Every finding on record at Lakeview Terrace Rehab and Health Care Center

Based on record review and interview, the facility failed to ensure the arbitration agreement included the required elements for 3 of 3 residents reviewed for arbitration (Residents #11, #36, and #35). Findings include:Review of Skilled Nursing Facility admission and Financial Agreement for Resident #11 entered into on 7/8/2025 between the facility and Resident #11 showed it contained a section titled 44. Dispute Resolution, which did not contain the information specifying that signing the dispute resolution was not a requirement of admission or continuing care; the resident or representative could rescind the dispute resolution within 30 days of signing; the resident was not prohibited from communicating with other entities or agencies; the arbitration would be held in a location convenient to both parties; and the resident or representative understood the dispute resolution agreement.Review of Skilled Nursing Facility admission and Financial Agreement for Resident #35 entered into on 12/11/2025 between the facility and Resident #35 showed it contained a section titled 44. Dispute Resolution, which did not contain the information specifying that signing the dispute resolution was not a requirement of admission or continuing care; the resident or representative could rescind the dispute resolution within 30 days of signing; the resident was not prohibited from communicating with other entities or agencies; the arbitration would be held in a location convenient to both parties; and the resident or representative understood the dispute resolution agreement.Review of Skilled Nursing Facility admission and Financial Agreement for Resident #36 entered into on 9/22/2025 between the facility and Resident #35 showed it contained a section titled 44. Dispute Resolution, which did not contain the information specifying that signing the dispute resolution was not a requirement of admission or continuing care; the resident or representative could rescind the dispute resolution within 30 days of signing; the resident was not prohibited from communicating with other entities or agencies; the arbitration would be held in a location convenient to both parties; and the resident or representative understood the dispute resolution agreement. During interview on 10/2/2025 at 8:08 AM, the Clinical Liaison confirmed the admission agreement with dispute resolution entered into by Resident #11, Resident #35 and Resident #36 was the arbitration agreement in effect at the facility.

Based on record review and interview, the facility failed to ensure the arbitration agreement provided for the selection of a venue convenient to both parties for 3 of 3 residents reviewed for arbitration (Residents #11, #36, and #35).Findings include:Review of Skilled Nursing Facility admission and Financial Agreement for Resident #11 entered into on 7/8/2025 between the facility and Resident #11 showed it contained a section titled 44. Dispute Resolution, which failed to specify that the arbitration would be held in a location convenient to both parties.Review of Skilled Nursing Facility admission and Financial Agreement for Resident #35 entered into on 12/11/2025 between the facility and Resident #35 showed it contained a section titled 44. Dispute Resolution, which failed to specify that the arbitration would be held in a location convenient to both parties.Review of Skilled Nursing Facility admission and Financial Agreement for Resident #36 entered into on 9/22/2025 between the facility and Resident #35 showed it contained a section titled 44. Dispute Resolution, which failed to specify that the arbitration would be held in a location convenient to both parties.During interview on 10/2/2025 at 8:08 AM, the Clinical Liaison confirmed the admission agreement with dispute resolution entered into by Resident #11, Resident #35 and Resident #36 was the arbitration agreement in effect at the facility.

Based on observation and interview, the facility failed to ensure accurate nurse staffing data was posted on a daily basis.Findings include:During an observation on 9/29/2025 at approximately 9:50 AM, the nurse staffing report posted on the Skilled Nursing Unit documented the resident census as 39 (Photographic evidence obtained).During an interview on 9/29/2025 at 9:51 AM, Staff C, Licensed Practical Nurse (LPN), stated that the posted staffing was not correct and the census should have been documented as 29 and it should be corrected.During an interview on 9/30/2025 at 1:43 PM, the Director of Nursing (DON) stated that the expectation was the daily staffing sheet was to be completed by the 11-7 shift [11:00 PM - 7:00 AM] and that the resident census was based on the midnight census. It was not possible that the midnight census on 9/29/2025 was 39, as was documented on the staffing report.

Based on observation, interview, and record review, the facility failed to ensure food was properly stored in 2 of 2 service kitchens (Rehabilitation Unit kitchen and Skilled Nursing Unit kitchen) and failed to ensure food was prepared in a sanitary manner. Findings include:During an observation on 9/29/2025 at 9:55 AM, there were four frozen individually wrapped packages of pancakes in a clear plastic packaging with no label inside of a plastic bin with no label or date inside of a freezer located in the skilled nursing facility kitchen.During an interview on 9/29/2025 at 9:55 AM, Staff F, Certified Dietary Manager (CDM), stated, We did not serve pancakes for breakfast today. We served waffles.During an observation on 9/29/2025 at 10:20 AM, there were one opened container of chocolate syrup, one opened container of mayonnaise, one opened container of hot sauce, and one opened sweet relish the Rehabilitation Unit refrigerator, which were not labeled with opened or discard by dates (Photographic evidence obtained).During an interview on 9/29/2025 at 10:20 AM, Staff F, CDM, stated, Food items and condiments should always be labeled with the date after opening. Review of the facility policy and procedure titled Food Storage with the last review date of 1/17/2025 read, Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants . Procedure: 8. Plastic containers with tight fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated . 13. Refrigerated food storage . f. All foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use dates, or frozen (where applicable) or discarded. During an observation on 9/30/2025 at 12:40 PM, Staff D, Dietary Lead Cook, placed beef into a food processor, pushed a button on the blender, then removed the canister from the food processor, and continued plating food for lunch service for the residents. Staff D then walked to a cabinet, retrieved a stack of dishes from the cabinet, and resumed plating the food. Staff D then passed a plate of food to a staff member with her right gloved thumb touching the inner food contact surface of the plate. Staff D then wiped her gloved thumb on a white towel, which was sitting on the tray line. Staff D then used the same white towel to wipe the top edge of a plate of food. Staff D picked up a baked potato with her gloved right hand and sliced the potato. Staff D did not perform hand hygiene or don new gloves before beginning each new task.During an interview on 9/30/2025 at 12:50 PM, Staff F, CDM, confirmed that the Dietary Lead [NAME] should have removed her gloves, washed her hands, and changed into new gloves before beginning new tasks.Review of the facility policy and procedure titled Hand Hygiene/Hand Washing with the last review date of 1/17/2025 read, Purpose: To prevent transmissible infections and prevent contamination by bloodborne pathogens. Hand washing is the single most effective deterrent to the spread of infection . Procedure: 1. All staff shall perform hand hygiene to prevent the spread of infection. Before handling clean equipment or supplies; Before and after serving food.

Based on record review and interview, the facility failed to coordinate assessments for the residents with newly evident or possible serious mental disorder for 1 of 3 residents reviewed for mood and behavior (Resident #6).Findings include:Review of Resident #6's admission record showed the resident was admitted on [DATE] with diagnoses that included major depressive disorder (onset date of 3/28/2023), adjustment disorder with mixed anxiety and depressed mood (onset date of 1/4/2024), and primary insomnia (onset date of 4/20/2023).Review of Resident #6's Preadmission Screening and Resident Review (PASRR), completed on 12/16/2024, did not include major depressive disorder, adjustment disorder with mixed anxiety and depressed mood, and primary insomnia as mental illness under Section I: PASRR Screen Decision-Making.Review of Resident #6's psychiatry subsequent note dated 9/10/2025 read, Chief Complaint: Depression, anxiety, dementia, insomnia, mood disorder, psychosis and Parkinsonism. Diagnostic Assessment and Plan: Major depressive disorder, generalized anxiety disorder, Dementia without behavioral disturbance, other specified persistent mood disorders, Parkinsonism, primary insomnia, brief psychotic disorder. Rationale behind diagnosis: MDD [Major Depressive Disorder], Recurrent: The history suggests that this patient has suffered from episodes of depression lasting for more than 2 weeks. The symptoms have caused significant distress and functional impairment to the patient and they have occurred without any underlying substance use or organic brain pathology. Mood Disorder: The history suggests that the patient has experienced severe mood swings causing emotional distress. As the mood swings are severe requiring monitoring and as needed intervention, the patient qualifies for that diagnosis. Insomnia: The history suggests that the patient has suffered from significant sleep problems. The sleep disturbance is not attributable to the physiological effects of a substance (e.g. [for example] a drug of abuse, a medication) or another medical condition.During interview on 10/1/2025 at 8:35 AM, the Director of Nursing confirmed Resident #6's PASRR completed on 12/16/2024, did not include major depressive disorder, adjustment disorder with mixed anxiety and depressed mood and primary insomnia.

Based on record review and interview, the facility failed to ensure medical records were complete and accurate regarding medication administration and blood sugar monitoring for 1 of 5 residents reviewed for unnecessary medications (Resident #2).Findings include:Review of Resident #2's physician order dated 9/3/2025 read, Accu-check blood sugar monitoring, two times a day.Review of Resident #2's Medication Administration Record (MAR) for blood sugar monitoring two times a day (discontinued on 9/19/2025 at 2:07 PM) for September 2025 revealed the resident refused the blood sugar check on 9/6/2025 at 9:00 AM and 9:00 PM, 9/7/2025 at 9:00 AM, 9/8/2025 at 9:00 AM, 9/9/2025 at 9:00 AM and 9:00 PM, 9/10/2025 at 9:00 PM, 9/11/2025 at 9:00 PM, 9/12/2025 at 9:00 AM and 9:00 PM, 9/13/2025 at 9:00 AM and 9:00 PM, 9/14/2025 at 9:00 PM, 9/15/2025 at 9:00 AM and 9:00 PM, 9/16/2025 at 9:00 AM and 9:00 AM, 9/17/2025 at 9:00 AM and 9:00 PM, 9/18/2025 at 9:00 AM and 9:00 PM, and 9/19/2025 at 9:00 AM.Review of Resident #2's physician order dated 9/19/2025 read, Accu-check blood sugar monitoring, twice a day 0630 [6:30 AM] and 2100 [9:00 PM] two times a day.Review of Resident #2's MAR for blood sugar monitoring twice a day at 6:30 AM and 9:00 PM for September 2025 revealed the resident refused the blood sugar check on 9/19/2025 at 9:00 PM, 9/20/2025 at 6:30 AM and 9:00 PM, 9/21/2025 at 9:00 PM, 9/22/2025 at 6:30 AM and 9:00 PM, 9/23/2025 at 6:30 AM, 9/24/2025 at 6:30 AM and 9:00 PM, 9/25/2025 at 9:00 PM, 9/26/2025 at 9:00 PM, 9/27/2025 at 6:30 AM and 9:00 PM, 9/28/2025 at 6:30 AM and 9:00 PM, 9/29/2025 at 6:30 AM; 9/29/2025 at 9:00 PM, 9/30/2025 at 9:00 PM.Review of Resident #2's physician order dated 9/19/2025 read, Accu-check blood sugar monitoring, twice a day 0630 [6:30 AM] and 2100 [9:00 PM] two times a day.Review of Resident #2's physician order dated 8/28/2025 read, Lantus SoloStar 100 unit/ml [milliliter] Solution pen-injector, Inject 10 unit subcutaneously at bedtime related to type 2 diabetes mellitus with other specified complication.Review of Resident #2's physician order dated 8/28/2025 read, Insulin Glargine Subcutaneous Solution 100 unit/ml (Insulin Glargine), Inject 10 unit subcutaneously at bedtime related to type 2 diabetes mellitus with other specified complication.Review of Resident #2's MAR for administration of Insulin Glargine for August 2025 revealed the resident refused the medication on 8/28/2025.Review of Resident #2's MAR for administration of Insulin Glargine for September 2025 revealed the resident refused the medication on the following dates: 9/9/2025, 9/10/2025, 9/11/2025, 9/12/2025, 9/14/2025, 9/15/2025, 9/18/2025, 9/19/2025, 9/20/2025, 9/21/2025, 9/22/2025, 09/24/2025, 9/25/2025, 9/26/2025, 9/27/2025, 9/28/2025, 9/29/2025, and 9/30/2025.Review of Resident #2's progress notes for September 2025 revealed no documentation of notification to or communication with Resident #2's primary care provider/physician regarding refusal of blood sugar monitoring and insulin administration.During an interview on 9/30/2025 at approximately 2:00 PM, Staff A, Licensed Practical Nurse (LPN), stated that the doctor was aware that Resident #2 was refusing his accu-checks and his insulin, but that according to his family, he had not had the same behavior at home. The doctor wanted the insulin given even if the resident refused to have his blood sugar checked. His blood sugars, when they were able to check them, were usually pretty stable.During an interview on 9/30/2025 at 2:30 PM, the Director of Nursing (DON) stated that residents had the right to refuse treatments or medications. If a resident refused three days in a row, they were supposed to notify the physician.During an interview on 10/1/2025 at 10:00 AM, Staff B, LPN, stated that if a resident refused a medication, she would attempt multiple times to administer it, because sometimes they would change their mind, and she knew it was better for the resident and her, if they took the medicine. If they continued to refuse the medication, she would follow the protocol which was to call the doctor and write a note.During an interview on 10/1/2025 at approximately 11:00 AM, Staff A, LPN, stated that regarding Resident #2 refusing his accu-checks and/or insulin, she communicated with the physician by writing a note in the physician communication binder at the nurses' station.During an interview on 10/1/2025 at 2:15 PM, the DON stated that she had reviewed Resident #2's chart and the Physician Communication Binder. The DON confirmed a number of occurrences where Resident #2 had refused either his accu-check and/or his insulin injection, and that there was no documentation except for the codes used on the MAR to indicate the resident had refused. The DON's previous statement regarding the policy of notifying the physician after a resident refused medication or treatment for three days, was an inaccurate statement and pertained to a policy from a facility where she worked previously.During an interview on 10/1/2025 at 3:59 PM, Staff E, LPN, stated that if a resident refused medication, she would educate them about what the medication was and why they needed it. She would let the doctor know. She would call them (the doctors) and document it.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration when required to prevent the possible spread of infection and communicable diseases.Findings include:During an observation on 10/1/2025 at 10:00 AM, Staff B, Licensed Practical Nurse (LPN), was preparing oral medications for Resident #25. Staff B touched a Ferrous Sulfate tablet with her ungloved hand. During administration, Resident #25 dropped a tablet from the medication cup into her lap. Staff B picked up the tablet with her ungloved hand and handed it to Resident #25 for oral administration.During an interview on 10/1/2025 at 10:08 AM, Staff B, LPN, stated that she usually attempted to just pour the pills out of the bulk bottle into the bottle lid and then into the cup because she knew she was not supposed to touch the medications. Staff B confirmed that she used her ungloved hand to pick up a tablet and hand it to Resident #25.During an interview on 10/2/2025 at approximately 9:00 AM, the Director of Nursing (DON) stated that the expectation was during medication administration, nurses should perform hand hygiene, wear gloves, and if a pill dropped onto an unclean surface, such as in a resident's lap, identify the pill, discard it, and replace the pill. If the nurse was not able to identify the pill, notify the physician, and write an incident report. Nurses should not touch medications with their hands.Review of the facility policy and procedure titled Administering Medications with the last approval date of 1/17/2025 read, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 25. Staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications. Review of the facility policy and procedure titled Hand Hygiene/Hand Washing, with the last approval date of 1/17/2025 read, Purpose: To prevent transmissible infections and prevent contamination by bloodborne pathogens. Hand washing is the single most effective deterrent to the spread of infection. Procedure: 1. All staff shall perform hand hygiene to prevent the spread of infection. Before and after assisting with medications; After contact with contaminated material or surfaces, even if gloves are worn.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration for 6 of 10 medication administration observations to prevent the possible spread of infection and communicable disease. Findings include: 1. During an observation on 7/10/2024 at 5:55 AM, Staff E, Licensed Practical Nurse (LPN), exited the nurses' station and went to the medication cart, removed keys from her pocket, unlocked the medication cart and prepared Resident #140's medications without performing hand hygiene. Staff E donned gloves without performing hand hygiene and locked the medication cart with her gloved hand. Staff E knocked on Resident #140's room door with her gloved hand, entered the resident's room, used the bed controls to adjust the height of the head of the bed with her gloved hands and administered Resident #140's oral medications. Staff E then pulled a syringe and alcohol swab out of her pocket with her gloved hand, cleaned Resident #140's arm with alcohol and administered medication to the resident. Staff E doffed her gloves and exited the room without performing hand hygiene and returned to the medication cart to prepare medications for another resident. During an observation on 7/10/2024 at 6:05 AM, Staff E, LPN, returned to the medication cart and began preparing medications for Resident #9 without performing hand hygiene. Staff E entered the resident's room, adjusted the overbed table and used the bed control to adjust the height of the head of the bed. Staff E administered the medications and exited the room without performing hand hygiene, returning to the medication cart to prepare medications for another resident. During an observation on 7/10/2024 at 6:15 AM, Staff E, LPN, returned to the medication cart and began preparing medications for Resident #23 without performing hand hygiene. Staff E donned gloves without performing hand hygiene, removed keys from her pocket and locked the medication cart with her gloved hand. Staff E knocked on the resident's room door with her gloved hand, entered the resident's room, adjusted the overbed table and used the bed controls to adjust the height of the head of the bed and administered the oral medication. Staff E then opened the nightstand, and removed respiratory equipment with her gloved hand, poured the medication into the passive nebulizer and adjusted the nebulizer mask on Resident #23's face. Staff E doffed her gloves and exited the room after the nebulizer was completed without performing hand hygiene. During an interview on 7/10/2024 at 6:50 AM, Staff E, LPN, stated, I should have used hand sanitizer before I put on gloves and before I did my medications. 46523 2. During an observation on 7/8/2024 at 9:54 AM, Resident #17's Wife asked Staff A, LPN, for lotion due to the resident being itchy. Staff A went to the medication cart and returned with a bottle of lotion and handed it to Resident #17's wife. Staff A returned to the medication cart and removed a nicotine patch for Resident #20 without performing hand hygiene. Staff A followed the Physical Therapist and Resident #20 into the resident's room and without performing hand hygiene, removed the nicotine patch from the package and placed the nicotine patch on Resident #20. Staff A exited Resident #20' room and returned to the medication cart and began preparing medications for Resident #15 without performing hand hygiene. Staff A entered the resident's room and administered the medications to the resident without performing hand hygiene. Staff A exited Resident #15's room without performing hand hygiene and returned to the medication cart. During an interview on 7/8/2024 at 10:10 AM, Staff A, LPN, stated, I should have done hand hygiene in between each resident. I think I did hand hygiene for one of them, but I cannot honestly remember. During an interview on 7/10/2024 at 8:47 AM, the DON stated, Staff is expected to perform hand hygiene in between each resident. Review of the facility policy and procedure titled Administering Medications with the last approval date of 1/19/2024 read, Policy Interpretation and Implementation . 25: Staff follows established infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the facility policy and procedure titled Hand Hygiene/Hand Washing with the last approval date of 1/19/2024 read, Purpose: To prevent transmissible infections and prevent contamination by bloodborne pathogens. Hand washing is the single most effective deterrent to the spread of infection . Procedure: 1. All staff shall perform hand hygiene to prevent the spread of infection. When coming on shift; Before applying and after removing gloves; Before and after each Resident contact or touching Resident surroundings (before and after resident contact, includes going between residents during dinner, activities and direct care); Before and after assisting with medications.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 2 of 3 residents reviewed for respiratory services, Residents #3 and #23. Findings include: 1. Review of Resident #3's admission record showed the resident was most recently admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unspecified dementia, hypertensive heart and chronic kidney disease without heart failure, chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery, and stage 3B chronic kidney disease. Review of Resident #3's physician order dated 2/24/2023 read, Oxygen at 2.5 LPM [liters per minute] via nasal cannula PRN [as needed] for O2 sats [oxygen saturation] below 90% as needed related to facial weakness following cerebral infraction. Review of Resident #3's Weights and Vitals Summary for O2 sats summary showed the resident received oxygen via nasal cannula on 5/21/2024 at 1:47 PM and 11:48 PM, on 5/22/2024 at 2:00 PM, on 5/23/2024 at 3:34 PM, on 5/24/2024 at 11:57 PM, on 5/25/2024 at 7:27 AM and 3:33 PM, on 5/26/2024 at 7:32 AM and 3:22 PM, on 5/28/2024 at 12:00 AM, on 5/29/2024 at 4:01 PM, on 5/30/2024 at 8:21 PM and 3:15 PM, on 5/31/2024 at 7:40 AM and 3:54 PM, and on 6/2/2024 at 7:09 PM. Review of Resident #3's Quarterly MDS dated [DATE] read, Section O0110- Special Treatments, Procedures, and Programs . C1. Oxygen therapy . B. While a Resident: No. During an interview on 7/9/2024 at 1:35 PM, the MDS Coordinator stated, [Resident #3's name] has orders for oxygen and checking of saturation. I do see where it was coded no on the MDS. It should be changed to yes. 41334 2. Review of Resident #23's admission record showed the resident was most recently admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease (COPD), unspecified atrial fibrillation, cerebral infarction due to embolism of right middle cerebral artery, essential (primary) hypertension, cerebral aneurysm, other seizures, and anemia. Review of Resident #23's physician order dated 11/17/2023 read, Oxygen at 2 LPM [liters per minute] via nasal cannula continuously every shift. Review of Resident #23's care plan initiated on 11/20/2023 and last revised on 6/14/2024 read, Focus: [Resident #23's name] receives oxygen therapy r/t [related to] COPD, shortness of breath . Interventions . Oxygen Settings: O2 @ [at] 2 LPM via NC [nasal cannula] as ordered. During an observation on 7/8/2024 at 9:38 AM, Resident #23 was resting in bed, administered oxygen via nasal cannula. During an observation on 7/8/2024 at 12:08 PM, Resident #23 was resting in bed, administered oxygen via nasal cannula. During an observation on 7/9/2024 at 12:02 PM, Resident #23 was resting in bed, administered oxygen via nasal cannula. Review of Resident #23's Quarterly MDS dated [DATE] read, Section O0110- Special Treatments, Procedures, and Programs . C1. Oxygen therapy . B. While a Resident: No. During an interview on 7/10/2024 at 10:15 AM, the MDS Coordinator stated, She [Resident #23] has been on oxygen since November of last year. The MDS is not correct. It should have been documented correctly. Review of the facility policy and procedure titled Initial Assessment- MDS (Minimum Data Set) with the last review date of 1/29/2024 read, Procedures: 1. A Comprehensive assessment (MDS) will be developed for all residents based on resident needs, strengths, goals, life history and preferences utilizing the Resident Assessment Instrument. It will be developed in collaboration with the IDT [Intradisciplinary Team], resident and coordinated to include PASRR [Preadmission Screening and Resident Review] recommendations. It will include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts . 7. All staff participating in completion of this assessment must sign to certify that all above information is correct and truthful to the best of their knowledge or face monetary penalties.

Based on record review and interview, the facility failed to ensure comprehensive person-centered care plans were developed for 3 of 12 residents reviewed, Residents #2, #3, #33. Findings include: Based on record review and interview, the facility failed to ensure comprehensive person-centered care plans were developed for 3 of 12 residents reviewed, Residents #2, #3, and #33. Findings include: 1. Review of Resident #33's admission record documented the resident was most recently admitted on [DATE] with diagnoses that included chronic atrial fibrillation, essential (primary) hypertension, arthritis, generalized anxiety disorder, muscle weakness (generalized), unsteadiness on feet, and major depressive disorder. Review of Resident #33's physician order dated 2/9/2024 read, Eliquis Oral Tablet 5 mg [milligram] (Apixaban), Give one tablet by mouth every 12 hours for A-fib. Review of Resident #33's care plan dated 5/16/2024 showed no focus or intervention related to anticoagulant therapy. During an interview on 7/9/2024 at 2:55 PM, the MDS Coordinator stated, I don't see she [Resident #33] was care planned for anticoagulant therapy. 46523 2. Review of Resident #3's admission record showed the resident was most recently admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and allergic dermatitis of unspecified eye (onset date of 3/18/2024). During an interview on 7/8/2024 at 9:19 AM, Resident #3's Wife stated, Now that he [Resident #3] is blind, I will go with him to the activities or to participate in exercise activities and he can hear what they are saying, but I assist him in doing the actual activities. During an interview on 7/9/2024 at 12:59 PM, Staff B, Licensed Practical Nurse (LPN), stated, [Resident #3's name] has an eye condition and something happened that he lost his vision. He is able to see now a bit more, but we have to get really up close to him in order for him to recognize us. [Resident #3's name] is alert and oriented and his wife is here day and night. She is very involved. We will always let him know what we will be doing and assist him. He [Resident #3] is able to verbally communicate with us. Review of Resident #3's Quarterly Minimum Data Set (MDS) dated [DATE] read, Section B- Hearing, Speech, and Vision . B100. Vision: 3. Highly Impaired. Review of Resident #3's physician note dated 4/26/2024 read, Assessments . 6. Encounter for examination of eyes and vision with abnormal findings. Treatment . 6. Encounter for examination of eyes and vision with abnormal findings: Notes: Opthomology [Sic.] referral to evaluate eyes as wife reports that patient is now blind from one eye. Review of Resident #3's care plan showed no focus or interventions for vision impairment. During an interview on 7/9/2024 at 1:30 PM, the MDS Coordinator stated, Based on [Resident #3's name] diagnosis and MDS coding, I should have made an entry for vision with interventions for safety. I do not see a focus for vision on [Resident #3's name] care plan and there should be a separate entry for this. 3. Review of Resident #2's admission record showed the resident was most recently admitted on [DATE] with diagnoses that included unspecified dementia, major depressive disorder, and bipolar disorder. Review of Resident #2's physician order dated 2/1/2024 read, Divalproex Sodium Capsule Delayed Release Sprinkle 125 mg [milligrams], Give 250 mg by mouth one time a day for Bipolar HX [history] of. Review of Resident #2's physician order dated 2/1/2024 read, Divalproex Sodium Capsule Delayed Release Sprinkle 125 mg, Give 375 mg by mouth at bedtime for bipolar HX of. Review of Resident #2's Quarterly MDS dated [DATE] showed bipolar disorder under Section I. Active Diagnoses. Review of Resident #2's physician progress note dated 3/5/2024 read, Assessments . 5. Bipolar disorder, current episode mixed, mild. Treatment . 5. Bipolar disorder, current episode mixed, mild. Notes: Continue current medication. Monitor for increased or new onset major depression symptoms (i.e. tearfulness, sadness, change in appetite, self-isolation), manic/hypomania episodes, decreased sleep, flight of ideas, or functional impairment- if these symptoms exacerbate or are new onset call MD/ARNP [Medical Doctor/ Advance Registered Nurse Practitioner] immediately. Psych consulted as needed. Review of Resident #2's psychiatry subsequent note dated 3/15/2024 read, Chief complaint: Depression, dementia, and bipolar disorder . History of Present Illness: This is an [AGE] years old patient with past psychiatrics history of depression, dementia and bipolar disorder. Prior to last visit, patient had mood swings. Patient had sundowning. Patient was irritable. Signs and symptoms related to depression or anxiety were not observed. Patient was sleeping and eating well without trouble. Increased Depakote to 375 mg QHS [once a day at bedtime] for behaviors/agitation. During an interview on 7/9/2024 at 1:45 PM, the MDS Coordinator stated, [Resident #2's name] has a history of bipolar disorder and should have been care planned for a separate entry for the diagnosis. During an interview on 7/10/2024 at 8:40 AM, the Director of Nursing stated, [Resident #2's name] has a diagnosis of bipolar disorder and is followed by psych. Review of the facility policy and procedure titled Resident-Centered Care Planning with the last review date of 1/19/2024 read, Purpose: To provide comprehensive and Person-Centered care and services so that residents attain or maintain the highest practical physical, mental and psychological well-being. Standards . A comprehensive Person-Centered care plan must be developed for each resident that includes measurable objectives and timetables . Procedures . 5. The comprehensive care plan shall be developed collaboratively with input from the IDT [Intradisciplinary Team], including the resident or resident representative to the extent possible. It shall include the following: a. Measurable goals and time frame to meet a resident's medical, nursing, and mental and psychological needs identified in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure residents received oxygen as ordered by the physician for 1 of 3 residents reviewed for respiratory care, Resident #23. Findings include: Review of Resident #23's admission record showed the resident was most recently admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease (COPD), unspecified atrial fibrillation, cerebral infarction due to embolism of right middle cerebral artery, essential (primary) hypertension, cerebral aneurysm, other seizures, and anemia. Review of Resident #23's physician order dated 11/17/2023 read, Oxygen at 2 LPM [liters per minute] via nasal cannula continuously every shift. During an observation on 7/8/2024 at 9:38 AM, Resident #23 was resting in bed, being administered oxygen at 4 liters per minute via nasal cannula on oxygen concentrator. During an observation on 7/8/2024 at 12:08 PM, Resident #23 was resting in bed, being administered oxygen at 4 liters per minute via nasal cannula. During an observation on 7/9/2024 at 12:02 PM, Resident #23 was resting in bed, being administered oxygen at 4 liters per minute via nasal cannula on oxygen concentrator. During an observation on 7/9/2024 at 12:04 PM, the Director of Nursing (DON) verified that the oxygen was being administered at 4 liters per minute. During an interview on 7/9/2024 at 12:05 PM, the DON stated, Her [Resident #23] order is for oxygen at 2 liters. Nurses should check oxygen when they assess the residents or when giving medications. During an interview on 7/9/2024 at 12:13 PM, Staff C, Licensed Practical Nurse (LPN), stated, We should be checking oxygen first thing in the morning. I did check her this morning, but she was on her portable tank. I did not check her when she went back on the concentrator. During an interview on 7/9/2024 at 12:41 PM, Staff D, LPN, Unit Manager, stated, Typically, we should be checking the oxygen when there is a change in a resident's condition, when we do a change over from portable to concentrator, when we are assessing their lung sounds. There are no notes that show she had a need to increase the oxygen. When we change oxygen, we should call and get orders to increase the oxygen. Review of Resident #23's nursing progress notes from 7/5/2024 through 7/9/2024 did not document notes for the need to increase the amount of oxygen being administered. Review of the facility policy and procedure titled Oxygen Administration with the last approval date of 1/19/2024 read, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration . Assessment . 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered . 13. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated.

Based on observation, interview, and record review, the facility failed to ensure the dressing on a Peripherally Inserted Central Catheter (PICC) line was changed every 48 hours as per professional standards of care for 1 of 1 resident with a PICC Line, Resident #36. Findings include: During an observation on 3/15/2023 at 2:30 PM, Resident #36 had a PICC line on left upper arm with gauze under transparent dressing. The dressing was dated 3/10/23 (photographic evidence obtained). Review of the admission record for Resident #36 revealed the resident was admitted to the facility on [DATE] with diagnoses including fusion of spine, spinal stenosis of lumbar region, and lower back pain. Review of Resident #36's Medication Administration Record (MAR) revealed the PICC line dressing change was completed on 3/14/2023. Review of the physician orders for Resident #36 reads, Order Summary: Change PICC site dressing on admission, then once weekly and PRN [as needed] every day shift every 7 day(s) for PICC care. Order Date: 03/06/2023 . Order Summary: Daptomycin Intravenous Solution Reconstituted (Daptomycin) Use 850 mg [milligram] intravenously in the evening for MRSA until 04/13/2023 23:59 [11:59 PM]. Order Date: 03/07/2023 . Order Summary: Meropenem Intravenous Solution Reconstituted 1 GM [gram] (Meropenem) Use 1 gram intravenously every 8 hours for MRSA until 04/17/2023 23:59. Order Date: 03/06/2023 During an interview on 3/15/2023 at 3:00 PM, Staff A, Licensed Practical Nurse (LPN), stated, Yes, the date on PICC dressing is 3/10/23. During an interview on 3/15/2023 at 3:07 PM, the Director of Nursing (DON) stated, That is wrong. I know that dressing change was done on admission. It is a documentation error. The dressing change on 3/10/23 was a PRN dressing change and not documented. My expectation for my nurses is for them to follow orders and document. I did not realize the batch orders from the pharmacy does not include to change the PICC line dressing every 48 hours when there is gauze. I was not familiar with this pharmacy batch PICC line orders. Review of facility policy and procedure titled Central Venous Catheter Dressing Changes dated April 2017 reads, Policy: Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter -related infections that are associated with contaminated, loosened, soiled, or wet dressings . General Guidelines . 6. Change gauze dressings or TSM [Transparent Semi-permeable Membrane] over gauze dressings every 48 hours . Documentation: 1. The following should be recorded in the resident's medical record: a. Date and time dressing was changed.

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for one of three sampled residents, Resident #14. Findings: On 9/20/2021 at 12:16 PM, Resident #14 was observed in his bedroom seated in a chair with his feet exposed that showed long toenails. During an interview on 9/20/2021 at 12:18 PM, Resident # 14 stated, I know my toenails are long. I want to see a podiatrist. During an interview on 9/21/2021 at 2:00 PM, Staff B, Licensed Practical Nurse (LPN), verified Resident #14's toenails were long and the resident needed staff help with hygiene and a podiatrist to cut the resident's toenails. During an interview on 9/21/2021 at 2:06 PM, Staff C, Certified Nursing Assistant (CNA), stated she provided Resident #14 help with hygiene. Staff C verified that the resident's toenails were long and they needed to be cut. Review of Resident #14's care plan read, Focus: [Resident #14's name] has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] disease process (recent COVID-19), Date Initiated: 10/27/2020 . Interventions: . Bathing/ Showering: Check nail length and trim and clean on bath day and as necessary. Report any change to the nurse. Review of Resident #14's clinical records revealed task list documentation that showed Resident #14 had received a shower on 9/21/2021 with no documentation of nail condition recorded. Review of Resident #14's Monthly Summary, dated 8/23/2021, read, Nails: . 21 B. Toes: D. Cut PRN [as needed] by staff. Review of the facility policy titled Fingernails/ Toenails, Care of, revised in February 2018, read, General Guidelines: 1. Nail care includes daily cleaning and regular trimming.

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner and to accurately take food temperatures to ensure food safety related to calibrating food temperature equipment for 1 of 2 satellite kitchens. Findings include: 1. A review of the policy titled Food Storage, reviewed 1/15/19, reads under #13 Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within 7 days or discarded. During the initial tour of the satellite rehab kitchen on 1/21/2020 at approximately 10:30 AM, the Rehab Resident Freezer was observed to have a package of waffles dated 1/17/20. An interview with the Kitchen Manager on 1/21/2020 at approximately 10:30 AM confirmed that it should be discarded on the date that is written on the packaged food. She confirmed the package of waffles should have been discarded on 1/17/2020. 2. A review of the facility policy titled Resource: Taking Accurate Temperature, reviewed 1/15/19, reads: Start with an accurately calibrated thermometer that is in good working condition. An observation of calibration of the digital thermometer was not completed prior to obtaining food temperatures during the lunch meal on 1/22/2020 beginning at 12:23 PM in the rehab satellite kitchen. An interview was conducted with Staff A, Cook on 1/22/2020 at 12:33 PM. She stated that she does not calibrate the thermometers. They use the digital ones and do not have to calibrate them. 3. A review of the facility policy titled Resource: Taking Accurate Temperatures, reviewed 1/15/19, reads 2. To take hot food temperatures, insert the thermometer at a 45 degree angle to the middle of the food item, taking care not to touch the container or bone if applicable. Wait for the thermometer to rise to the maximum temperature, read and record the temperature and then remove the thermometer from the food item and immediately clean and sanitize. An observation of the steam table foods for temperature compliance on 1/22/2020 at 12:45 PM revealed the following: Staff A wiped off the probe of the digital thermometer with a alcohol wipe and put the probe of the digital thermometer into the ham then let go and let the plastic top of the thermometer lay on the food. Staff A then wiped the thermometer probe with the same alcohol wipe that was used prior to the temperature on the ham. Staff A put the probe of the digital thermometer into the cauliflower and then let the plastic top of the thermometer lay on the food. Staff A was later observed to clean the probe of the digital thermometer with an alcohol wipe then touch the probe with her gloved hand before putting it into the soup. During an interview with the Dietary Manager, The Executive Chef and the Director of Food and Beverage on 1/22/2020 at 4:30 PM, it was confirmed that the digital thermometers should have been calibrated before checking foods for temperature compliance, and the digital thermometer plastic top should not touch the food.

Based on record review and interview the faciltiy failed to develop a baseline care plan for 1 of 3 cognitively impaired residents for wandering. (#1). Findings: Review of the Incident Reports since 1/1/19 revealed Resident #1 was found in room [ROOM NUMBER] A which belonged to Resident #2. The 2 Residents were found by the Certified Nursing Assistant /Staff A when she responded to a call light on 2/6/19 at 10:08 PM in room [ROOM NUMBER] A. The report described Staff A found Resident #1 partially clothed in another resident's bed. Resident #2 was found standing behind the door, partially clothed. The report noted Staff A determined both residents were safe and then removed Resident #1 from the room and notified the Charge Nurse/Staff B. The Charge Nurse/Staff B assessed both residents and found no injuries according to the report. The Charge Nurse/Staff B documented she notified the Physician, family and the state Protective Services Agency hotline. Further, the report stated Resident #1was transported to the hospital emergency roiagnom on [DATE]. The report stated there were no findings of sexual assault. It stated both residents were separated and placed on one to one observations. The report noted Law Enforcement arrived on 2/6/19 and determined no arrests would be made. The State Protective Services Agency was notifed on 2/6/19. Review of Resident #1's closed record revealed she was admitted on [DATE] and discharged to another skilled nursing facility, in another city, approximately 350 miles away, on 2/21/19. Her Physician's report dated 1/31/19 lists Dementia without behavioral disturbance. Under General, the Physician wrote, she gets up and wanders. The Care Plan dated 2/1/19, does not address the wandering behavior. Review of the Minimum (MDS) data set [DATE], has a score of 5 under the Cognition section. Review of the facility Policy for Wandering-Prone residents revealed residents who are determined to wander aimlessly have staff members assigned to monitor a specific resident for the designated shift .and the resident's whereabouts will be determined every 30 minutes or other determined increment. This policy was not implemented since the facility did not address the Physician's declaration for wandering. During an interview with the facility Unit Manager and the Director of Nurisng on 3/18/19 at 11:00 AM, they confirmed there was no directive for wandering on the Baseline Care Plan dated 2/1/19. They confirmed the Physician's assessment dated [DATE] notes Resident #1gets up and wanders.

Based on record review and interview the facility failed to follow their facility policy for a smoke free and safe environment for 1 of 6 cognitively impaired residents. (#4) Photographic Evidence. Findings: Observation of Resident #4 in her room on 3/1819 beginning at 7:50 AM with the facility Unit Manager revealed a box of cigarettes with a lighter on the Resident's over bed table. The resident was laying in bed awake but not speaking very much. The Unit manager removed the items immediately. During an observation of the Resident at approximately 8:40 AM on 3/18/19 with the Director of Nursing (DON), she stated the resident did not smoke. She said the smoking paraphernalia must belong to a staff member. During an interview with the DON at approximately 11:15 AM on 3/18/19, she stated the cigarettes and lighter belonged to Certified Nursing Assistant /Staff E. She stated Staff E was assigned to Resident #4 today and had been providing care a little earlier. She confirmed the facility was a Smoke Free Campus. She confirmed the resident suffered from Dementia and was very confused. During an interview with Certified Nursing Assistant /Staff E on 3/18/19 at approximately 1:30 PM she confirmed the cigarettes and lighter belonged to her. She stated she knew there was no smoking. She stated she had a smoke break and did not return the items to a safe place. She took them back on to the resident's hallway with her. Review of Resident #4's record revealed she had a very low score of 01 on the Cognition section of the Minimum (MDS) data set [DATE]. Further review of her record revealed no information she was or had been a smoker. It confirmed the resident had range of motion and could have reached the over bed table and accessed the cigarettes and lighter. Review of the facility policy for a Tobacco Free facility directed There will be no use by employees of tobacco products on facility grounds at any time.

Based on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan for the use of [MEDICAL CONDITION] medications, specifically antianxiety medications for 1 (Resident #21) of 5 residents out of a sample of 15 care plans reviewed. Findings: An observation of Resident #21 on 1/2/19 revealed the resident was sitting in the TV lounge. The resident was observed in a geri-chair, legs elevated, oxygen observed on back of wheelchair. Resident was clean, well groomed and free from odor. Resident was observed to ask for help. A staff member was observed to speak with resident, resident stated she was thirsty. Resident was removed from TV lounge and taken to her room where she was provided fluids. A few minutes later, the resident was again observed in the TV lounge and told a staff member she was hungry. Staff were observed to get her a pudding cup and the resident was again removed from the lounge to her room and was assisted with her pudding. Resident #21 was observed on 1/3/19 at 2:10 PM in a music activity. On 01/04/19 at 10:05 AM, Resident #21 was observed sitting in a geri chair in common room, legs elevated, sleeping. A record review of the physicians orders for Resident #21 revealed an order dated 1/17/18 for [MEDICATION NAME], 0.5 milligrams (mg), 1 tablet every 12 hours for Anxiety Disorder. A record review of the care plan for Resident #21 revealed no developed care plan for the use of a [MEDICAL CONDITION] Medication, specifically an antianxiety medication. An interview was conducted with the MDS (Minimum Data Set) Coordinator, a Licensed Practical Nurse (LPN), on 1/4/18 at 12:30 PM. She confirmed there was no care plan developed for the use of [MEDICATION NAME], an antianxiety medication, for Resident #21.

Based on observation, interview and record review, the facility failed to attempt a Gradual Dose Reduction (GDR) to manage a resident's drug regimen to promote or maintain the resident's highest practicable mental , physical and psychosocial well being for 1 of 5 residents reviewed for medications out of a sample of 15 residents. Findings: An observation of Resident #21 on 1/2/19 revealed the resident was sitting in the TV lounge. The resident was observed in a geri-chair, legs elevated, oxygen observed on back of wheelchair. Resident was clean, well groomed and free from odor. Resident was observed to ask for help. A staff member was observed to speak with resident, resident stated she was thirsty. Resident was removed from TV lounge and taken to her room where she was provided fluids. A few minutes later, the resident was again observed in the TV lounge and told a staff member she was hungry. Staff were observed to get her a pudding cup and the resident was again removed from the lounge to her room and was assisted with her pudding. Resident #21 was observed on 1/3/19 at 2:10 PM in a music activity. On 01/04/19 at 10:05 AM, Resident #21 was observed sitting in a geri chair in common room, legs elevated, sleeping. A record review of the physicians orders for Resident #21 revealed an order dated 1/17/18 for [MEDICATION NAME], 0.5 milligrams (mg), 1 tablet every 12 hours for Anxiety Disorder. An interview was conducted with the Director of Nursing (DON) on 1/4/19 at 12:30 PM. She stated the last Gradual Dose Reduction (GDR) recommendation was completed by the pharmacist on 2/3/18. The attending Advanced Registered Nurse Practitioner (ARNP) documented in her notes dated 2/9/18 that the resident was improved and well controlled on [MEDICATION NAME]. She stated that there has not been another attempted GDR for Resident #21. A review of the Medication Regimen Review Checklist dated 2/3/18 showed a recommendation from the pharmacist to evaluate Resident #21 for the medications [MEDICATION NAME] and [MEDICATION NAME]. A review of the physician note dated 2/9/18 reads pt (patient) has episodes of anxiety that have been improved and well controlled with [MEDICATION NAME]. A review of the facility Policy entitled [MEDICAL CONDITION] Drugs, revised date 11/2017, revealed on page 3, number 11 Residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions, and behavioral inventions, unless clinically contraindicated, in an effort to discontinue these drugs. b. Gradual dose reduction must be attempted for 2 separate quarters (with at least one month between attempts).

Based on observation, interview the facility failed to ensure that clean techniques were used during the folding of clean linen. Findings: An observation on 01/04/2018 at 8:30 AM showed two of two staff persons working in the laundry room (one staff person from resident's being housed at the facility) one facility employee. The staff persons were folding the clean linen up against their personal clothing without a barrier between the clean linen and their personal clothing. During an interview on 01/04/2018 at 8:50 AM, with (staff A, this facility staff person) she stated, she is aware that she is supposed to place a barrier over her clothing when she is folding clean linen, and that the clean linen is not supposed to touch her personal clothing. The staff person further stated someone took the blue gowns the staff usually use to cover their personal clothing with, and she has not been able to locate the gowns. The staff did state that she could have placed a clean facility gown over her personal clothing.

Based on observation, record review and interview, the facility failed to maintain vinyl safety floor mats in 3 of 9 rooms (# 112, 108, 102) and clean privacy curtains in 1 of 9 rooms (# 108) along with resident care and housekeeping equipment. Findings: During a Tour of the facility with the Housekeeping Supervisor and Staff on 12/5/17 beginning at 11:00 AM, 4 of 12 vinyl safety floor mats were observed to be worn to the point of numerous holes, deep creases with a black substance and slits along the edges. The mats were located in Rooms 102, 108 and 112 (one room had 2 worn mats). Further, a privacy curtain, in room [ROOM NUMBER], was soiled. There was a liquid substance mark extending out from the lower corner about 2 feet and upwards about 10 inches. There were ink marks and other small dried dark substance stains. Review of the facility's policy for Infection Control for Linens states Linens will be handled , stored, processed and transported to prevent the spread of contamination. During an interview with the Housekeeping Supervisor and Staff on 12/5/17 at approximately 11:30 AM they confirmed the mats were worn resulting in dirt and holes. They confirmed it is an safety and infection control issue. They confirmed the privacy curtain in room [ROOM NUMBER] was soiled and needed to be replaced immediately.