognitive impairment). Section G coded bathing as 4 (total dependence). Review of Resident #2's care plan dated 05/19/2020 read, ADL deficit d/t (due to) recent revision for hardware repair recent patellar fracture. Currently non-weight bearing to Rt. (right) leg and requires staff assistance for safe transfers. Interventions: Restorative program for ROM (Range of Motion) as directed. Assist with setting up meal tray. Encourage resident to assist with ADL care as capable. Set up and assist with AM/PM and PRN (as needed). Hygiene care to include brushing hair, wash face, assist with or provide nail care, shaving to ensure resident is neatly groomed. Showers per schedule and (PRN) as needed or as requested. 3. During an interview on 07/29/2020 at 8:53 AM, Resident #4 stated that he had not had a shower for over a week and needed one. He stated he couldn't shower because the shower room was not available for them to use. Review of Resident #4's MDS dated [DATE] revealed a BIMS score of 13 (cognitively intact). Section G for personal hygiene was coded as supervision with one-person physical assist. Review of Resident #4's care plan with start date of 01/31/2020 read, ADL deficit related to requiring the use of a walker for ambulation. Interventions: encourage resident to assist with ADL care routinely as capable. Set-up and assist with AM/PM and as needed (PRN) hygiene care to include brushing hair, wash face, assist with or provide nail care, shaving. Shower per schedule and PRN (as needed) or as requested. Review of the physician's orders [REDACTED].#4 read, Resident shower choice is every Wednesday and Saturday - once a day on Wednesday and Saturday. 4. On 07/28/2020 at 5:06 PM, Resident #5 was observed sitting at the edge of her bed. Her hair was matted. During an interview on 07/28/2020 at 5:06 PM, Resident #5 stated she had not had a shower for over a week. When asked if she had a bed bath, she replied, No bath, no shower because there is not enough help. I tried to clean myself at the sink. Review of Resident #5's MDS dated [DATE] revealed BIMS score of 13 (cognitively intact). Section G revealed personal hygiene coded as extensive assistance with one-person physical assist. Review of Resident #5's care plan with a start date of 12/05/2018 read, Activity of daily living (ADL) deficit related to generalized weakness, tremors, has poor motivation. Requires encouragement to assist with ADLs. Interventions: Set-up and assist with AM/PM and PRN hygiene care to include brushing hair, wash face, assist with or provide nail care, shaving, motivate and encourage to do as much for herself as she can. Showers per schedule and PRN as needed or as requested. Encourage resident to assist with ADL care routinely as capable, praise for participation. On 07/29/2020 at 8:56 AM, Resident #5 was observed in bed, awake, and with matted hair. During an interview on 07/29/2020 at 8:56 AM, Resident # 5 stated she had not received a shower yet. Review of the physician's orders [REDACTED].#5 read, [MEDICATION NAME] shampoo 2% once a day on Mondays and Thursdays. 5. During an interview on 07/28/2020 at 3:43 PM, Staff A, CNA, stated she had ten residents. She stated there was not enough staff and no shower had been provided since last Monday (9 days prior to survey date). Staff A stated she did not give any shower to any of her 10 residents today. When asked if she provided bed bath to her residents today, Staff A replied, some. On 07/28/2020 at 4:02 PM, Resident #6 was observed with his fingernails unclean, with black colored sediments under the nails. His hair was matted. During an interview on 07/28/2020 at 4:03 PM, Resident # 6 stated no one had offered to clean or trim his fingernails or offered a shower. During an interview on 07/28/2020 at 4:35 PM, Staff E, CNA, stated, We are short with help. I did not provide any shower to any of my 10 residents but gave a partial bath. We stopped giving showers since over a week ago, we were told by management not to give showers. During an interview on 07/29/2020 at 8:38 AM, Staff G Regional Nurse Consultant, stated she directed the nursing staff to stop giving showers until they have developed a cleaning process to sanitize the public shower room in between resident use. Showers have not been provided for the past two weeks, the facility had not yet developed a cleaning process, and the facility did not have a shower schedule. On 07/29/2020 at 11:57 AM, Resident #6 was observed seated at the edge of his bed attending to his laptop. His hair was matted. During an interview on 07/29/2020 at 11:57 AM, Resident #6 stated, I need a shower very badly. I have not had a shower for over a week. I will ask the girl if I can get a shower today. Review of Resident #6's MDS dated [DATE] revealed personal hygiene was coded as extensive assistance of one-person physical assist. Review of Resident #6's care plan with a start date of 08/10/2018 read, ADL deficit related to requiring staff assistance with ADLs. He has contractures of his left knee and is non-ambulatory. He has long hair and often looks unkempt and at times needs encouragement for showers. Interventions: Set-up and assist with AM/PM and as needed (PRN) hygiene care to include brushing hair, wash face, assist with or provide nail care, shaving, motivate and encourage to do as much for herself as she can. Showers per schedule and PRN as needed or as requested. Encourage resident to assist with ADL care routinely as capable, praise for participation. Review of the physician's orders [REDACTED].#6 read, Resident preferred shower choice is every Mondays and Thursdays on 7-3 shift. Once a day on Mondays and Thursdays. Review of the facility ADL policy and procedure read, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: 1. Hygiene Bathing, dressing, grooming, and oral care), 2. Mobility (transfer and ambulation, including walking), 3. Elimination (Toileting), 4. Dining (meals and snacks); and 5. Communication (functional communication systems).