Every finding on record at Lefa Seran SNF

Based on clinical record review, interview, and document review the facility failed to ensure 5 of 24 residents (Resident #6, #7, #10, #11, and #15) were screened for eligibility to receive a COVID-19 (COVID) vaccine, education regarding the vaccine was provided to the resident and/or the resident representative, and the vaccine was offered and either administered or declined. This deficient practice had the potential to result in residents to become ill with a preventable disease and experiencing severe or prolonged illness, hospitalization, or death as the result of infection with the COVID virus. Findings include: Resident #6 Resident #6 was admitted to the facility on [DATE], with diagnoses including dementia, unspecified severity, adult failure to thrive, and unspecified protein calorie malnutrition. Resident # 7 Resident #7 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including chronic atrial fibrillation, unspecified, pneumonia, unspecified organism, shortness of breath, and essential hypertension. Resident #10 Resident #10 was admitted to the facility on [DATE], with diagnoses including chronic systolic (congestive) heart failure, Parkinson's disease without dyskinesia, and mild neurocognitive disorder due to known physiological condition without behavioral disturbance. Resident #11 Resident #11 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including acute bronchitis, chronic obstructive pulmonary disease with (acute) exacerbation, and type two diabetes mellitus without complications.Resident #15 Resident #15 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including spastic quadriplegic cerebral palsy, and tachycardia, unspecified.The electronic health records (EHR) for Resident #6, #7, #10, #11, and #15 lacked documentation of eligibility screening, the offering, education, and administration/declination of the COVID vaccination for 2026. On 06/03/2026 at 9:37 AM, the Director of Nursing (DON) explained the residents were offered the COVID vaccination upon admission. Residents were offered the annual vaccine verbally and were documented only if the resident accepted the vaccine via the consent form. The DON confirmed when a resident declined a COVID vaccine, it was done so verbally and was not documented in the EHR. On 06/04/2026 at 9:13 AM, the Infection Preventionist (IP) explained the facility followed the Centers for Disease Control and Prevention (CDC) guidance related to COVID-19, including vaccination requirements for residents. The IP communicated the CDC guidelines recommended adults receive a COVID 2025-2026 vaccination to stay up to date. The IP confirmed the IP had not tracked resident COVID vaccination declinations. On 06/04/2026 at 1:57 PM, the DON confirmed the lack of documented evidence of an eligibility screening, offering, education, and administration/declination of the COVID 2025-2026 vaccination in the EHR for Residents #6, #7, #10, #11, and #15. The facility policy titled Resident Immunizations, last revised 04/23/2025, documented Covid immunizations would be administered based on current CDC guidelines and would be evaluated by the Infection Preventionist quarterly. The immunization schedule would follow current CDC guidelines and education on the benefits and potential side effects of the immunizations would be provided to the resident and/or the resident's legal representative. A progress note would be completed in the EHR if a vaccine was not recommended by the provider. A Consent/Declination/Education form for each immunization with the date offered would be uploaded to the resident's EHR.

Based on interview, personnel record review, and document review, the facility failed to ensure annual elder abuse prevention training was completed timely for 1 of 16 sampled employees (Employee #1). This deficient practice had the potential to place all residents at risk for abuse and neglect. Findings include:Employee #1 Employee #1 was hired as the Administrator on 06/15/2022. Employee #1's personnel record documented elder abuse prevention training completed on 03/20/2025, and annual elder abuse prevention training completed on 04/03/2026, 14 days late. On 06/04/2026 at 7:55 AM, the Human Resources (HR) Manager verbalized all staff were required to take elder abuse prevention training prior to working on the floor in the facility and annually thereafter. The HR Manager explained Employee #1 was required to complete annual elder abuse training no later than 03/20/2026, and confirmed Employee #1 completed annual elder abuse and prevention training late. The facility policy titled Abuse; Suspected Abuse; Reporting Unwitnessed Injuries; Abuse Prevention, last revised 01/07/2026, documented residents were to remain free from verbal, mental, sexual, or physical abuse, neglect, mistreatment, exploitation of person or property, involuntary seclusion, or corporal punishment by staff, volunteers, other residents, family, and visitors. To ensure compliance all staff would complete elder abuse training upon hire at the facility and annually thereafter.

Based on interview, clinical record review and document review, the facility failed to ensure a drug was not administered outside of ordered parameters for 1 of 12 sampled residents (Resident #2). This deficient practice had the potential to result in the administration of unnecessary drugs and physical harm to the resident. Findings include:Resident #2 Resident #2 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified, and chronic atrial fibrillation, unspecified. A physician's order, dated 04/06/2026, documented Metoprolol Tartrate oral tablet. Give 50 milligrams (mg) by mouth two times a day related to chronic atrial fibrillation unspecified. Hold if blood pressure (BP) < (less than) 90/60 and/or heart rate (HR) <60. Resident #2's 2026 Medication Administration Record (MAR) chart codes documented a check mark implied a medication was administered. The MAR documented Metoprolol was administered outside parameters on the following dates:-During the 6:30 AM administrations on 04/12, 04/22, 04/26, 05/02, 05/03, 05/05, 05/09, 05/11, 05/21, 05/23, 05/24, 05/27, and 05/28/2026.-During the 6:30 PM administrations on 04/20, 05/19, 05/23, and 06/02/2026. On 06/04/2026 at 9:29 AM, a Licensed Practical Nurse (LPN) explained Resident #2 took Metoprolol to manage blood pressure. The LPN confirmed the metoprolol order included parameters to hold if BP <90/60 and/or HR <60. The LPN explained the LPN would hold Resident #2's Metoprolol if both the systolic BP measured less than 90 millimeters of mercury (mmHg) and the diastolic BP read less than 60 mmHg. The LPN explained the LPN would not hold the Metoprolol if one of only one of the blood pressures fell below the ordered parameters. The LPN was unsure whether to hold the metoprolol if the resident's pulse fell below 60 beats per minute (bpm). On 06/04/2026 at 11:00 AM, the Director of Nursing (DON) explained resident vitals were taken prior to medication administration when parameters were included in a physician's order. The DON explained, according to the physician's order, Resident #2's Metoprolol should be held if one of the following was true: the systolic BP was below 90 mmHg, the diastolic BP was below 60 mmHg, or the pulse was below 60 bpm. The DON explained a check mark on a resident's MAR would indicate a medication was administered. The DON confirmed Resident #2's Metoprolol was administered outside parameters on the aforementioned dates. The DON verbalized the excessive administration of Metoprolol could lead to poor perfusion and increase the resident's risk of falling. The facility policy titled, Medication Administration Policy, revised 03/14/2024, documented prior to medication administration the healthcare professional must verify the five rights of medication administration: right patient, right medication, right dose, right route, and right time. All medications would be administered strictly according to the prescriber's orders.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a care plan was developed to address a resident's known behavior of placing a urinal on the overbed table for 1 of 12 sampled residents (Resident #8). This deficient practice had the potential to prevent the implementation of individualized interventions to address known resident behaviors and placed the resident at risk of physical harm. Findings include:Resident #8 Resident #8 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of chronic obstructive pulmonary disease, unspecified. On 06/04/2026 at 8:28 AM, Resident #8 was in bed in the resident's room. A meal tray was placed atop the overbed table. A urinal was set on the meal tray next to a bowl of cereal. Resident #8 verbalized being unsure how and when the urinal came to be on the meal tray. The resident explained the resident did not want the urinal placed next to the resident's food. On 06/04/2026 at 8:28 AM, a Certified Nursing Assistant (CNA) confirmed the urinal placement and verbalized the CNA would remove the urinal. On 06/04/2026 at 8:52 AM, the CNA explained any floor staff may deliver meal trays to residents. The CNA explained Resident #8 often placed the urinal on the meal tray and had previously been educated on where to appropriately place the urinal. The CNA explained the urinal should not be placed next to resident food as the urinal was contaminated with bacteria and other germs. On 6/04/2026 at 11:06 AM, the Director of Nursing (DON) verbalized a resident's urinal should never be placed next to a resident's food due to the increased risk of bacteria transmission. The DON explained approximately one month prior, the Infection Preventionist informed the DON Resident #8 kept the resident's urinal on the overbed table. The DON explained staff should regularly round on residents to ensure appropriate urinal placement. Resident #8's clinical record lacked documented evidence of an updated care plan to include behaviors related to urinal placement and infection control. On 06/04/2026 at 11:56 AM, the DON explained care plans could be updated by any department manager, including the DON, Social Worker, and Dietician. The DON would expect to see target behaviors to be presented on a care plan, including Resident #8's behavior of placing the urinal on the resident's meal tray. The DON confirmed the DON would have been responsible to update Resident #8's care plan. The facility policy titled, Care Plans, revised 02/08/2005, documented each resident would have a comprehensive care plan developed by the interdisciplinary team. These care plans would be updated as the needs of the resident changed. The Resident Care Manager or DON would make the changes in the care plan. Cross reference with tag F0880.

Based on interview and document review, the facility failed to ensure the Chief of Staff/Medical Director (MD) attended the Quality Assurance and Performance Improvement (QAPI) committee meetings between 06/05/2025 and 04/14/2026. This deficient practice had the potential to limit the ability of the MD to be informed of and inform the QAPI committee of identified concerns within the facility. Findings include:The facility provided QAPI Committee sign-in sheets for the following dates:-03/19/2025.-06/05/2025.-08/13/2025. The QAPI Committee sign-in sheet lacked documented evidence the MD attended and participated as a committee member.-09/17/2025. The QAPI Committee sign-in sheet lacked documented evidence the MD attended and participated as a committee member.-11/19/2025. The QAPI Committee sign-in sheet lacked documented evidence the MD attended and participated as a committee member.-01/27/2026. The QAPI Committee sign-in sheet lacked documented evidence the MD attended and participated as a committee member.-04/14/2026. On 06/04/2026 at 12:44 PM, the Director of Nursing (DON) defined the QAPI committee as an interdisciplinary team including the Risk Manager, DON, Assistant DON, Administrator, MD, Physical Therapy Manager, Minimum Data Set (MDS) Coordinator, Social Worker, Infection Preventionist and dietary representative. The QAPI committee attempted to meet every two months. The DON was unable to confirm whether the MD attend the aforementioned QAPI meetings and explained being aware the MD had previously neglected to initial the sign-in sheets. The QAPI Plan, revised 02/03/2025, documented the purpose of QAPI was to monitor caregiver, resident and family input, adverse events, performance indicators, survey findings, and complaints. The QAPI committee provided the backbone and structure for QAPI and would consist of representation from the MD.

Based on observation, document review and interview, the facility failed to ensure a resident's urinal was not located on the resident's meal tray and next to the resident's food for 1 of 12 sampled residents (Resident #8), The deficient practice had the potential to expose the resident to contamination and increase the risk of infection.Findings include:Resident #8 Resident #8 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of chronic obstructive pulmonary disease, unspecified. On 06/04/2026 at 8:28 AM, Resident #8 was in bed in the resident's room. A meal tray was placed atop the overbed table. A urinal was set on the meal tray next to a bowl of cereal. Resident #8 verbalized being unsure how and when the urinal came to be on the meal tray. The resident explained the resident did not want the urinal placed next to the resident's food. On 06/04/2026 at 8:28 AM, a Certified Nursing Assistant (CNA) confirmed the urinal placement and verbalized the CNA would remove the urinal. On 06/04/2026 at 8:52 AM, the CNA explained any floor staff may deliver meal trays to residents. The CNA explained Resident #8 often placed the urinal on the meal tray and had previously been educated on where to appropriately place the urinal The CNA explained the urinal should not be placed next to resident food as the urinal was contaminated with bacteria and other germs. On 6/04/2026 at 11:06 AM, the Director of Nursing (DON) verbalized a resident's urinal should never be placed next to a resident's food due to the increased risk of bacteria transmission. The DON explained approximately one month prior, the Infection Preventionist informed the DON Resident #8 kept the resident's urinal on the overbed table. The DON explained staff should regularly round on residents to ensure appropriate urinal placement. The facility policy titled, Cleaning and Storage of Personal Care Items, revised 05/13/2026, defined personal care items as a toothbrush, toothpaste, hairbrushes, urinals, emesis basins and bed pans. All personal care supplies would be labeled, cleaned, and stored in a manner preventing cross contamination between resident's personal items and of the environment. Urinals and bedpans must never be placed on an over the bed table or bedside table. Cross reference with tag F0657.

Based on observation and interview, the facility failed to ensure the results of the most recent survey of the facility were posted in a place readily accessible to residents, family members, and legal representatives of residents. This deficient practice had the potential to prevent all 24 residents in the facility from being educated on the facility from which they receive care. Findings include:On 06/02/2026 at 12:58 PM, during a resident council interview, a resident verbalized the results of the most recent survey was previously posted in a binder and available at the nursing station for review. Recently, the facility was painted and the binder was removed. No residents present in the resident council interview knew where the binder was moved to. On 06/03/2026 at 11:25 AM, the results of the most recent survey were not posted in the facility. On 06/03/2026 at 11:25 AM, the Director of Nursing (DON) explained the facility posted the most recent survey results in a binder easily accessible to residents. In March of 2026, the facility was painted and all of the billboards were removed from the walls, including the survey results binder. The DON explained it was important residents had access to the results of the most recent survey so residents and their families could make educated decisions about where to receive care.

Based on interview, clinical record review, and document review, the facility failed to ensure the facility's Quality Assurance and Performance Improvement Program identified areas of concern with the facility's Infection Prevention and Control Plan including concerns with pneumococcal immunizations and the immunization policy affecting 21 of 21 residents residing in the facility. This deficient practice had the potential to result in high-risk areas of concern and deficient infection control practices not being corrected and leading to infectious disease outbreaks and residents suffering severe illness or death from lack of vaccinations. Findings include: The facility document titled Infection Prevention and Control Annual Plan 2024/2025, documented a surveillance activity from the prior year was Prevention and Reduction of Pneumonia in long term care residents. The 2024 outcome of the surveillance activity was five residents had pneumonia in 2024. The effectiveness of the surveillance activity was documented as goal not met. The surveillance activity was not carried over to the 2024/2025 Infection Prevention Plan. The facility policy titled Immunizations, revised 04/06/2012, documented all residents would be offered influenza or pneumococcal immunizations unless medically contraindicated. The facility would follow current CDC guidelines for immunization schedules. Influenza immunizations would be offered as soon as the vaccination was available in the fall and continued until March 31st yearly. Pneumococcal immunizations would be offered once before the age of 65 and once after the age of 65. On 04/10/2025 at 9:43 AM, the Infection Preventionist (IP) verbalized the IP did present information during the QAPI committee meetings, but did not review the vaccination status of the residents and the Infection Prevention and Control Annual Plan was not presented to the QAPI committee for review. On 04/10/2025 at 4:11 PM, the Risk Manager verbalized the Infection Prevention Plan should have been reviewed by the QAPI committee and an unmet goal for a surveillance activity should have been reevaluated and carried over to the current plan. The Risk Manager confirmed the facility policy for Immunizations was not up to date or accurate and the facility was not vaccinating residents for pneumonia per current CDC guidelines. Cross reference with 883

Based on interview, clinical record review, and document review, the facility failed to ensure the facility's immunization policy was accurate and included correct, up to date information for vaccinations, resident's were provided vaccinations when the resident's consented to receive pneumococcal vaccines, and staff were training on accurate and correct information related to pneumococcal vaccinations affecting 21 of 21 residents residing in the facility (Residents #12, #17, #14, #8, #6, #20, #13, #2, #4, #5, #16, #19, #15, #11, #7, #10, #21, #3, #18, #1, and #9). This deficient practice had the potential to result in staff providing inaccurate education and information to residents based on the facility policy and training provided and residents experiencing severe or life-threatening illness from infection with pneumococcal bacteria due to lack of completing a pneumococcal vaccination series. Resident #12 Resident #12 was admitted to the facility on [DATE], with diagnoses including obesity, unspecified and personal history of COVID-19. A Pneumonia Vaccination Administration consent for Resident #12, dated 04/05/2017, documented the resident's responsible party had consented to the resident receiving the vaccine as recommended by the Centers for Disease Control and Prevention (CDC). The Immunization Record for Resident #12 documented the resident had received the following pneumococcal vaccines: - Pneumococcal conjugate vaccine to protect against 13 strains of streptococcus pneumoniae bacteria (PCV-13) administered 02/09/2017. - Pneumococcal polysaccharide vaccine to protect against 23 serotypes of streptococcus pneumoniae bacteria (PPSV23) administered 09/21/2018. Resident #17 Resident #17 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease and chronic systolic (congestive) heart failure. The clinical record for Resident #17 lacked a consent or education regarding the influenza vaccination. The facility was unable to provide an immunization record for Resident #17. Resident #14 Resident #14 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified, acute bronchitis, unspecified, and nicotine dependence, cigarettes, with unspecified nicotine-induced disorders. A Pneumonia Vaccination Administration consent for Resident #14 documented the resident had consented to receiving the vaccine on 12/16/2024. An Influenza Vaccine Administration consent for Resident #14 documented the resident had consented to receiving the vaccine on 12/16/2024. The Immunization Record for Resident #14 documented the resident had last received an influenza vaccine on 10/03/2023, and had received the following pneumococcal vaccines: - PCV-13 on 06/05/2019. - PPSV23 on 03/17/2020. Resident #8 Resident #8 was admitted to the facility on [DATE], with diagnoses including cerebral infarction, unspecified and nicotine dependence, cigarettes, with unspecified nicotine-induced disorders. A Pneumonia Vaccination Administration consent for Resident #8 documented the resident had consented to receiving the vaccine on 07/22/2021. The clinical record for Resident #8 lacked an Influenza Vaccination Administration consent for the 2024/2025 influenza season. The Immunization Record for Resident #8 documented the resident had last received an influenza vaccine on 09/28/2021, and had not received a pneumococcal vaccine. Resident #6 Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including shortness of breath and chronic obstructive pulmonary disease, unspecified. A Pneumonia Vaccine Administration consent for Resident #6, dated 10/31/2022, was signed by the resident and witnessed by a Licensed Practical Nurse (LPN) under both the section consenting to administration of the vaccine and the section declining administration of the vaccine. The Immunization Record for Resident #6 documented the resident had received the following pneumococcal vaccines: - PPSV23 on 11/05/2015. - PPSV23 on 01/15/2021. Resident #20 Resident #20 was admitted to the facility on [DATE], with diagnoses including hypothyroidism, unspecified and atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. The clinical record for Resident #20 lacked a Pneumonia Vaccine Administration consent or declination. The Immunization Record for Resident #20 documented the resident had received the following pneumococcal vaccines: - PPSV23 on 12/11/2009. - PCV-13 on 05/11/2017. - PPSV23 on 09/27/2019. Resident #13 Resident #13 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including pneumonia, unspecified organism and chronic obstructive pulmonary disease. A Pneumonia Vaccine Administration consent for Resident #13 documented the resident's representative had consented to the resident receiving the vaccination on 07/31/2023. The Immunization Record for Resident #13 documented the resident had received the following pneumococcal vaccines: - PCV-13 on 11/01/2018. - PPSV23 on 02/04/2020. Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type II diabetes mellitus without complications, nicotine dependence, cigarettes, with unspecified nicotine-induced disorders, and morbid (severe) obesity due to excess calories. A Pneumonia Vaccine Administration consent for Resident #2 documented the resident had consented to receiving the vaccine on 02/06/2020. The Immunization Record for Resident #2 documented the resident had received the PPSV23 vaccine on 12/24/2019. Resident #4 Resident #4 was admitted to the facility on [DATE], with diagnoses including spastic quadriplegic cerebral palsy, acute cough, and wheezing. The clinical record for Resident #4 lacked a Pneumonia Vaccine Administration consent or declination. The facility was unable to provide an immunization record for Resident #4. Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus without complications and adult failure to thrive. A Pneumonia Vaccination Administration consent for Resident #5 documented the resident had consented to receiving the vaccine on 06/30/2020. The Immunization Record for Resident #5 documented the resident had received the PPSV23 vaccine on 07/03/2013. Resident #16 Resident #16 was admitted to the facility on [DATE], with diagnoses including heart failure, unspecified and chronic kidney disease, unspecified. A Pneumonia Vaccination Administration consent for Resident #16 documented the resident had consented to receiving the vaccine on 04/27/2023. The Immunization Record for Resident #16 documented the resident had received the PCV-13 vaccine on 10/05/2016. Resident #19 Resident #19 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified and congenital pneumonia, unspecified. An Influenza Vaccine Administration consent for Resident #19 documented the resident had consented to receiving the vaccine on 01/02/2025. A Pneumonia Vaccination Administration consent for Resident #19 documented the resident had consented to receiving the vaccine on 01/02/2025. The Immunization Record for Resident #19 documented the resident had not received a pneumococcal or influenza vaccine. Resident #15 Resident #15 was admitted to the facility on [DATE], with diagnoses including chronic atrial fibrillation, unspecified, lobar pneumonia, unspecified organism, and contact with and (suspected) exposure to other viral communicable diseases. The clinical record for Resident #15 lacked a consent or declination for an influenza vaccine for the 2024/2025 influenza season. The most recent consent/declination forms for both influenza and pneumococcal vaccines available in the resident's record were dated 09/28/2021. The Immunization Record for Resident #15 documented the resident had last received an Influenza vaccine on 10/23/2023, and the resident had not received any pneumococcal vaccines. Resident #11 Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including heart failure, unspecified and chronic obstructive pulmonary disease, unspecified. A Pneumonia Vaccination Administration consent for Resident #11 documented the resident had consented to receiving the vaccine. The consent was undated. The Immunization Record for Resident #11 documented the resident had not received any pneumococcal vaccines. Resident #7 Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type II diabetes mellitus without complications and essential (primary) hypertension. A Pneumonia Vaccination Administration consent for Resident #7 documented the resident's representative had consented to the resident receiving the vaccine on 07/27/2023. The Immunization Record for Resident #7 documented the resident had received the PCV-13 vaccine on 01/16/2020. Resident #10 Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE], and 06/28/2024, with diagnoses including chronic obstructive pulmonary disease, unspecified and pneumonia, unspecified organism. A Pneumonia Vaccination Administration consent for Resident #10 documented the resident had consented to receiving the vaccine on 03/22/2023. The Immunization Record for Resident #10 documented the resident had received the following pneumococcal vaccinations: - PPSV23 on 09/26/2014. - PCV-13 on 02/15/2016. - Pneumococcal, UF (unspecified vaccine) on 02/15/2016. - PCV-13 on 02/08/2017. Resident #21 Resident #21 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus without complications and adult failure to thrive. A Pneumonia Vaccination Administration consent for Resident #21 documented the resident had consented to receiving the vaccine on 02/10/2025. The Immunization Record for Resident #21 documented the resident had received the following pneumococcal vaccinations: - PPSV23 on 02/16/2010. - PCV-13 on 08/12/2015. - PPSV23 on 04/05/2018. Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], and 07/03/2023, with diagnoses including chronic obstructive pulmonary disease, unspecified and type II diabetes mellitus without complications. A Pneumonia Vaccination Administration consent for Resident #3 documented the resident's representative had consented for the resident to receive the vaccine on 07/05/2023. The Immunization Record for Resident #3 documented the resident had received the following pneumococcal vaccinations: - PPSV23 on 12/04/2008. - PCV-13 on 01/31/2016. Resident #18 Resident #18 was admitted to the facility on [DATE], with diagnoses including adult failure to thrive and personal history of benign neoplasm of the brain. A Pneumonia Vaccination Administration consent for Resident #18 documented the resident had consented to receive the vaccine on 05/28/2024. The Immunization Record for Resident #18 documented the resident had not received a pneumococcal vaccine. Resident #1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including epilepsy, unspecified, not intractable, without status epilepticus and hydrocephalus, unspecified. A Pneumonia Vaccination Administration consent for Resident #1 documented the resident had received a pneumococcal vaccine on 04/10/2013. The consent was not signed by the resident and was signed by an LPN on 04/19/2022. The Immunization Record for Resident #1 documented the resident had received the PPSV23 vaccine on 04/10/2013. Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including other myeloid leukemia not having achieved remission, acute cough, and type II diabetes mellitus with diabetic neuropathy, unspecified. A Pneumonia Vaccination Administration consent for Resident #9 documented the resident had consented to receive the vaccine on 08/15/2023. The Immunization Record for Resident #9 documented the resident had received the following pneumococcal vaccinations: - PPSV23 on 03/04/2013. - PCV-13 on 02/01/2016. - PPSV23 on 03/04/2017. On 04/09/2025 at 10:25 AM, the Director of Nursing (DON) verbalized Resident #19 had not received the influenza or pneumococcal vaccination the resident had consented to because the facility was waiting until the resident was well enough to receive the vaccine. The DON verbalized the resident did not have fevers but the resident just wasn't themselves. The DON confirmed the resident had not been given further education on delaying the vaccinations and the resident's clinical record lacked documentation of a clinically indicated reason for the delay in vaccination. On 04/09/2025 at 10:27 AM, the Infection Preventionist (IP) verbalized the facility followed CDC guidelines for vaccination and would follow the CDC recommendations for vaccine schedules. The IP confirmed Resident #11 had consented to receive the pneumonia vaccine, but a pneumonia vaccine had not been administered to the resident. On 04/09/2025 at 6:08 PM, the DON verbalized the facility followed CDC guidelines for vaccine schedules. The DON confirmed none of the 21 residents in the facility had completed a pneumococcal vaccine series per the CDC pneumococcal vaccine schedule. On 04/10/2025 at 9:38 AM, the IP verbalized the immunization program for residents was the responsibility of the IP. The IP confirmed the IP was responsible for providing the orientation and training to facility staff on the immunization program. The IP verbalized the facility was following CDC guidelines. The IP verbalized the IP's understanding of pneumococcal vaccines was for a resident to receive one vaccine before age 65 and one vaccine after age 65. The IP confirmed the IP was unaware of the most current CDC schedule for pneumococcal immunizations. The IP confirmed residents in the facility had only received either the PPSV23 or PCV-13 vaccine. When shown the current CDC complete pneumococcal vaccine schedule for adults the IP confirmed PPSV23 and PCV-13 did not complete a pneumococcal vaccine series. The IP confirmed the facility had not administered the pneumococcal conjugate vaccine to protect against 20 strains of the bacteria streptococcus pneumoniae (PCV20), the pneumococcal conjugate vaccine to protect against 21 strains of the bacteria streptococcus pneumoniae (PCV21), or the 15-valent pneumococcal conjugate vaccine (PCV15). The facility document titled Infection Prevention and Control Annual Plan 2024/2025, documented a surveillance activity from the prior year was Prevention and Reduction of Pneumonia in long term care residents. The 2024 outcome of the surveillance activity was five residents had pneumonia in 2024. The effectiveness of the surveillance activity was documented as goal not met. The surveillance activity was not carried over to the 2024/2025 Infection Prevention Plan. On 04/10/2025 at 4:11 PM, the Risk Manager verbalized the Infection Prevention Plan should have been reviewed with the Quality Assurance and Performance Improvement committee and an unmet goal for a surveillance activity should have been reevaluated and carried over to the current plan. The Risk Manager confirmed the facility policy for Immunizations was not up to date or accurate and the facility was not vaccinating residents for pneumonia per current CDC guidelines. The CDC guideline titled Pneumococcal Vaccine Timing for Adults, dated 10/2024, documented adults [AGE] years or older had the following options to complete a pneumococcal vaccine schedule: - Those with no prior vaccine had the option to receive either the PCV20 or PCV21 or the option to receive the PCV15 and then the PPSV23 a year later. - Those who received the PPSV23 at any age had the option to receive either the PCV20 or PCV21 at least one year later or the option to receive the PCV15 at least one year later. - Those who received the PCV13 at any age would receive the PCV20 or PCV21 at least one year later. - Those that received the PCV13 at any age and the PPSV23 after [AGE] years of age would receive the PCV20 or PCV21 after at least five years. The schedule for adults 19 to [AGE] years old with chronic health conditions included offering those with no prior vaccines either the option of receiving the PCV20 or PCV21 or the option of receiving the PCV15 and then the PPSV23 after one year. The facility policy titled Immunizations, revised 04/06/2012, documented all residents would be offered influenza or pneumococcal immunizations unless medically contraindicated. The facility would follow current CDC guidelines for immunization schedules. Influenza immunizations would be offered as soon as the vaccination was available in the fall and continued until March 31st yearly. Pneumococcal immunizations would be offered once before the age of 65 and once after the age of 65. Cross reference with F726 and F867

Based on interview, clinical record review, and document review, the facility failed to 1) develop a person-centered Comprehensive Care Plan for the use of psychotropic medications for 1 of 12 sampled residents (Resident #18), and 2) ensure a resident's persistent symptoms associated with an ongoing concern of a low sodium level were care planned for 1 of 12 sampled residents (Resident #14). These deficient practices had the potential to result in health management concerns to remain unidentified and unaddressed. Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE], with a primary diagnosis of disorder of brain, unspecified. A physician's order dated 04/03/2025, documented Lorazepam oral concentrate 2 milligrams (mg) per milliliter (ml), give 0.5 ml by mouth every four hours as needed for terminal agitation for 14 days. Resident #18's health record lacked documented evidence a care plan had been developed to include Resident #18's Lorazepam. On 04/10/2025 at 9:23 AM, the Assistant Director of Nursing (ADON) verbalized it was important for care plans to include psychotropics to facilitate communication across shifts and to ensure residents received needed care. The ADON confirmed the Lorazepam was not addressed in Resident #18's care plan. 41848 Resident #14 Resident #14 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type II diabetes mellitus without complications, hyperglycemia, unspecified, and irritable bowel syndrome with diarrhea. On 04/07/2025 at 10:30 AM, Resident #14 verbalized the resident had been hospitalized for a low sodium level and was still experiencing frequent nausea from low sodium levels. A Progress Note, dated 12/09/2024, documented the resident was transferred to the Emergency Department (ED) for evaluation and subsequent admission for observation due to hyponatremia (low sodium levels). A Progress Note, dated 12/24/2024, documented the resident was sent to the ED for a critical low sodium level of 108 (the laboratory documented a reference range for a normal sodium level would be between 136 to 145 millimoles per liter (mmol/L). A Laboratory Report for Resident #14 documented the resident had a low sodium level of 129 mmol/L on 03/05/2025, a low sodium level of 133 mmol/L on 03/12/2025, and a low sodium level of 131 mmol/L on 03/19/2025. The Care Plan for Resident #14 did not include a care plan to address the ongoing concern of low sodium levels or symptoms of low sodium levels for the resident. On 04/09/2025 at 11:14 AM, the Registered Nurse (RN) for Resident #14 verbalized the Director of Nursing (DON) was responsible for updating the care plan. The RN verbalized the resident's low sodium levels had resulted in the resident experiencing symptoms of nausea, altered mental status, and changes in eating and drinking habits. The RN verbalized the cause of the low sodium levels had not yet been determined. The RN confirmed the resident did not have a care plan addressing the concerns of low sodium levels and the symptoms and interventions to alleviate symptoms should have been care planned. On 04/09/2025 at 2:45 PM, the DON confirmed the DON would frequently document the care plans but any nurse caring for a resident could document in the care plan. The DON confirmed Resident #14 did not have a care plan related to the resident's low sodium levels and verbalized a care plan would have been helpful to the nurses managing the resident's symptoms. The facility policy titled Care Plans, revised 03/22/2017, documented each resident would have a comprehensive person-centered care plan developed by the interdisciplinary team. The care plans would be updated as the needs of the resident changed. Comprehensive person-centered care plans must include measurable objectives and timeframes to meet a resident's mental and psychosocial needs. Comprehensive care plans must meet the requirements of the baseline care plans to incorporate physician orders.

Based on interview, clinical record review, and document review, the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 1 of 12 sampled residents (Resident #1). This deficient practice had the potential to deprive the resident of a person-centered care plan and the associated interventions relative to their current health management needs. Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of generalized anxiety disorder. A physician's order dated 10/15/2024, documented Buspirone Hydrochloride (HCl) oral tablet 10 milligrams (mg). Give 10 mg by mouth three times a day related to generalized anxiety disorder. Resident #1's physician orders lacked documentation of an antipsychotic medication. A quarterly MDS assessment dated [DATE], Section N0415 (Medications - High-risk Drug Classes: Use and Indication), documented Resident #1 took antipsychotic medications during the seven-day look-back period. The MDS assessment lacked documentation Resident #1 took antianxiety medications during the seven-day look-back period. Resident #1's February 2025 Medication Administration Record (MAR), documented Buspirone HCl was administered daily 02/01/2025-02/28/2025. The MAR lacked documented evidence an antipsychotic was administered to Resident #1. On 04/10/2025 at 9:20 AM, the Assistant Director of Nursing/MDS Coordinator verbalized Resident #1 did receive Buspirone HCl and did not receive an antipsychotic medication during the MDS assessment's seven-day look-back period. The MDS Coordinator confirmed Resident #1's MDS assessment did not indicate an antianxiety medication was received but should have, and documented an antipsychotic medication was received but should not have. The facility policy titled, MDS Process, dated 08/11/2003, documented if a revision was needed, the MDS Coordinator would be notified, and the revision would be made.

Based on interview, personnel record review, and document review, the facility failed to ensure initial communications training was completed timely per facility policy for 1 of 18 sampled employees (Employee #4). This deficient practice had the potential to prevent residents with communication needs from attaining or maintaining their highest practicable physical, mental and psychosocial well-being. Findings include Employee #4 Employee #4 was hired as the Registered Dietician on 10/21/2024. Employee #4's personnel record documented communication training completed on 11/30/2024, 40 days after hire. On 04/10/2025 at 2:39 PM, the Human Resources (HR) Generalist confirmed communication training was required for all employees and to be completed prior to working on the floor. The HR Generalist explained employee orientation lasted two to three days after hire. After completion of orientation, the employee would be released to work on the floor. On 04/10/2025 at 3:01 PM, the HR Manager confirmed Employee #4's personnel record lacked documented evidence of communication training completed prior to 11/30/2024. The facility policy titled, Training Policy, revised 02/06/2024, documented new employees were required to complete communication training prior to beginning work on the floor.

Based on interview, clinical record review, and document review, the facility failed to ensure resident consents for the COVID-19 (Covid) vaccination were offered or completed correctly for 2 of 5 residents sampled for vaccinations (Resident #18 and #21). This deficient practice had the potential to result in residents wishing to receive a Covid vaccination not receiving the vaccine and experiencing severe or prolonged illness, hospitalization , or death as the result of infection with the Covid virus. Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE], with diagnoses including adult failure to thrive and personal history of benign neoplasm of the brain. A Covid vaccine consent and declination form for Resident #18 had both the checkboxes for consent and declination completed and was signed by the resident and a facility employee on 10/29/2024. The Immunization Record for Resident #18 documented the resident's most recent dose of the Covid vaccine was administered on 04/21/2022. On 04/09/2024 at 9:24 AM, the Infection Preventionist (IP) confirmed Resident #18's consent form for the Covid vaccine indicated the resident both wanted the vaccine and was declining the vaccine. The IP verbalized the consent should have been clarified and corrected to indicate the resident's choice. Resident #21 Resident #21 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus without complications and adult failure to thrive. The clinical record for Resident #21 lacked a consent or declination form for the Covid vaccine. The Immunization Record for Resident #21 documented the resident had not received any doses of the Covid vaccine. On 04/09/2025 at 10:42 AM, the Director of Nursing (DON) verbalized a consent or declination form for the Covid vaccine had not been completed for Resident #21. The facility policy titled COVID-19 Voluntary Vaccination Policy, revised 02/20/2024, documented the facility would provide education and resources to promote the benefits and safety of COVID-19 vaccination. Regular communication efforts would be made to inform individuals about the availability, benefits, and recommended guidelines for COVID-19 vaccination.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure the Infection Prevention and Control Plan included a method of ongoing surveillance of active infections in the facility. This deficient practice had the potential to result in a delay in recognition of infection outbreaks and reversible trends going unrecognized leading to missed opportunities for staff education and infection spreading among residents and staff in the facility. Findings include: On 04/10/2025 at 9:24 AM, the Infection Preventionist (IP) verbalized the IP would compile a spreadsheet at the end of every month for residents in long term care with culture results and antibiotic orders. The IP was unable to provide an ongoing surveillance tool with locations of infections within the facility and verbalized the IP did not have a tool to monitor trends including location of infections, staff providing care to infected residents, residents colonized with multi drug resistant organisms, or infections not requiring antibiotics. The IP verbalized the facility was small so the IP would know if there was a concern with multiple infections but was unable to provide documentation of infection surveillance. The facility policy titled Surveillance Plan, revised 10/06/2024, documented the plan would assess the magnitude of healthcare associated infections within the facility, recognition of trends in infections rates, antimicrobial resistance, and healthcare associated pathogens.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure the Facility Assessment (FA) was accurate and included nicotine dependence and addiction with the facility's common diagnoses and conditions. This deficient practice had the potential to result in facility staff not receiving adequate training on the care of residents with nicotine dependence and addiction diagnoses and the needs of those residents not being met. Findings include: During the entrance conference with the facility on 04/07/2025, a list of cigarette smokers (smokers) residing in the facility and the FA was provided by the facility. The list of smokers in the facility included six residents. Three residents were able to smoke unsupervised and three residents required supervision during the designated smoking times of every two hours between 7:00 AM and 11:00 PM. The smoking location was designated as the smoke shack off the outside patio accessed through the facility dining room. The facility document titled Facility Assessment, reviewed 01/15/2025, did not include nicotine abuse or addiction under the list of common diagnoses and listed the number of active or current substance abuse disorders among residents as zero. On 04/10/2025 at 2:09 PM, the Director of Nursing (DON) verbalized the DON assisted with reviewing and completing the FA. The DON confirmed nicotine addiction was not identified on the FA as a diagnosis in the facility and the FA documented the number of residents with active or current substance use disorders was zero. The DON verbalized the DON did not consider nicotine addiction to be a substance use disorder. The DON confirmed six residents in the facility were current cigarette smokers. The Centers for Disease Control and Prevention article titled Treatment of Substance Use Disorders, dated 04/25/2024, documented a substance use disorder was a treatable, chronic disease and could range in severity from moderate to severe. A substance use disorder could be applied to many types of drugs including tobacco (nicotine). The facility document titled Facility Assessment Tool, undated, documented the FA would include the care required by the resident population considering the types of diseases and other pertinent facts present within the population.

Based on interview, clinical record review, and document review, the facility failed to ensure side effects and behaviors were monitored related to an ordered psychotropic medication for 1 of 12 sampled residents (Resident #18). This deficient practice had the potential to result in an unmanaged medication regimen, missed signs of worsening condition, and compromised resident safety. Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE], with a primary diagnosis of disorder of brain, unspecified. A physician's order dated 04/03/2025, documented Lorazepam oral concentrate 2 milligrams (mg) per milliliter (ml), give 0.5 ml by mouth every four hours as needed for terminal agitation for 14 days. The behavior and side effect monitoring binder lacked psychotropic monitoring for Resident #18. On 04/10/2025 at 9:23 AM, the Assistant Director of Nursing (ADON) explained all residents on psychotropic medications required behavior and side effect monitoring. Monitoring was done in a binder at the nurse's station. The ADON confirmed the binder lacked side effect and behavior monitoring for Resident #18's Lorazepam. On 04/10/2025 at 10:31 AM, the Director of Nursing (DON) verbalized behavior and side effect monitoring for Resident #18's Lorazepam had not yet begun. On 04/10/2025 at 1:28 PM, the Director of Nursing (DON) explained Lorazepam was being used to treat Resident #18's terminal agitation. In December of 2024, Resident #18 began to have terminal agitation exhibited by hallucinations, decreased communication, decreased appetite, sleeping more often, and sensitivity to light. The facility policy titled Psychotropic Medication Use, revised 04/20/2023, documented psychotropic medications included hypnotics, antipsychotics, benzodiazepines, sedatives, and antidepressants. Licensed nurses would be aware of potential side effects of psychotropic medications and all medical and nursing staff would evaluate the effectiveness of as needed psychotropic drugs to manage behavior.

Based on observation, interview, clinical record review, and document review, the facility failed to 1) ensure a resident's nutrition care plan was updated after the resident had a significant weight loss for 1 of 12 sampled residents (Resident #11). This deficient practice had the potential to result in a resident with significant weight loss not receiving interventions to correct the weight loss or prevent further weight loss; and 2) to ensure a resident's activity care plan included interventions related to activity preferences and services for 1 of 12 sampled residents (Resident #21). This deficient practice had the potential to result in a resident with activity preferences not receiving the activity, care, and services for the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #11 Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type II diabetes mellitus without complications, pressure-induced deep tissue damage of right heel, and chronic obstructive pulmonary disease, unspecified. On 04/07/2025 at 1:22 PM, the resident was lying in bed and the resident's face appeared gaunt with a sunken appearance around the resident's eyes and cheeks. The resident verbalized the resident had been eating less due to a decreased appetite and the resident did not like the food served by the facility. The resident verbalized the resident felt the resident had lost weight because of not eating. The Weights and Vitals Summary for Resident #11 documented the following: - On 02/02/2025, the resident's weight was 156.8 pounds (lbs). A 10.25 percent (%) weight loss over five months from the resident's weight of 174.7 lbs on 09/01/2024. - On 04/06/2025, the resident's weight was 154.6 lbs. A 15.01% weight loss over three months from the resident's weight of 181.9 lbs on 01/06/2025. The Care Plan for Resident #11 included a care plan for altered nutrition status. The care plan had last been revised on 09/08/2024, prior to the resident's significant weight loss recorded on 02/02/2025, and 04/06/2025. On 04/09/2025 at 2:48 PM, the Director of Nursing (DON) verbalized the nutrition care plan for Resident #11 should have been updated when significant weight loss was identified. On 04/10/2025 at 9:06 AM, the Registered Dietitian (RD) verbalized interventions to implement after significant weight loss would include evaluating meal intake and percentage of meals eaten, assessing skin integrity, encouraging protein intake, and ensuring the resident was turned every two hours to prevent skin breakdown. Cross reference with F692 43311 Resident #21 Resident #21 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus without complications, failure to thrive, and acquired absence of unspecified leg below knee. Resident #21's Care Plan documented the following activities care plan focus on 02/18/2025: The resident partially depended on staff for activities due to physical limitations of using a wheelchair and requiring staff to assist with transfers. The goal documented Resident #21 wanted to go on a nature adventure within the review period and was dated 02/18/2025. The goal was revised on 03/29/2025, to include a target date of 05/16/2025. Resident #21's Care Plan lacked interventions related to the documented activities focus and goals. On 04/09/2025 at 2:21 PM, the DON explained the Activities Director (AD) would fill out the activities portion of the care plan for all residents. The DON verbalized an expectation the AD would accurately and completely document the resident's preferred activities focus, goals, and interventions on the care plan. The DON confirmed Resident #21's Care Plan lacked interventions related to the residents' preferred facility activities and services. On 04/09/2025 at 4:07 PM, the AD explained the activities portion of Resident #21's Care Plan was created by the AD during the resident interview. The AD explained the AD was not aware the interventions were missing from the care plan and would be necessary to provide activities in a manner the resident preferred. The AD confirmed the activities interventions were the AD's responsibility to document and implement and were not documented on Resident #21's Care Plan. The facility policy titled Care Plans, revised 03/22/2017, documented each resident would have a comprehensive person-centered care plan developed by the interdisciplinary team. The care plans would be updated as the needs of the resident changed and would include any updated information based on details of the comprehensive assessment. The care plan included the instructions needed to provide effective person-centered care of the resident that met professional standards of quality care. The comprehensive person-centered care plan was consistent with resident's rights and included measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment and included the description of any services that were furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview, clinical record review, and document review, the facility failed to ensure nursing staff responsible for administering vaccinations had been trained according to accurate vaccination guidelines and were not instructed to follow a facility policy containing outdated and inaccurate information affecting 21 of 21 residents residing in the facility. Findings include: On 04/09/2025 at 6:08 PM, the Director of Nursing (DON) verbalized the facility would follow the Centers for Disease Control and Prevention (CDC) guidelines for vaccine schedules. The DON confirmed none of the 21 residents in the facility had completed a pneumococcal vaccine series per the CDC pneumococcal vaccine schedule. On 04/10/2025 at 9:38 AM, the Infection Preventionist (IP) verbalized the immunization program for residents was the responsibility of the IP. The IP confirmed the IP was responsible for providing the orientation and training to facility staff on the immunization program. The IP verbalized the facility was following CDC guidelines. The IP verbalized the IP's understanding of pneumococcal vaccines was for a resident to receive one vaccine before age 65 and one vaccine after age 65. The IP confirmed the IP was unaware of the most current CDC schedule for pneumococcal immunizations and confirmed the facility was not following the CDC guidelines for pneumococcal vaccinations when presented with the CDC's guidelines on pneumococcal vaccine timing for adults. On 04/10/2025 at 4:11 PM, the Risk Manager confirmed the facility policy for Immunizations was not up to date or accurate and the facility was not vaccinating residents for pneumonia per current CDC guidelines. The facility policy titled Immunizations, revised 04/06/2012, documented all residents would be offered influenza or pneumococcal immunizations unless medically contraindicated. The facility would follow current CDC guidelines for immunization schedules. Influenza immunizations would be offered as soon as the vaccination was available in the fall and continued until March 31st yearly. Pneumococcal immunizations would be offered once before the age of 65 and once after the age of 65. Cross reference with F883

Based on observation, interview, clinical record review, and document review, the facility failed to ensure the facility policy for weight loss was followed when a resident experienced a significant weight loss for 1 of 12 sampled residents (Resident #11). This deficient practice had the potential to result in a resident experiencing adverse outcomes from a significant weight loss not identified by the facility and a delay in care from the Registered Dietitian (RD) not being notified of the resident's weight loss. Findings include: Resident #11 Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type II diabetes mellitus without complications, pressure-induced deep tissue damage of right heel, and chronic obstructive pulmonary disease, unspecified. On 04/07/2025 at 1:22 PM, the resident was lying in bed and the resident's face appeared gaunt with a sunken appearance around the resident's eyes and cheeks. The resident verbalized the resident had been eating less due to a decreased appetite and the resident did not like the food served by the facility. The resident verbalized the resident felt the resident had lost weight because of not eating. The Weights and Vitals Summary for Resident #11 documented the following: - On 04/06/2025, the resident's weight was 154.6 lbs. A 15.01% weight loss over three months from the resident's weight of 181.9 lbs on 01/06/2025. The Weights and Vitals Summary for Resident #11 did not include documentation of a weight taken on 04/07/2025 to verify the significant weight loss. The clinical record for Resident #11 did not include documentation of notification of the significant weight loss to the RD. On 04/09/2025 at 11:19 AM, the Registered Nurse (RN) for Resident #11 verbalized a resident with a significant weight loss would be reweighed the following day to verify the findings. The RN verbalized the RN would not contact the RD to notify of the significant weight loss. On 04/09/2025 at 2:46 PM, the Director of Nursing (DON) confirmed Resident #11 did have significant weight loss based on the weight recorded from 04/06/2025. The DON verbalized the process for reviewing significant weight loss was for staff to discuss resident weights during an interdisciplinary team (IDT) meeting on Monday mornings and the RD would attend the IDT meeting once a month. The DON verbalized a resident with a significant weight loss would be reweighed the following day to verify the weight loss and the RD would be notified. The DON confirmed Resident #11 had not been reweighed and the RD had not been notified. On 04/10/2025 at 9:06 AM, the RD verbalized the RD was sent an email from the facility on Monday mornings notifying the RD if a resident has a nutrition concern or significant weight loss. The RD verbalized the RD reviewed the communication the RD was sent by the facility on Monday, 04/07/2025, and Resident #11 was not discussed in the email. The RD confirmed the RD had not been informed of Resident #11's most recent significant weight loss. The RD confirmed a 15% weight loss over three months was considered a significant weight loss. The RD verbalized the RD would expect the facility to reweigh the resident to verify the weight change and would then review the resident's recent meal intake and percentage of meals eaten. The RD discussed possible interventions the RD would initiate included adding a nutritional supplement, increasing protein due to the increased risk of skin breakdown, reinforcing the importance of turning the resident every two hours, and requesting bloodwork. The facility policy titled Weight Loss, revised 09/06/2012, documented residents would be evaluated for weight loss. Residents with a weight change of five pounds would be reweighed the next day. Significant changes in weights would initiate a nutrition meeting and weekly weights until weights were stable. Cross reference with F657

Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) a resident did not have a wooden trap (a trap using a spring-loaded mechanism with a metal bar designed to snap shut with sufficient force to trap and kill a rodent when the trap was triggered) set and baited with peanut butter in a resident's bathroom for 1 of 12 sampled residents (Resident #15). This deficient practice had the potential to result in a resident accidentally triggering the trap when entering the bathroom and sustaining injury to the resident's foot; and 2) unsecured medications prescribed to facility staff were not left unattended at the Nurse's Station. This deficient practice had the potential to cause harm by ingestion of unsecured medications by residents residing in the Long Term Care Unit. Findings include: Resident #15 Resident #15 was admitted to the facility on [DATE], with diagnoses including chronic atrial fibrillation, unspecified and adult failure to thrive. On 04/07/2025 at 11:50 AM, there was a wooden rodent trap set and baited in the resident's bathroom. The resident verbalized the resident had woken up one night and saw a mouse near the entrance to the bathroom. The resident verbalized the resident told staff and staff's solution was to put the rodent trap in the resident's bathroom. On 04/08/2025 at 2:36 PM, the Director of Nursing (DON) verbalized the facility had found no evidence of mice in resident rooms and the trap in the resident's bathroom could have been a safety hazard if the resident accidentally triggered the trap with the resident's foot. 43311 Unsecured Medications On 04/09/2025 at 5:02 PM, a duffle bag was observed at the Nurse's station to be open, unsecured, and unattended with four medication bottles in view. On 04/09/2025 at 5:42 PM, a Registered Nurse (RN) explained the open duffle bag belonged to staff and was left unattended at the Nurse's Station with four medication bottles in view. The RN confirmed there were four medication bottles that were prescribed to a staff member in the duffle bag and were left unsecured and available to residents for an unknown amount of time. The RN explained the RN had moved the duffle bag into the DON's office once the unsecured bag was discovered. The RN confirmed the labeled contents of the four unsecured medication bottles were as follows: -Hydrochlorothiazide 25 milligrams (mg), -Lisinopril 10 mg, -Losartan potassium 100 mg, and -Losartan potassium 50 mg. The RN confirmed the medications could have caused a resident's blood pressure to bottom out, which meant a resident's blood pressure could be rendered low enough to cause a medical emergency. On 04/09/2025 at 5:46 PM, the DON confirmed the staff duffle bag was left unsecured and contained a staff member's personal medications. The DON explained the expectation of staff was to secure any personal belongings and not allow resident access to unprescribed medications for safety concerns. The facility document, titled Resident Rights, revised 08/2018, documented the resident had the right to a safe environment. This included ensuring the physical layout of the facility maximized resident independence and did not pose a safety risk.