Every finding on record at Lebanon Center, Genesis HealthCare

Based on observations, interviews, and record reviews, the facility failed to adhere to its policies and procedures for infection control and Legionella prevention. The facility failed to follow the established water management plan by neglecting remediation or testing of the water system after a confirmed resident case of Legionella. Furthermore, the facility failed to document the results of control measures as required by the Water Management Plan. Additionally, the facility allowed the use of a humidifier in a resident's room, which creates a potential risk for the spread and growth of Legionella. Collectively, these failures in following policies, procedures, and the Water Management Plan expose the facility's census of 80 residents to the potential spread and growth of Legionella.Findings include:Review on 10/6/25 of Resident #1's medical record revealed that Resident #1 was admitted and resided at the facility since November 2024. Resident #1 was transferred to the hospital on 9/30/25 for acute respiratory failure with hypoxia (low levels of oxygen in your body tissues). Review on 10/6/25 of Resident #1's Nurse Practitioner Progress Note dated 9/30/25 revealed, .[name omitte/d] is fevering today with hypoxia and rigors, lips are purple and finger poorly perfused . is at high risk for decline and high risk of bacteremia given central line . Ultietmly [sic] given above, [name omitted] is unable to be managed in LTC [Long Term Care] setting and decision made to send to ED [Emergency Department] . This was signed by Staff E (Nurse Practitioner). Review on 10/6/25 of Resident #1's hospital Medical Intensive Care Unit Progress Note dated 10/1/25 revealed, . Date of admission: [DATE] . Significant Events Last 24 Hours/Interval History . Urine legionella Ag [Antigen] positive . Active Problems and Important Diagnoses .Legionella pneumonia . Further review revealed that the urine antigen test for Legionella had been obtained and resulted on 9/30/25. The diagnoses being managed were Multi-system organ failure, Acute hypoxemic respiratory failure, Septic Shock, Metabolic acidosis, and coagulopathy. Interview on 10/6/25 at 11:15 a.m. with Staff E confirmed that Resident #1 had been be sent to the hospital on 9/30/25 for hypoxia where they tested positive for Legionella and passed away. Interview on 10/6/25 at 2:15 p.m. with Staff B (Director of Nursing) revealed that the facility followed the Centers for Disease Control and Prevention (CDC) for guidance for Infection Control. Review on 10/7/25 of the CDC's Clinical Guidance for Legionella Infections retrieved from https://www.cdc.gov/legionella/hcp/clinical-guidance/index.html revealed, .Testing for healthcare-associated Legionnaires' disease is especially important if any of the following are identified in a healthcare facility . Healthcare-associated Legionnaires' disease diagnosis in the last year . Review on 10/6/25 of the facility's policy titled Outbreak Investigation/Management revealed . An outbreak will be defined as an excess over expected (usual) level of a disease within the Center or according to defined clinical parameters. Legionnaires' Disease [greater than or equal to] one case of definite healthcare-associated Legionnaire's disease (a case in a patient who spend the entire 10 days prior to onset of illness in the facility) is identified at any time. 3. Search for additional causes and cases. 3.1 Review surveillance and lab reports. 3.2 Obtain appropriate lab specimens as directed by physician or state/local health departments. Review on 10/6/25 of the facility Legionella Water Management Plan reviewed September 2025 revealed, .Verification & Validation. Laboratory testing will also be conducted in the event of a resident is diagnosed with legionnaire's [sic] disease to confirm the water systems in the facility were the cause of the diagnosis. Interview on 10/6/25 at 11:45 a.m. with Staff B (Director of Nursing) revealed that they had not tested the facility's water system or equipment where Legionella bacteria could grow and spread for Legionella after they were informed Resident #1 had tested positive for Legionella. Interview on 10/6/25 at 9:15 a.m. with Staff C (Maintenance Supervisor) confirmed the above water management plan and revealed that he/she had not conducted any Legionella testing after Resident #1 tested positive for Legionella. Review on 10/6/25 of the facility's procedure titled Legionnaires' Disease with a review date of 9/15/25 revealed, . Follow primary prevention guidelines for Legionnaires' disease . 1.2 Do not use portable room humidifier . Interview on 10/6/25 at 12:35 p.m. with Staff A (Licensed Nursing Assistant (LNA)) revealed that Resident #1 had a humidifier in his/her room for a couple of months. Staff A revealed that he/she was unaware that Residents could not have a humidifier in their room until after Resident #1 went to the hospital. Interview on 10/6/25 at 10:40 a.m. with Staff B (Director of Nursing) revealed that Staff B found out that Resident #1 had a humidifier in his/her room after they tested positive for Legionella. Interview on 10/6/25 at 11:46 a.m. with Staff B and Staff D (Infection Preventionist) revealed that a water sample of Resident #1's humidifier had been collected but not been tested. Review on 10/7/25 of the CDC's Routine Testing Legionella retrieved from https://www.cdc.gov/control-legionella/php/toolkit/routine-testing-module.html revealed, . Legionella testing may be useful for . Non-routine purposes . Investigation potential sources of environmental exposure for people with disease .Certain types of facilities may benefit from routine testing, including those that house or treat people at increased risk for Legionnaires' disease . ? Review on 10/6/25 of the facility Legionella Water Management Plan reviewed September 2025 revealed, . IV. Control Measures and Monitoring. The facility does not monitor for Legionella. Once a week all unused rooms, showers are run to prevent Legionella. Our hot water tanks heat to 160 degrees [Fahrenheit] well above the temp[temperature] of 140 that kills Legionella . V. Ways to Intervene When Control Limits Are Not Met. Facility does not monitor for Legionella but the following interventions would be instituted, Ice Machines, eye Was [sic] Stations, Water heaters etc [sic] will be taken out of service immediately, a [sic] outside contractoe [sic] would be called in to clean, descale, and sanitize using appropriate control measures, Testing would be done to ensure units are free of Legionella before units are put back in service. Further review revealed, 3. Hot Water. The domestic hot water supply is heated by 3 indirect boilers to approximately 160 degrees Fahrenheit and transferred into two 120 gallon hot water storage tanks. Water temperatures are monitored, recorded and documented in our Tels system [a system that tracks maintenance tasks] on a weekly basis .Areas Subject to Legionella. 1. Ice Machines 2. Dead Legs 3. Less frequently used areas including eyewash stations 4. Hot water holding tanks 5. HVAC-PTAC units [Heating, ventilation, and air conditioning - Packaged Terminal Air Conditioner] Further review revealed that humidifiers were not identified to be at risk for waterborne pathogens in the water management plan. Interview on 10/6/25 at 9:15 a.m. with Staff C (Maintenance Supervisor) confirmed the above water management and revealed that he/she does not test for Legionella routinely as part of the facility's water management plan. Interview on 10/6/25 at approximately 1:00 p.m. with Staff C revealed that he/she checks but does not log the water heater temperature of the hot water tanks. Staff C revealed that he/she would clean any portable air conditioners units twice monthly. Staff C could not provide documentation to show which portable air conditioners had been cleaned.

Based on observation, interview, and record review, it was determined that the facility failed to determine if self-administration of medications was clinically appropriate for 2 of 3 residents reviewed for choices in a final sample of 18 residents. (Resident identifiers are #6 and #8.) Findings include:Resident #6 Observation on 8/12/25 at approximately 10:08 a.m in Resident # 6's room revealed that there were 2 prescription lotions, Ammonium Lactate External Lotion 12% and Anti-Itch External Lotion 0.5-5%, located on the Resident's windowsill. Interview on 8/12/25 at approximately 10:08 a.m with Resident #6 revealed that Resident #6 would have the above mentioned lotion applied by nursing staff and that he/she would also apply the lotion as needed. Observation on 8/12/25 at approximately 10:18 a.m. of Resident #6's room revealed that the prescription lotions remained at the resident's bedside on a bedside table. Observation on 8/13/25 at approximately 1:50 p.m. with Staff A (Licensed Vocational Nurse) revealed that the 2 prescription lotions remained in the resident's room, at that time the prescription lotions were on resident dresser with other toiletries. Review on 8/13/25 of Resident #6's medical record revealed that there was no self administration assessment, care plan, or order. Review on 8/13/25 of Resident #6's orders for Ammonium Lactate External Lotion 12% and Anti-Itch External Lotion 0.5-5% did not include MD instruction for the resident to self administer. Interview on 8/13/2025 at approximately 3:22 p.m. with Staff A confirmed that Resident #6 did not have a self administration assessment, care plan or order to self administer the medications. Resident #8 Observation on 8/12/25 at approximately 9:30 a.m. of Resident #8's room revealed Resident #8 sleeping in his/her bed. There was a clear medicine cup containing a white capsule and a white round tablet on the tray table over the bed. Interview on 8/12/25 at approximately 9:30 a.m. with Staff I (Licensed Practical Nurse) revealed that the white capsule was gabapentin and the white tablet was atorvastatin. Further interview revealed that Resident #8 receives Gabapentin and Atorvastatin on the evening shift. Review on 8/12/25 of Resident #8's August 2025 MAR (Medication Administration Record) revealed that the last administered dose of Gabapentin and Atorvastatin was on the evening of 8/11/25. Interview on 8/13/25 at approximately 9:30 a.m. with Resident #8 revealed that they preferred the nursing staff to leave the medications with him/her so they could take them at their own pace. Resident #8 stated that he/she must have fallen asleep before they finished taking their medication on the evening of 8/11/25. Review on 8/13/25 of Resident #8's medical record revealed no care plan, no physician order, and no assessment to self-administer medications. Interview on 8/13/25 at approximately 1:30 p.m. with Staff L (Registered Nurse) confirmed that Resident #8 had no care plan, no physician order, and no assessment to self-administer medications. Review on 8/13/25 of the facility policy titled NSG309 Medication Self Administration revised 10/15/24, revealed .Patients who request to self-administer medication swill be evaluated for safe and clinically appropriate capability based on the patient's functionality and health condition. If it is determined that the patient is able to self administer: A physician/advanced practice provider (APP) order is required. Self-administration and medication self- storage must be care planned. When applicable, patient must be provided with a secure, locked area to maintain medications.Evaluation of capability must be performed initially, quarterly and with any significant change in condition.

Based on record review and interview, it was determined that the facility failed to hold routine interdisciplinary care plan meetings for 2 of 18 residents and failed to develop and update comprehensive care plans for 1 of 18 reviewed in a final sample of 18 residents. (Resident identifiers are #13, #24 and #47.)Findings include:Resident #13Interview on 8/13/25 at approximately 8:41 a.m. with Resident #13 revealed that they have had meetings about his/her care, but not for several months. Resident #13 would like to attend his/her care planning meetings.Review on 8/13/25 of Resident #13's medical record revealed that the last documented care plan meeting was 9/4/24.Interview on 8/13/25 at approximately 2:08 p.m. with Staff F (Director of Social Services) confirmed the above findings. Resident #24Interview on 8/12/25 at approximately 2:05 p.m. with Resident #24's DPOA (Durable Power of Attorney) revealed that he/she was invited to a care plan meeting twice last year. The last meeting he/she recalled attending was in December of 2024. DPOA stated that he/she attended all meetings possible.Review on 8/12/25 of Resident #24's medical record revealed that the last documented care plan meeting was 12/17/24.Interview on 08/13/2025 at approximately 2:17 p.m with Staff F confirmed that they did not hold quarterly interdisciplinary care plan meetings for Resident #13 and Resident #24. Resident #47Observation on 8/12/25 at approximately 10:14 a.m. of Resident #47's room revealed a continuous positive airway pressure (CPAP) machine on Resident #47's bedside table. Interview on 8/13/2025 at approximately 3:12 p.m. with Resident #47 revealed that the resident used the CPAP machine nightly. Review on 8/13/25 of Resident #47's care plan revealed that there was no care plan for the use or maintenance of a CPAP machine.Interview on 8/13/25 at approximately 3:26 p.m. with Staff G (Registered Nurse) confirmed that there was no care plan for Resident #47's nightly use of the CPAP machine.

Based on observation, interview, and record review, it was determined that the facility failed to follow menu preferences, allergies, and intolerances for 1 resident of 1 resident reviewed for food concerns and 1 resident of 1 resident reviewed for nutrition in a final sample of 18 residents. (Resident Identifiers are #17 and #73.)Findings include:Resident #17Observation on 8/12/25 at approximately 12:58 p.m. of Resident #17 in the dining room, during lunch, revealed Resident #17's meal ticket to read ADD FINGER FOODS TO MEALS. Further observation revealed no finger food items provided and Resident #17 was attempting to pick up the ground chicken and gravy with his/her fingers. Resident #17 attempted to drink their pudding from the dish.Observation on 8/13/25 at approximately 8:00 a.m. in the dining room, during breakfast, revealed Resident #17 attempting to eat a bowl of milk-soaked cereal with his /her fingers. Further observation revealed a scoop of scrambled eggs that were untouched on Resident #17's plate. There was no finger food items on Resident #17's plate.Review on 8/13/25 of Resident #17's medical record revealed the following current dietary order: Regular/Liberalized Diet with Dysphagia Advanced texture and Nectar Thickened Liquids, with a start date of 7/25/25.Further review of Resident #17's medical record revealed a Dietary Communication form, dated 7/25/25, that indicated Dysphagia Advanced consistency, Nectar thick liquids, and add finger foods to meals under preferences.Interview on 8/13/25 at approximately 12:00 p.m. with Staff N (Speech Therapist) confirmed that Resident #17 was currently working with them on meal intake and that Staff N had requested finger foods be added to the meal trays.Interview on 8/13/25 at approximately 1:00 p.m. with Staff M (Food Service Manager) confirmed that Resident #17's meal ticket stated to add finger foods to meals. Staff M stated that they had given dry cereal to Resident #17 as a finger food item as they do not have specific finger food items or a protocol as to what to offer for finger food items. Resident #73Interview on 8/12/25 at approximately 2:25 p.m. with Resident #73 stated they are not supposed to have dairy but enjoyed creamer in their coffee and ice cream without having issues. Resident #73 stated they do not offer non dairy options so their choices are limited at meals.Observation on 8/13/25 at approximately 8:00 a.m. of Resident #74 during breakfast revealed Resident #73's meal ticket to read No milk, Allergies: Lactose Intolerant.Interview on 8/13/25 at approximately 1:30 p.m. with Staff M confirmed that Resident #73 has a milk allergy. Staff M stated that the facility did have Lactose free milk as an alternative for residents that cannot have milk but have not provided any to Resident #73.Review on 8/14/25 of facility policy titled Dining and Food Preferences, revised on 10/2022, revealed .The Dining Service Director, or designee, will interview the resident or resident representative to complete a food preference Interview with in 72 hours of admission.Food allergies, food intolerances, food dislikes, and food and fluid preferences will be entered into the resident profile in the menu management software system.The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies & intolerances, and preferences.

Based on observation, interview, and record review, it was determined that the facility failed to ensure proper storage of washed linens and ensure proper processing of linens to reduce risk of accidental contamination for 1 of 1 laundry observed. Findings include: Observation on 8/14/25 between 10:09 a.m. and 10:45 a.m. in the laundry room with Staff H (Infection Preventionist) and Staff P (Director of Housekeeping) revealed a small residential washing machine was running on normal mode and cold water setting. Interview on 8/14/25 between 10:09 a.m. and 10:45 a.m. with Staff P revealed the residential washing machine had been used for almost a year for resident's clothes, kitchen rags, bed sheets, and other linens. They use a household detergent bought from a local store on all linens and added bleach for white linens. The washing machine was not hooked up to the hot water and ran loads with cold water. Staff P was unable to provide the facility's policy for using the residential washing machine, in regards to the manufacturer's' instructions, temperature, detergent or laundry additives.Interview on 8/14/25 between 10:09 a.m. and 10:45 a.m. with Staff Q (Laundry Aide) revealed they were not able to explain how much bleach and detergent to use to wash and disinfect linens in the residential washing machine.

Based on observation, interview, and record review, it was determined that the facility failed to implement their smoking policy for 1 of 1 residents reviewed for smoking in a final sample of 18 residents. (Resident identifier is #1.)Findings include: Review on 8/14/25 of the facility's smoking policy with a review date of 2/24/25, revealed .Smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluid, batteries, refill cartridges, etc. [etcetera]) will be labeled with the patient's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nursing station .Interview on 8/12/25 at 10:44 a.m. with Resident #1 revealed that Resident #1 was an independent smoker and he/she kept his/her cigarettes and lighter in their room in a black bag. Interview on 8/13/25 at 2:36 p.m. with Staff L (Registered Nurse) confirmed that Resident #1 was an independent smoker and that Resident #1 kept his/her cigarettes and lighter in their room. Observation on 8/14/25 at 1:10 p.m. in Resident #1's room revealed that Resident #1's cigarette and lighter was in a black pouch and stored in an unlocked black bag. Interview on 8/14/25 at 1:10 p.m. with Staff L confirmed the above observation.

Based on interview and record review, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the residents' status for 4 residents in a final sample of 18 residents. (Resident identifiers are #1, #2, #4, and #24).Findings include:Resident #1 Interview on 8/12/25 at 10:44 a.m. with Resident #1 revealed that he/she was an independent smoker since he/she was admitted to the facility in June 2025. Review on 8/13/25 of Resident #1's smoking care plan, initiated on 6/26/25, revealed that Resident #1 was an independent smoker. Interview on 8/13/25 at 2:36 p.m with Staff L (Registered Nurse) confirmed that Resident #1 was an independent smoker since Resident #1's admission. Review on 8/13/25 of Resident #1's admission MDS with an Assessment Reference Date (ARD) of 6/30/25 revealed that under section J1300 (Current Tobacco use) Resident #1 was coded as no. Interview on 8/14/25 at 8:26 a.m. with Staff O (Director of Nursing) confirmed the above MDS findings for Resident #1. Resident #4 Review on 8/12/25 of Resident #4's June 2025's Electronic Medication Administration Record (EMAR) revealed no anticoagulant medications were administered to Resident #4. Review on 8/12/25 of Resident #4's Annual MDS with an ARD of 6/26/25 revealed that under section N (Medication) Resident #4 was coded as taking anticoagulant medications. Interview on 8/13/25 at 12:13 p.m. with Staff B (MDS coordinator) confirmed the above findings and that Resident #1 was not taking anticoagulant medications during the look back period for the Annual MDS dated [DATE]. Resident #2 Review on 8/13/25 of Resident #2's MDS with an ARD of 6/6/2025 revealed that under section M0300 (Current Number of Unhealed Pressure Ulcer/Injury at each stage) revealed that Resident #2 was coded as having 1 unstageable pressure ulcer (slough and or eschar) that was present on admission. Review on 8/13/25 of Resident #2's wound assessment dated [DATE] with Staff C (Wound Nurse) revealed wound picture revealing the presence of a deep tissue injury (pressure ulcer/injury). Interview on 8/13/25 at approximately 1:32 p.m. with Staff C confirmed the above findings. Interview on 8/13/25 at approximately 2:31 p.m. with Staff B (MDS coordinator) confirmed that the MDS was coded as Resident #2 having an unstageable pressure injury instead of a deep tissue injury. Resident #24 Interview on 8/13/25 at approximately 9:30 a.m. with Resident #24 revealed that Resident #24 denied the use of insulin. Review on 8/13/25 of Resident #24's May 2025 EMAR revealed that Resident #24 did not take an insulin medication but rather Semaglutide injectable medication (GLP-1 (glucagon-like peptide-1)). Review on 8/13/25 of Resident #24's Quarterly MDS with ARD date of 5/29/25 revealed that under Section N (Medications) Resident #24 was coded as receiving Insulin Injections for 1 day of the 7 day look back period. (5/22 to 5/29) Review on 8/13/25 of Resident #24's February and March 2025 EMAR revealed no insulin medication administered. Review on 8/13/25 of Resident #24's Quarterly MDS with ARD date of 3/3/25 revealed that under Section N (Medications) Resident #24 was coded as receiving Insulin Injections for 1 day of the 7 day look back period. (2/24 to 3/13) Interview on 8/13/25 at 12:13 p.m. with Staff B confirmed the above findings and that Resident #24 was not taking insulin.

Based on record review and interview, it was determined that the facility failed to obtain written authorization of a resident to act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility for 3 of 5 residents reviewed. (Resident identifiers are #1, #2, and #3.)Findings include:Resident #1Review on 7/7/25 of Resident #1's Resident Statement Landscape for January 1, 2025 to June 30, 2025 revealed that Resident #1's social security benefit was direct deposited into their resident fund on 1/3/25, 2/3/25, 3/3/25, 4/3/25, 5/2/25, and 6/3/25. The following amounts of money were transferred directly to the facility with description Care Cost Auto WDL: $3058.04 on 1/9/25; $40.00 on 1/21/25; $1399.00 on 2/3/25; $1399.00 on 3/3/25; $1399 on 4/3/25; $1399.00 on 5/2/25; and $949.00 on 6/3/25.Review on 7/7/25 of Resident #1's Resident Fund Management Service form, the facility's authorization and agreement to handle resident funds, dated 5/31/24, revealed that Resident #1 did not authorize the facility to automatically transfer care cost payments due to the facility and was not signed by the resident or Resident #1's guardian.Resident #2Review on 7/7/25 of Resident #2's Resident Statement Landscape for January 1, 2025 to June 30, 2025 revealed that Resident #2's social security benefit was direct deposited into their resident fund and an amount of $1498.00 was automatically transferred to the facility under the description Care Cost Auto WDL on 1/3/25, 2/3/25, 3/3/25, 4/3/25, 5/2/25, and 6/3/25.Review on 7/7/25 of Resident #2's Resident Fund Management Service form, the facility's authorization and agreement to handle resident funds, dated 2/7/24, revealed that Resident #2 did not authorize the facility to direct deposit their social security benefit payments or to automatically transfer care cost payments due to the facility.Resident #3Review on 7/7/25 of Resident #3's Resident Statement Landscape for January 1, 2025 to June 30, 2025 revealed that Resident #2's social security benefit was direct deposited into their resident fund and an amount of $1334.07 was automatically transferred to the facility under the description Care Cost Auto WDL on 1/3/25, 2/3/25, 3/3/25, 4/3/25, 5/2/25, and 6/3/25.Review on 7/7/25 of Resident #3's Resident Fund Management Service form, the facility's authorization and agreement to handle resident funds, dated 11/09/24, revealed that Resident #3 did not authorize the facility to direct deposit their social security benefit payments.

Based on record review and interview, it was determined that the facility failed to provide Quarterly statements in writing to the resident or the resident's representative within 30 days after the end of the quarter for 2 of 5 residents reviewed for personal funds. (Resident identifiers are #1 and #2.) Findings include:Resident #1Review on 7/7/25 of Resident #1's quarterly statement for the quarter ending 12/31/24 revealed the quarterly statement was signed by Staff A (Administrator) on 2/3/25, not Resident #1 or Resident #1's guardian. Review on 7/7/25 of Resident #1's quarterly statement for the quarter ending 3/31/25 revealed the quarterly statement was signed by Staff A on 4/14/25, not Resident #1 or Resident #1's guardian. Interview on 7/7/25 at approximately 1:45 p.m. with Resident #1's guardian revealed that they had not received quarterly statements for Resident #1's personal fund account. Resident #2Interview on 7/7/25 at 11:20 a.m. with Resident #2 revealed they had not received any quarterly statements for their personal funds and thought they might be sent to their power of attorney. Review on 7/7/25 of Resident #2's quarterly statements for the quarter ending 3/31/25 revealed the quarterly statement was signed by Staff A on 2/3/25, not by Resident #2 or Resident #2's power of attorney. Review on 7/7/25 of Resident #2's quarterly statements for the quarter ending 3/31/25 revealed the quarterly statement was signed by the administrator on 4/14/25, not by Resident #2 or Resident #2's power of attorney.Interview on 7/7/25 at 1:40 p.m. with Resident #2's activated power of attorney revealed that they had not received any quarterly statements for Resident #2's personal funds. Interview on 7/7/25 at approximately 2:15 p.m. with Staff A confirmed the above quarterly statements for Resident #1 and Resident #2 were not given to the residents or their representatives.

Based on record review and interview, it was determined that the facility failed to notify a resident when the amount in the resident's personal fund account reaches or exceeds $200 less than the SSI (supplemental security income) recourse limit for 1 of 5 residents reviewed for personal funds. (Resident identifier is #1.)Findings include:Review on 7/7/25 of Resident #1's Resident Statement Landscape for January 1, 2025 to June 30, 2025 revealed the following monthly balances: January $5784.29; February $5335.58; March $4958.66; April $4550.90; May $3604.10; June $4102.22. Interview on 7/7/25 at 1:00 p.m. with Staff B (Regional Business Office Manager) revealed that the [NAME] Medicaid SSI resource limit is $2500. Interview on 7/7/25 at 1:53 p.m. with Staff A (Administrator) revealed the facility did not notify Resident #1 that they had exceeded their SSI resource limit each month from January 2025 through June 2025. Review on 7/7/25 of the facility's policy titled Accounts Receivable Policies and Procedures, AR600 Resident Funds, with a revision date of 1/16/23, revealed the following: .10. Medicaid Eligibility Letters: 10.1 In accordance with state and federal regulations, all Medical Assistance residents must be notified monthly when he resident's account reaches $200 of the state's asses level for Medicaid eligibility 10.2 Maintain a copy of the notification letter in the resident's file.

Based on record review and interview, it was determined that the facility failed to provide sufficient nursing staff as determined by their facility assessment. Findings Include: Review on 7/9/24 of the facilities Payroll Based Journal Staffing Data report Quarter 2, 2024 (January 1-March 31) revealed the facility had excessively low weekend staffing. Review on 7/11/24 of the facility assessment nursing staff and personnel total number needed revealed that the facility assessment determined the required Hours Per Patient Day (HPPD) for nurses aides was 1.63 HPPD. Review on 7/10/24 of the nursing staff punch reports for 6/9/24-7/10/24 revealed the following weekend dates had staffing that was below the staffing numbers determined by the facility assessment: Sunday 6/9/24- Nurse aides 1.57 HPPD; Saturday 6/22/24- Nurses aides 1.49 HPPD; Sunday 6/23/24- Nurse aides 1.45 HPPD; Saturday 6/29/24- Nurses aides 1.49 HPPD; Saturday 7/6/24- Nurses aides 1.47 HPPD; Sunday 7/7/24- Nurses aides 1.43 HPPD. Interview on 7/11/24 at approximately 1:15 p.m. with Staff M (Scheduler/Human Resources) confirmed the above findings.

Based on interview, observation, review of facility policy, and review of the facility menu, it was determined that the facility failed to offer the residents a nourishing snack at bedtime while having 15 hours between the evening meal and the breakfast meal. Findings include: Interview on 7/9/24 at approximately 2:00 p.m. with the facility's Resident Council (13 residents) revealed that the majority of the residents that attended did not receive bedtime snacks. The Resident Council President stated he/she met with Staff F (Food Service Director) back in January to request more substantial snacks such as tuna, egg salad or chicken salad be available in the kitchettes. Review on 7/10/24 of the facility dining times revealed the following meal schedule: Breakfast 7:30 a.m.; Lunch 11:30 a.m.; Dinner 4:30 p.m. Review on 7/11/24 of the facility's Week At A Glance Menu of week 2 revealed the following evening snack: Sunday: Cranberry Juice and Oatmeal Creme Cookie; Monday: Apple Juice and Chocolate Creme Cookie Tuesday: Cranberry Juice and [NAME] Crackers; Wednesday: Apple Juice and Oatmeal Creme Cookies; Thursday: Cranberry Juice and Chocolate Creme Cookies; Friday: Apple Juice and [NAME] Cookies; Saturday: Cranberry Juice and Oatmeal Creme Cookies. Interview on 7/11/24 at approximately 9:30 a.m. with Staff F (Food Service Director) confirmed that the above snacks are the available snacks in the kitchenettes. Review on 7/11/24 of the facility policy titled, Snacks, with a revision date of 10/2022 revealed: .Policy Statement .Bedtime (HS) snacks will be provided for all residents .Procedures .1. The Dining Services Department will collaborate with the residents/patients, nursing and management team to identify necessary beverage and snack items to be provided to each resident/patient .6. Nursing Services is responsible for delivering the individual snacks to the identified residents and for offering evening snacks to all other residents. 47129 Resident #88 Interview on 7/11/24 at 12:59 p.m. with Resident #88 revealed the he/she was not offered a snack in the evening. Resident #71 Interview on 7/9/25 at 11:00 a.m. with Resident #71 revealed that he/she was not offered a snack anytime during the day or night. Resident #71 stated that the snacks available in the kitchenette were oatmeal cookies, goldfish crackers, and/or chips.

Based on observation, interview and record review, it was determined that the facility failed to ensure that a resident received medication as ordered for 1 out of 26 medications observed (Resident Identifier #32). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders .The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Observation on 7/9/24 at approximately 1:00 p.m. with Staff B (Licensed Practical Nurse) of the Intravenous (IV) medication of Heparin administration, revealed Staff B administered 50 units of Heparin. Review on 7/9/24 of Resident #32's Medication Administration Record (MAR) revealed the following physician's order: Heparin Sodium (Porcine) Injection Solution (Heparin Sodium (Porcine)) Use 100 units intravenously two times a day for flush right arm piccline, Start Date 6/19/24. Interview on 7/9/24 at approximately 1:00 p.m. with Staff B confirmed that he/she administered the incorrect dose.

Based on interview and record review it was determined that the facility failed to ensure that orders for psychotropic drugs are limited to 14 days for 1 of 1 residents reviewed for psychotropic/opiod side effects (SE) in a final sample of 19 residents reviewed (Resident Identifier #83). Findings include: Review on 7/10/24 of Resident #83's Medication Administration Record (MAR) revealed the following physician's order: Ativan Oral Tablet 0.5 milligrams (mg) (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for Anxiety/Nausea, Start Date 6/16/24 with no stop date indicated. Further review revealed of Resident #83's MAR revealed that Resident #83 received 10 doses of the as needed Ativan after 14 days of the order being initiated. Interview on 7/11/24 at approximately 10:45 a.m. with Staff D (Director of Nurses) confirmed the above findings. Review on 7/11/24 of the facility policy titled, 3.8 Psychotropic Medication Use, Revision Date 10/24/22 revealed: .8. PRN (as needed) psychotropic medications should be ordered for no more than 14 days

Based on observation, interview and record review, it was determined that the facility failed to ensure that a resident was free from a significant medication error for 1 out of 26 medications observed. (Resident identifier is # 32.) Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Observation on 7/9/24 at approximately 1:00 p.m. with Staff B (Licensed Practical Nurse) of the IV (Intravenous) medication of heparin administration, revealed Staff B administered 50 units of Heparin. Review on 7/9/24 of Resident #32's MAR (Medication Administration Record) revealed the following physician's order: Heparin Sodium (Porcine) Injection Solution (Heparin Sodium (Porcine)) Use 100 unit intravenously two times a day for flush right arm piccline, Start Date 6/19/24. Interview on 7/9/24 at approximately 1:00 p.m. with Staff B confirmed that he/she administered the incorrect dose.

Based on observation, interview, record review, and policy review, it was determined that the facility failed to follow Centers for Disease Control and Prevention (CDC) guidance for Enhanced Based Precautions (EBP) for 1 of 1 residents with an Intravenous (IV) access in a final sample of 19 residents (Resident Identifier #32). Findings include: Observation on 7/9/24 at approximately 10:00 a.m. of Resident #32's room door revealed signage stating EBP required. Observation on 7/9/24 at approximately 12:55 a.m. of Staff B (Licensed Practical Nurse) accessing Resident #32's IV site revealed Staff B did not put on a gown while accessing Resident #32's IV site. Interview on 7/9/24 at approximately 12:55 p.m. with Staff B confirmed the above findings. Interview on 7/10/24 at approximately 8:00 a.m. with Staff C (Infection Preventionist) revealed that the facility would expect a gown to be worn when accessing a IV. Review on 7/10/24 of the facility policy titled, IC308 Enhanced Barrier Precautions, Revision Date 1/8/24 , revealed: .purpose, to reduce the risk of transmission of epistemologically microorganisms by direct or indirect contact Review on 7/10/24 of the CDC Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug Resistant Organisms (MDRO's), Updated July 2022 revealed: .Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. MDRO's may be indirectly transferred from resident-to-resident during these high-contact activities. Nursing home resident with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO's. The use of gown and gloves for high-contact resident care activities is indicated, .Enhanced Barrier Precautions, Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: .Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator .

Based on interview, review of the facility's policy for antibiotic stewardship, review of the facility's antibiotic stewardship program, and review of the facility's antibiotic line listings from March 2024 - June 2024, the facility failed to use antibiotic use protocols that identify unnecessary or inappropriate antibiotic use for 2 out of 4 months reviewed, which could affect all residents prescribed antibiotics. Findings include: Review on 7/10/24 of the Antibiotic Line Listings revealed the following antibiotic was prescribed that did not meet the facilities criteria for determining antibiotic use: April 2024- 1 resident was prescribed antibiotics for a Urinary Tract Infection (UTI); and June 2024- 6 residents were prescribed antibiotics for UTI's. Interview on 7/11/24 at approximately 07:30 a.m. with Staff C (Infection Preventionist) confirmed that the above antibiotics were prescribed to residents without the facility's criteria for antibiotic use being met. Review on 7/11/24 of the facility policy titled, IC402 Antibiotic Stewardship, with a revision date of 7/1/24, revealed: Policy .Centers will implement an Antibiotic Stewardship Program (ASP) that includes antibiotic use protocols and systems for monitoring antibiotic use .

Based on interview and record review, it was determined that the facility failed to ensure that training and education was provided to staff on abuse, neglect, exploitation, and misappropriation of resident property for 1 of 5 staff reviewed (Staff Identifier is Staff L (Licensed Nursing Assistant)). Finding include: Review on 7/11/24 of Staff L's education file revealed no documentation of training or education for abuse, neglect, exploitation and misappropriation of resident property. Interview on 7/11/24 at 2:30 p.m. with Staff D (Director of Nursing) confirmed that Staff L did not have training or education for abuse, neglect exploitation and misappropriation of resident property prior to Staff L's start date on 4/23/2024. Review on 7/11/23 of facility policy titled, Abuse Prohibition, revised on 10/24/22, revealed .4. Training and reporting obligations will be provided to all employees - through orientation, Code of Conduct training, and a minimum of annually - and will include . 43408

Based on interview and record review, it was determined that the facility failed to notify the resident and/or representative of quarterly care plan meetings for 1 of 19 residents reviewed for care plans (Resident Identifier #52). Findings include: Resident #52 Interview on 7/9/24 at approximately 12:00 p.m. with Resident #52's activated alternate Durable Power of Attorney (DPOA) revealed he/she had been invited to two care plan meetings since Resident #52 was admitted in April of 2023. Review on 7/10/24 of Resident #52's medical record revealed two quarterly care plan attendance sheets dated 4/26/23 and 2/27/24. Both attendance sheets had identified that the DPOA and the alternate DPOA were in attendance. Interview on 7/10/24 at approximately 2:20 p.m. with Staff K (Social Services) confirmed the above findings. Staff K was unable to provide documentation of other quarterly care plan meetings.

Based on interview, observation, and record review, it was determined that the facility failed to ensure that the residents' Minimum Data Set (MDS) accurately reflected the resident's status for 4 of 19 residents (Resident Identifiers #11, #24, #53, and #76). Findings include: Resident #11 Review on 7/10/24 of Resident #11's Quarterly MDS dated [DATE], section P0100- Restraints and Alarms, revealed that the section Used in Bed; A. Bed rail was coded with a #2, indicating it was used daily. Review on 7/11/24 of Resident #11's Bed Rail Evaluation, dated 1/6/20, revealed that Resident #11 requested to use two half upper rails on the bed to enable mobility and assist with transfers and was not a restraint. Interview on 7/11/24 at approximately 11:00 a.m. with Staff A (MDS Coordinator) confirmed the above findings. 38218 Resident #53 Review on 7/10/24 of Resident #53's MDS dated [DATE], section P0100- Restraints and Alarms, revealed that the section Used in Bed; A. Bed rail was coded with a #2, indicating it was used daily. Interview on 7/9/24 at approximately 9:30 a.m. with Staff B (Licensed Practical Nurse) revealed that Resident #53's bed rail was not a restraint. Interview on 7/11/24 at approximately 11:00 a.m. with Staff A confirmed that Resident #53's bed rail was not a restraint and that the MDS submitted was not accurate. 43408 Resident #76 Review on 7/9/24 of Resident #76's MDS, dated [DATE], section P0100- Restraints and Alarms, revealed that the section Used in Bed; A. Bed rail was coded with a #2, indicating it was used daily. Interview on 7/11/24 at approximately 11:00 a.m. with Staff A confirmed that Resident #76's bed rail was not a restraint and that the MDS submitted was not accurate. 47129 Resident #24 Review on 7/10/24 of Resident #24's MDS, dated [DATE], section P0100- Restraints and Alarms, revealed that the section Used in Bed; A. Bed rail was coded with a #2, indicating it was used daily. Review on 7/11/24 of Resident #24's Consent for Use of Bed rails dated 4/10/24 revealed that Resident #24's bed rails were used as a mobility enabler and not a restraint. Interview on 7/11/24 at 11:06 a.m. with Staff A revealed that Resident #24's MDS had been incorrectly coded.