Every finding on record at Lemont Nursing & Rehab Center

Based on interview and record review, the facility failed to update a Care Plan indicating the need for transfer assistance after a significant change in condition for R1. This deficiency affects one (R1) of three residents reviewed for Care Plan revision.Findings include:On 6/6/26 at 12:00PM, physician note dated 4/18/26 was reviewed and indicates the following for R1: Right Lower Extremity- non weight bearing due to fracture (RLE-NWB d/t fracture).R1 has an Activity of Daily Living (ADL) self-care performance/mobility deficit Care Plan-date Initiated: 10/01/2025 with intervention TRANSFER: The resident is able to: move between surfaces with max assist x 1person date Initiated: 10/27/2025.On 6/6/26 at 2:15PM, V1 (Director of Nursing) said that for R1 the Transfer status as of 4/18/26 should be updated to reflect the residents non weight bearing status. V1 said she is unsure why the care plan shows transfer status x 1 person assist and should be a Mechanical lift transfer due to non-weight bearing to the right lower extremity. R1 is a [AGE] year-old admitted to the facility on [DATE] with the following diagnosis in part but not limited to: encounter for other orthopedic aftercare, infection and inflammatory reaction due to internal right hip prosthesis, subsequent encounter, methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere, history of falling, periprosthetic fracture around internal prosthetic right hip joint, subsequent encounter.Minimum Data Set (MDS) dated [DATE] section GG - Functional Abilities- Mobility indicated R1 is 01-Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. For Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).Facility Policy on Care Plans (Comprehensive) revised 10/2022Policy: An individualized Comprehensive Care Plan that indicates measurable objectives and timetables to meet the resident's medical, nursing, mental and/or psychological needs is developed for each resident.Policy specifications:The Facilities Care Planning/Interdisciplinary team, in coordination with the resident, his/her family or his/her representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.5. Care plans are revised as changes in the residents condition dictates.

Based on observation, interview and record review the facility failed to maintain the kitchen in a manner that prevents food borne illness.This applies to all 135 residents receiving dietary services.Findings include:The CMS 671 start date of 01/06/2026 shows a total of 135 residents residing in the facility. On 01/07/2026 at 2:35 PM, V1 Administrator confirmed all 135 residents received meal services from the dietary department.On 01/06/2026 at 1:51 PM, R108 stated he did not want to eat from the facility cutlery because it isn't clean when he receives it. R108 stated he would rather use plastic.On 01/06/2026 at 9:53 AM, the kitchen tour began with V19 Dietary Manager.The stove had a silver facility pan on an open flame with brown gravy and had plastic wrap covering.Two areas of the kitchen were prepping food. Only one red sanitation bucket was in use. The red sanitization bucket tested at 0 ppm (Parts Per Million).The high temperature dish machine was run to test. The dishwasher was dirty inside and out with the mint-colored flaps in the dishwasher caked and with a thick tan [NAME]. Test strips used turn orange at 160 degrees. The wash dial reached a maximum temperature of 150 degrees Fahrenheit. The rinse dial reached a maximum temperature of 120 degrees Fahrenheit.No logs for refrigerators, coolers, red buckets, three compartment sink or dishwasher were noted in the kitchen.V30 Dietary Aide stated he knew he was supposed to have a red sanitization bucket in his area, but forgot. V30 stated he had not logged the dish machine temperatures in weeks, and he did not know where the logs were. V30 stated he should inform V19 (Dietary Manager) of any issues with the dishwasher or if it does not get to a rinse temperature of 180 degrees. V32 Dietary Aide stated he hadn't logged the sanitizer level of the three-compartment sink in over three weeks and had forgotten to complete the task. V31 [NAME] stated they have never done logs for the red sanitization buckets.V19 Dietary Manager stated the dishwasher hadn't gotten to 180-degree Fahrenheit since she started working in the facility. V19 stated the dishes were still safe to use if the test strip turns orange at 160 degrees Fahrenheit.The mixer, meat slicer and equipment identified as a tomato slicer that were not in use were dirty and uncovered. The toaster oven was dirty with excessive amounts of crumbs. Cooking utensils on an open cart were dirty. Two sliver drawers containing utensils were dirty inside and held dirty utensils.DRY STORAGETwo personal winter coats were hanging on storage racks. Food item identified as breadcrumbs by V19 was wrapped in plastic without a label or dates. Tortilla chips in a clear plastic bag had no label or dates. A bin with contents identified by V19 as powdered sugar had no label or dates and had a measuring cup stored in the product. A bin of flour without a label or dates had a scoop stored in the product. A large trashcan-like container labeled oats was lined with a garbage bag and did not have dates. A large trashcan-can like container lined with a garbage bag with contents identified by V19 as breadcrumbs had no label or dates. A bin identified by V19 as sugar had no label or dates. The bin contained a scoop, black particles, and a piece of parchment paper resting in the product. A 6lb 10oz can of mandarin oranges, a 3lb 2oz can of chicken soup, and two 6lb 10oz of apple sauce were dented.A facility container with panko breadcrumbs was open to air and was dated 11/27/24, use by 5/27/28. Potato pearls 31.9 oz wrapped in plastic was undated. Bran cereal with raisins in a facility container had a single date of 9/12/25. Granola cereal in a facility container had a single date of 9/25/25. Corn flaked cereal, crisped rice cereal and oat circles cereal in facility containers were without labels and dates.WALK IN COOLERThe floor was dirty with crumbs, and the corner had an orange spill against the wall and floor.Two blocks of white sliced cheese were poorly wrapped in plastic with the edges open to air and corners dried out with a single date of 12/25. Two blocks of yellow sliced cheese were poorly wrapped in plastic with the edges open to air and corners dried out. One block of sliced white cheese was poorly wrapped in plastic and open to air. There was a silver facility bin with tomato soup with a single date of 12/12, banana pudding in a facility container dated 12/31, and a silver bin with barbecue sauce with a single date of 12/26.A 2-gal (gallon) container of kosher dill chips with chips floating on top was open to air and had a single date of 11/08/25. Ten cups identified by V19 as apple crisps had no labels, dates or lids. One hundred and thirty cups identified by V19 as pear cobbler had no labels, dates or lids. Thirteen saucers identified by V19 as yellow cake had no labels, dates or lids.WALK IN FREEZERA clear plastic bag identified by V19 as sausage patties had no labels or dates, and a clear plastic bag identified by V19 as hash brown patties had no labels or dates.On 01/08/2026 at 2:54 PM, V19 Dietary Manager stated kitchen equipment like slicers and mixers should be cleaned and covered to keep them from being contaminated. Personal belongings should not be kept in the kitchen because it can cause contamination of food items. Food items should be labeled with contents and prepared-on and use-by dates so staff can be sure it is safe to use. V19 stated scoops and cups should not be kept in bins with food items because it can be a source of cross contamination. V19 stated I don't know if those bags (liners) were food safe or not. The containers should probably not be lined with those bags if they aren't food safe- it could leach into the food and contaminate the food potentially causing illness. Parchment paper should not be in the product. V19 stated the bins need to be washed sanitized and filled with new product. Dented cans should be tossed and not used. They could be contaminated and cause illness.V19 stated foods should not be left open to air when being stored so they don't dry out or become contaminated. V19 stated outdated items should be thrown out so they aren't served and cause illness. Individual servings of food should be covered with a lid or wrapped so they don't become contaminated. V19 stated the gravy that was being heated on the stove with plastic wrap could melt and contaminate the gravy.V19 stated the kitchen staff is responsible for cleaning the kitchen and that includes mopping the floors and wiping everything down. Utensils should be put away clean and without food particles, so it doesn't contaminate food we are preparing.V19 stated I don't know the low range of the ppm (parts per million) for red buckets or the three compartment sink, the high end is 400 ppm. The sanitization level should be checked and logged to prevent illness. The refrigerator logs were not done either. Tracking the temperatures assures the food stored at the proper temperature and is not spoiling or going bad. V19 stated red buckets should be at every food prep station so we can assure the stations are clean and sanitary if not it can cause cross contamination. V19 stated the wash temp for dishwasher should be 160 F and the rinse temperature should be 180 F to assure the dishes are properly disinfected. If the required temperatures are not reached, dishes aren't disinfected so they would need to be manually sanitized. Serving food on unsanitary dishes can cause illness. Kitchen staff should be reporting it to me or maintenance so it can be fixed immediately. The company came out and added an extra line, and the dishwasher now disinfects by chlorine. V19 stated I don't know what the chlorine level should be and I don't have test strips and there is no log. The facility policy Food Storage dated June 2023 stated:The food storage area shall be clean at all times Refrigerator and freezer temperatures will be monitored twice daily and recorded on temperature monitor logs by culinary personnel Staple foods are stored in an orderly and systematic arrangement with the older stock to the front of the shelves. First in first out system Food and nonfood supplies are to be clearly labeled Leftover foods are labeled, dated, immediately placed under refrigeration and used within 72 hours or discarded All exposed foods should be stored tightly covered No personal items will be stored with food items.The facility policy Equipment Maintenance dated June 2023, states all food service equipment will be operated, maintained, serviced and cleaned according to manufacturer's directions.The facility policy Sanitation and Infection Control dated June 2023, states utilize and fill red buckets with sanitizing solutions, replace every 2 hours. Sanitizer solution should read 200 ppm.Dishwasher sanitizing method- Keep the machine clean. Clean and sanitize daily before closing down and before using the machine. Check the water temperature, pressure and sanitizer levels document temperatures daily. Wash temperature should reach 150 degrees Fahrenheit. Rinse temperatures should reach 180 degrees Fahrenheit.

Based on interview and record review, the facility failed to provide the required twelve (12) hours per year of continuing competence training for Certified Nursing Assistants (CNA's), including dementia management training. This failure has the potential to affect all 135 residents in the facility. The findings include: The facility's January 6, 2026, Centers for Medicare and Medicaid Services (CMS) Form 671, Long-Term Care Facility Application for Medicare and Medicaid, showed 135 residents live in the facility. On 01/07/26 at 2:19 PM, V5 (Human Resources Director) said V2 (Director of Nursing) is responsible for in-service trainings and competencies of the CNAs. V5 stated she did not know who tracks the CNA yearly hours and did not know how many hours are required. V5 stated she did not know which mandatory trainings must be included in the hours. On 01/07/26 at 2:32 PM, V2 stated she did not know how many training hours CNAs were supposed to have every year. V2 stated she didn't know what the mandatory trainings for the CNAs were. On 01/07/26, review of the facility's CNA orientation packet showed no evidence of dementia-related in-services. A sample review of five CNA personnel files also showed no documentation of dementia specific training. On 01/08/26 at 9:15 AM, V12 and V7 (CNAs) stated they do not keep track of their own annual training hours. On 01/08/26 at 9:45 AM, V10 and V11(CNAs) stated they do not keep track of their annual training hours. Review of the facility's Diagnosis Report dated 01/08/26 showed 87 current residents with diagnoses of dementia and/or Alzheimer's disease. On 01/08/26 at 8:37 AM, V1 (Administrator) stated the facility did not have a specific policy regarding staff education requirements, they follow the regulation.

Based on observation, interview, and record review, the facility failed to ensure residents have orders in place for pacemaker monitoring and that the orders are carried out. This applies to 2 residents (R4 and R93) reviewed for pacemaker care.The findings include:1.On 1/6/26 at 10:49 AM and 1/8/26 at 9:52 AM a pacemaker monitor with a green light was observed on the nightstand in R4's room.R4's Face sheet shows she was initially admitted to the facility on [DATE] and has the following diagnoses: dementia, hypertension, heart failure, sick sinus syndrome, and presence of cardiac pacemaker. As of 1/7/26, R4's POS (Physician Order Sheet) did not show any physician order for pacemaker checks and there was no documentation in the electronic health record showing what type of pacemaker R4 had, the model or serial number, the programmed pulse rate, and/or how often pacemaker checks are to be completed. R4's Care Plan initiated on 11/18/25 shows she has a pacemaker related to atrial fibrillation and dysrhythmias but does not specify the pacemaker type in the area designated. Intervention states monitor/document/report PRN (as necessary) any signs or symptoms of altered cardiac output or pacemaker malfunction including pulse rate lower than programmed rate.On 1/8/26 at 9:53 AM, V15 (LPN/Licensed Practical Nurse) said as R4's nurse she knows R4 has a pacemaker, but she does not know what the settings and/or model are or how often the pacemaker checks occur. V15 said the model and serial number used to be documented in the electronic medical record, but since the facility got a new documentation system in the past year, she does not know where to find that information now.2. On 1/6/26 at 12:09 PM R93 was observed asleep in her bed with a pacemaker monitor device on her nightstand, not lit up.R93's Face sheet shows she was initially admitted to the facility on [DATE] and she has the following diagnoses: dementia, hypertension, atrial fibrillation, sick sinus syndrome, heart failure, and presence of cardiac pacemaker. As of 1/7/26 at 2:18 PM, R93's POS did not show any physician order for pacemaker checks and there was no documentation in the electronic health record showing what type of pacemaker R93 had, the model or serial number, the programmed pulse rate, and/or how often pacemaker checks are to be completed. As of 1/8/26, R93's Care Plan was reviewed and there was no Care Plan specific to R93's pacemaker care or interventions.On 1/8/26 at 9:44 AM, V13 (RN/Registered Nurse) said she was not sure what the nurse's role was when the resident has a pacemaker. V13 said she would need to check with V2 (DON/Director of Nursing). V13 said R93 has the pacemaker monitor on her nightstand, and the cardiology office hasn't called regarding the pacemaker function, so she assumes the pacemaker is working. V13 said she does not know how often R93's pacemaker checks are done.On 1/8/26 at 1:28 PM, V2 (DON) said the facility's responsibility when providing care for a resident with a pacemaker is to follow the physician orders and both R4 and R93 need to have physician orders entered for pacemaker checks. V2 said both R4 and R93 should be care planned for having a pacemaker and the interventions should say to check the pacemaker as ordered. V2 said both R4 and R93 have forms that document the pacemaker model, but she has not uploaded the forms into the electronic medical record yet. V2 said R93 has not had a pacemaker check completed since her admission to the facility. V2 said it is important to complete pacemaker checks and monitor pacemaker functionality because the pacemaker is responsible for pacing the resident's heart rate and there are a lot of negative outcomes, up to and including death, that can occur if the pacemaker is not functioning appropriately.The facility's policy titled, Pacemakers dated 4/04 states, General: To provide guidance on the care of residents with pacemakers. Responsible Party: Nursing Staff Guideline:.2. Pacemaker checks are done per manufacturer's instructions and per orders.

Based on observation, interview, and record review, the facility failed to implement interventions for a resident's comprehensive pressure ulcer management strategy, including offloading a wound, mattress use, and nutritional supplement use. This applies to 1 resident (R123) reviewed for pressure injuries in a sample of 3. The findings include: R123's Face Sheet shows an admission date of 8/9/2025 with diagnoses including stage 4 pressure ulcer of the sacral region, dementia, and dysphagia. On 1/8/2026 at 1:40 PM, V26 (R123's Primary Physician) stated that his expectation is for facility staff to follow V24's (Wound Doctor) recommendations to ensure proper offloading, perform turning/repositioning, and administer nutrition supplements as ordered to support healing. V26 stated that failure to implement these interventions could impact functional status, wound healing, and overall health, including delayed healing, disease exacerbation, and increased risk of infection. R123's Kardex dated 1/8/2026, provided by V2 DON (Director of Nursing) showed that R123 requires total assistance for bed mobility and should be turned and repositioned in bed as necessary. V2 stated the Kardex system is intended to provide floor staff with resident instructions since they do not have access to residents' full care plans. Observation by surveyor from 10:36 AM to 12:50 PM on 1/6/2026, (either inside R123's room or within visual range of his door) noted the following staff activity and resident interactions:10:50 AM: V22 (CNA) entered briefly to set supplies down.10:55 AM: V22 returned to provide perineal care.11:00 AM: V2 (DON/Director of Nursing) observed outside room; did not enter.11:14 AM: V22 removed bagged dirty linen per V18 (R123's Niece) request.11:16 AM: V18 (R123's Niece) requested R123 be weighed via mechanical lift.11:20 AM: V21 (Nursing Supervisor) and V22 (CNA) positioned resident to prepare to obtain R123's weight per V18's request 11:31 AM: V23 (RN/Registered Nurse) had just finished checking R123's blood sugar as V24 entered for wound care.12:00-12:30 PM: Facility staff observed in hallway for tray service; V18 remained in R123's room and assisted him with lunch.12:50 PM: V18 (R23's Niece) stated R123 had not been positioned to offload his wound during this shift. Per V18, V24 (Wound Care Coordinator-WCC) stated manual turning is unnecessary due to R123's alternating-pressure mattress. On 1/7/2026 at 2:56 PM, V24 (WCC) stated that residents with alternating pressure mattresses do not require manual turning every two hours, as the mattress redistributes pressure and turning could cause pain or discomfort. V24 stated that such specialty mattresses take the place of manual turning, repositioning, and offloading. On 1/6/2026 at 10:36 AM, R123's specialty mattress was set for a 160 lb. (pound) person. The next day on 1/7/2026 at 2:30 PM and the day after that on 1/8/2026 at 12:40 PM, the mattress remained set for a 160 lb. person. R123's most recent weight was documented as 125.6 lbs. as of 1/2/2026. The (brand of mattress) Operation Manual for R123's mattress showed the mattress system is intended for prevention and treatment of pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. The Manual does not indicate that the mattress would replace wound offloading, manual turning, or repositioning interventions. On 1/7/2026 at 2:56 PM, V24 stated that floor nurses are expected to verify and adjust mattress weight settings each shift, and incorrect settings could affect pressure distribution and wound offloading, potentially worsening the injury. R123's POS (Physician Order Sheet) included an order to check and ensure mattress settings match resident weight each shift. R123's January 2026 POS (Physician Order Sheet) also included orders for (arginine powder) oral packet (a nutritional supplement to support wound healing) to be given three times per day, since admission in August. Review R123's EMAR (Electronic Medical Record) showed 75 doses of the (arginine powder) had been missed/not given and documented as not available or awaiting pharmacy delivery. V25's (Wound Doctor) 11/11/2025 wound assessment included wound deterioration as Lower back wound looks more pale. There are areas of undermining in the most inferior portion of the wound not present there before with watery drainage and pale granulation tissue. Assessment: patient wound base looks less organized with areas covered with granulation tissue now bare. Bone coverage is not great. There are areas of undermining that were not present before on his last visit. It is imperative that patient continue offloading this area. We should supervise that patient nutrition is high protein and minimal carbohydrate. On 1/8/2026 at 2:15 PM, V2 (DON) stated that it is her expectation that the facility's pressure ulcer prevention and management protocols be followed. V2 stated this includes ensuring residents receive ordered nutritional supplements; residents with impaired mobility are turned and repositioned every two hours regardless of mattress type; soiled dressings are removed; and new dressings are applied after appropriate wound cleansing. Per V2, failure to follow these interventions could result in infection and delayed wound healing. The facility's policy, Pressure Ulcer and Wound Prevention/Management Program (revised 9/30/2025), states that residents admitted with pressure ulcers or who develop them in-house must receive necessary treatment and services to promote healing, prevent infection, and prevent new sores when possible, and that wound care is managed by a team of healthcare professionals.

Based on observation, interview, and record review, the facility failed to ensure residents were seen by Podiatry for foot care needs.This applies to 1 resident (R10) reviewed for podiatry services in a sample of 28 residents.The findings include:One 1/6/26 at 12:11 PM, R10 said she asked the facility staff in November if she could be seen by a Podiatrist to have her toenails cut. Her toenails were observed to be long, thick, and uneven, measuring about a quarter inch to half inch above the tips of her toes. R10 said her long toenails cause her pain when her sheet or blanket gets stuck on them. R10 said the last time her toenails were cut was prior to admission, when she was at home and she would have a Podiatrist come to her house every 2 months. On 1/8/26 at 9:38 AM, R10 said she told her nurse again a few days prior that she needed her toenails cut and the nurse told her she had to wait until the Podiatrist comes around again and makes his rounds.On 1/8/26 at 9:42 AM, V13 (RN/Registered Nurse) said when a resident tells her they want to see the Podiatrist, the facility procedure is for her to notify Social Services so they can add the resident to the podiatry list. On 1/7/26 at 2:03 PM, V14 (Social Service Director) said she is notified by the nurses when a resident requests to see the Podiatrist, and then V14 will coordinate with Podiatry to see the resident the next time they come to the facility. V14 said the Podiatrist comes to the facility anywhere from 2-3 times a month and the Podiatrist will see every resident at a minimum of every 3 months. V14 said the Podiatrist sends the facility the list of what residents have been seen during each visit and the facility keeps a running list of what residents need to be seen. On 1/8/26 at 11:39 AM, V1 (Administrator) provided the running Podiatry list of which residents need to be seen. R10 is not listed. The facility provided Podiatry List of residents that have been seen since 8/2025 was reviewed, R10 is not listed. On 1/8/26 at 1:28 PM, V2 (DON/Director of Nursing) said every resident should be seen by Podiatry at a minimum of every 3 months, and diabetic residents more frequently. V2 said it is not appropriate for a diabetic resident to go over 4 months without seeing a Podiatrist because they are at greater risk for foot infection/foot sores due to poor circulation and delayed healing.R10's Face sheet shows she was initially admitted to the facility on [DATE]. R10's Face sheet shows diagnoses: Morbid Obesity, Non-Pressure Chronic Ulcer of left lower leg, Type 2 Diabetes Mellitus, and long-term use of insulin. R10's POS (Physician Order Sheet) shows an order dated 9/16/25 she may be seen by the Podiatrist. R10's MDS (Minimum Data Set) dated 11/12/25 shows her cognition is intact. R10's Care Plan initiated 11/17/25 states she has Diabetes Mellitus and intervention states Refer to Podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails.The facility provided policy titled, Foot Care last revised 10/25 states, General: Foot care is given to promote cleanliness, prevent infection, control odor, provide comfort, monitor for skin breakdown and promote healing. Responsible Party: All nursing staff. Guideline:.9. Residents with diabetes and circulatory issues will be referred to the podiatrist as necessary.

Based on observation, interview, and record review, the facility failed to provide indwelling urinary catheter care in a manner to prevent urinary tract infection (UTI). This applies to 1 resident (R123) reviewed for urinary catheters. R123's Face Sheet shows an admission date of 8/9/2025 with diagnoses including sepsis, urinary tract infection, benign prostatic hyperplasia with lower urinary tract symptoms, and obstructive uropathy. Review of R123's Minimum Data Set (MDS) dated [DATE] shows R123 had an indwelling Foley catheter in place, was always incontinent of bowel, and was totally dependent on staff for toileting hygiene and perineal care. On 1/6/2026 at 10:55 AM, R123 was observed with bowel movement present in the perineal area and V22 (CNA/Certified Nursing Assistant) provided incontinence care. R123 had an indwelling Foley catheter in place at the time of care. During this episode, V22 did not cleanse the Foley catheter, catheter tubing, or the catheter insertion site after removal of bowel movement. During the same observation, V22 was observed wiping the scrotal area upward toward the penile head rather than using a front-to-back cleansing technique. On 1/8/2026 at 2:15 PM, V2 (DON/Director of Nursing) stated that Foley catheter care and perineal care should be performed together, and that proper technique is essential for urinary tract infection prevention, especially for high-risk residents. Per V2, it is her expectation that staff perform routine checks at least every two hours, cleanse the area around the catheter insertion site per facility policy, and wipe away from the urinary meatus, as improper technique increases the risk of infection. Review of R123's hospital record titled Emergency Department Note dated 12/17/2025 showed R123 was sent to the emergency room for altered mental status and was hospitalized with an admitting diagnosis of urinary tract infection (UTI). Review of R123's POS (Physician Order Sheet) with active orders as of 1/8/2026 showed an order for Indwelling Catheter: Catheter care daily and as needed every shift. Review of R123's Care Plan dated 12/26/2025 included interventions directing staff to provide catheter care every shift and as needed. Review of the facility policy titled Catheter Care, Urinary (last revised September 2005) states that the purpose of catheter care is to prevent infection of the resident's urinary tract. The policy outlines catheter care for male residents, including cleansing around the meatus using a circular motion from the meatus outward, changing the washcloth with each stroke, and rinsing using the same technique. Review of the facility policy titled Incontinence Care states that care is provided to keep residents clean, dry, comfortable, and odor-free, and specifies that cleansing of the perineal area should always be performed from front to back.

Based on observation, interview, and record review, the facility failed to provide double portions and nutritional shakes as ordered for a resident with diagnoses of pressure ulcer and malnutrition.This applies to 1 resident (R123) reviewed for following diets in a sample of 28 residents.R123's Face Sheet shows an admission date of 8/9/2025 with diagnoses including dehydration, diabetes mellitus, stage 4 pressure ulcer of the sacral region, dementia, and dysphagia. On 1/6/2026 at 10:36 AM, R123 was lying in bed with the head of the bed elevated attempting to drink a protein shake that family had brought in. V18 (R123's Niece) was at bedside. V18 assisted R123 as he was drinking. Per V18, she had repeatedly expressed concern to facility staff regarding R123's weight loss and stated that staff were not assisting with feeding, providing double portions, or supplying ordered nutritional supplements. V18 further noted that the protein shake at the bedside was family-supplied because the facility had not provided it, and that a milkshake ordered with breakfast was not provided that morning. On 1/6/2026 at 12:32 PM, R123 was observed during lunch with V18 assisting him. The tray did not include any supplements, and the beef entree was served as a regular portion, not double. On 1/7/2026 at 12:15 PM, R123 was observed for lunch again. No supplements were on the tray, and the spaghetti entree was served as a regular portion, not double. On 1/6/2026 at 12:35 PM, V22 (R123's CNA/Certified Nursing Assistant) stated there was no need to assist R123 with feeding because since he is independent. On 1/9/2026 at 9:20 AM, V18 (R123's Niece) stated that R123 was sent to the emergency room on 1/8/2026 and remains hospitalized with an admitting diagnosis of failure to thrive and severe malnutrition with muscle wasting. On 1/9/2026 at 9:36 AM, R123's status and admitting diagnosis were confirmed by the hospital-assigned RN (Registered Nurse). R123's Physician Order Sheet (POS) included a diet order for a NAS/LCS mechanical soft diet with Mighty Shakes (nutritional supplement) at breakfast and lunch with double portions, Med Pass (nutritional supplement) twice daily, and bedtime snacks, along with an order to notify the primary physician of significant weight changes. R123's Care Plan dated 12/26/2025 specifies that the resident requires partial to moderate assistance with eating due to ADL (Activities of Daily Living) self-care deficit. Interventions include that staff are expected to provide the diet as ordered, and the dietitian is to evaluate the resident and make diet change recommendations as needed. The facility's policy titled Interventions for Unintended Weight Loss (last revised June 2023) states, Individuals with unintended weight loss or insidious weight loss will be identified and monitored so that appropriate interventions can be implemented. Purpose: to address the needs of high-risk residents.

Based on observation, interview, and record review, the facility failed to safely and securely store medications.This applies to 1 of 1 resident (R125) reviewed for medication storage in the sample of 28.The findings include:On 01/06/26 at 10:23 AM, R125 had one container of (nystatin) topical powder 100,000/30 grams and a two-ounce tube of (Zinc Oxide Paste) Maximum Strength paste on the dresser. R125 stated she applies the (Zinc Oxide Paste) herself but rarely uses the (nystatin) topical powder. On 01/08/26 at 9:50 AM, the container of (nystatin) topical powder and the (Zinc Oxide Paste) Maximum Strength paste remained on the dresser in R125's room. On 01/08/26 at 9:50 AM, V24 (Wound Care Nurse) stated R125 did not have orders for medications to be left at the bedside. On 01/08/26 at 3:29 PM, V2 (Director of Nursing) stated medications should not be left unsecured in the resident's possession. V2 stated another resident can accidentally take the medications that are stored in resident's rooms. V2 stated the medications can be used incorrectly.R125 was admitted to the facility on [DATE] with multiple diagnoses which included acute on chronic congestive heart failure, chronic obstructive pulmonary disease, cognitive communication deficit, dementia, major depressive disorder, and anxiety per the face sheet.R125's MDS (Minimum Data Set) dated 12/29/25 showed R125 had moderate cognitive impairment. R125's current Order Summary Report dated 01/08/26, showed no active orders for (nystatin) powder or (Zinc Oxide Paste) Maximum Strength paste.The facility's Storage of Medications Policy, effective date 10/25/24, showed, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on interview and record review, the facility failed to provide documentation of a resident's AD (Advance Directives) to the ALS (Advance Life Support) paramedics and the hospital during a hospital transfer. This applies to 1 of 3 residents (R1) reviewed for facility-initiated transfer to the hospital and AD. The findings include: The EMR (Electronic Medical Record) showed that R1, a [AGE] year-old with diagnoses that includes acute and chronic respiratory failure, fluid overload, congestive heart failure, dependence on oxygen supplement, asthma, diabetes mellitust type 2, chronic kidney diase, end stage renal disease and dependence on renal dialysis, anemia, cardiomyopathy, aortic valve stenosis, lack of coordination, osteoarthritis, and presence of vascular implants and grafts, R1 was originally admitted to the facility on [DATE]. R1 was sent out to the hospital via 911 on March 11,2025 and returned to facility on March 14, 2025. The Social Service Notes dated February 28,2025 showed that R1, an African American female who admitted to the facility .primary language is English. (R1's) speech is clear, and her hearing appears adequate. (R1) is alert x3. (R1) is able to understand, as well as be understood Discussed advanced directives. (R1) reported she did not have a POA (Power of Attorney); however, per nursing notes resident's daughters provided POA paperwork and POLST (Practitioner Order Life Sustaining Treatment). (R1) did confirm she would like to be DNR (Do Not Resuscitate). The MDS (Minimum Data Set) assessment dated [DATE], showed that R1 was cognitively intact with BIMS (Brief Interview Mental Status) score of 15/15. The POLST form signed by R1 marked with a date of March 19,2019 showed R1's AD wishes as follows: DNR (if patient with no pulse); When not in cardiopulmonary arrest and patient is breathing- Comfort-Focused Treatment: primary goal of maximizing comfort; Relieve pain and suffering through use of medication, by any route, as needed, use oxygen, suctioning, and manual treatment of airway obstruction. Do not use treatments Listed in Full and Selective Treatment unless consistent with comfort goal. REQUEST TRANSPORT TO HOSPITAL ONLY IF COMFORT NEEDS CANNOT BE MET IN CURRENT LOCATION. The progress notes dated March 11,2025 showed that R1 was sent out to the hospital via 911 due to shortness of breathing. R1 was admitted to hospital's ICU (Intensive Care Unit) with diagnoses of cardiac overload. The hospital H&P (History and Physical) dated March 11,2025 showed that (R1) to ER (emergency room ) for worsening SOB (shortness of breathing) over the last 2 hours . Upon arrival, (R1) was in significant amount of distress .admitted to ICU. The EMR's SS (Social Service) progress note dated March 14, 2025, which was documented by V4 (Social Serve Director) showed that V12 (R1's daughter/POA/Power of Attorney) had requested the facility for a care plan meeting due to multiple concerns. One of the concerns was regarding R1's hospital transfer on March 11,2025. On March 25,2025 at 11:36 A.M., V4 said that on March 13,2025, she had received an email from V12. V4 added that the email was about V12 asking that a copy of R1's Advance Directives/POLST (Practitioner Order Life Sustaining Treatment) Form be fax immediately to the hospital. The facility provided the email correspondence between V12 and V4 dated March 13,2025. The email showed that V12 asked V4 Please fax a copy of (R1's) DNR (Do Not Resuscitate form) to .(hospital) .Pursuant to Illinois state law protocols, a copy of the DNR should have been provided to the transporter (ambulance) as well as a copy to the receiving facility .Please confirm once completed. The facility's concern form dated March 18,2025 showed that V12 was concern that DNR Form/POLST was not sent with (R1) to the hospital. On March 26,2025 at 4:55 P.M., V9 (LPN/Licensed practical Nurse) said that she sent R1 out to the hospital on March 11,2025 sometime around 10:00 A.M. V9 said that R1 was sent out due to labored breathing, and pulse oxygen level showed an alarming result of 72 % (normal 95). V9 said that she only provided documentation to paramedics of R1's Face Sheet/ and Medication List. V9 added that she did not provide R1's POLST documentation to the paramedics. V9 further said that she was informed by the nurse for the next shift that a POLST copy should be provided to the paramedics who then will provide to the hospital during resident's transfer. V9 said that she was also informed by V2 (Director of Nursing) after V12 had complained that a copy of the POLST was not provided to the paramedics/and hospital. V9 said that she was told that an in-service regarding appropriate documentation forms to be provided during transfer will be given; however, had not receive the in-service up to the current time. V9 also said that she has been working in the facility since July of 2024 and this was not the first time, she had sent a resident to the hospital. V9 said she was not aware that a copy of documentation of AD/POLST was to be provided to paramedics/hospital during transfer. The EMS (Emergency Medical Services) transport report dated March 11, 2025, showed that 911 was summoned by the facility on March 11,2025 at 8:30 A.M., paramedics were dispatched at 8:31 A.M., en route at 8:33 A.M., with (R1) at 8:39 A.M., and at hospital at 9:08 A.M. The EMS transport report also showed that R1 was in minor distress, with hyperventilation and fluctuation of oxygen saturation level, remained alert and oriented times 4 spheres (name, time place, person). The report also showed NONE for R1's Advance Directives. On March 25,2025 at 1:30 P.M., V13 (EMS Director) had validated that according to the EMS transport report for R1, none was checked for Advance Directives. V13 also sent a correspondence email dated March 25,2025 that paramedics crew that transported R1 to the hospital were only provided documents that included medication list and a face sheet. On March 24,2025 at 3:45 P.M., V12 said that facility had not provided a copy of POLST/DNR/Advance Directives to the paramedics and the hospital. V12 said she had sent an email to V4 once she had found out POLST copy was not sent out with R1 at time of transfer. V12 also said that R1 did not coded en route of transfer nor at the hospital. V12 also added it's the ramification of not sending a copy and (R1's) wishes would not be implemented. She (R1) does want a DNR status. On March 25,2025 at 12:30 P.M., R1 was observed sitting in her wheelchair in her room. R1 was alert and oriented times 3. R1 said that she was sent out to the hospital a week or 2 weeks ago. R1 said her wish was to remain a DNR status. On March 26,2025, V1 (Administrator) explained the facility's policy and procedure regarding resident transfer to the hospital. V1 said that their policy was to give forms that included face sheet and medication list that was on the POS (Physician Order Sheet).

Based on interview and record review, the facility failed to obtain a resident's urine specimen in a timely manner to rule out a urinary tract infection. This applies to 1 of 6 residents (R2) reviewed for quality of care. The findings include: R2's Face Sheet showed she was admitted to the facility on [DATE] and her diagnoses include history of UTIs (Urinary Tract Infections), ESBL (extended-spectrum beta lactamase) resistance, acute kidney failure, and anemia of chronic disease. R2's 1/21/25 nursing progress note from 5:08 PM showed .writer also spoke to resident's daughter [name] who said she talked to her mom and it was disturbing. She noted her mother seems paranoid and just wanted to let writer know. Writer informed daughter of my own interaction with her and daughter believes she could maybe have a UTI because 'this happens when she has a UTI ' Labs ordered to be drawn in the AM, urine to be collected per NP [Nurse Practitioner] . R2's 1/22/2025 Psychiatric Evaluation progress note from 12:16 PM (written by V7- Psychiatric NP), showed .Obtain a urine sample for urinalysis and culture to rule out a UTI. Will await results to identify reversible causes of confusion and psychosis R2's 1/23/2025 NP progress note from 7:39 AM showed .LABS: Awaiting UA/CS [urinalysis/culture & sensitivity] results . R2's 1/25/2025 nursing progress note from 4:47 PM (four days after initial order on 1/21/25) showed Family came in and asked writer if resident UA collection has been done, writer stated that it had been collected but due to the lid of the specimen cup not being tightly secured the urine fell into the bag and the collection was contaminated, writer stated to family that I could straight cath resident and collect another specimen, family stated that they wanted to take her to the ER Resident left facility with family to [local] Urgent Care. R2's 12/3/2024 MDS (Minimum Data Set) showed she only requires partial/moderate assistance for walking 50 feet, toileting transfers, and toileting hygiene. The same MDS showed she is always incontinent of bladder and bowel. On 2/4/25 at 3:18 PM, V7 (Psychiatric NP) stated he ordered R2's UA. V7 stated They need to collect it- the resident shouldn't wait for 4 days. R2's current and discontinued orders for January 2025 showed an order for R2's UA/CS was not transcribed until 1/25/2025. On 2/4/25 at 9:30 AM, V2 DON (Director of Nursing) stated that R2's family took her to urgent care and they did a urinalysis and R2 has a UTI. R2's 1/28/2025 nursing admission note from 5:14 PM showed she returned from the hospital via ambulance with an IV line. The facility's February 2014 Medication and Treatment Order Policy showed .3. Telephone and/or verbal orders taken by licensed personnel must be promptly recorded on the Physician's Order Sheet in the resident's record

Based on observations, interview and record review, the facility failed to serve pureed diet as ordered by a Physician to a resident (R1) that has had a recent history of swallowing problems. This failure contributed to the resident having a significant weight loss. This applies to 1 of 3 residents (R1) reviewed for improper nursing in the sample of 6. The findings include: R1's EMR (electronic medical records) included diagnoses of osteomyelitis, pressure ulcer of sacral region, stage 4, pressure ulcer of right buttock, stage 4, unspecified severe protein-calorie malnutrition, adult failure to thrive, other cerebral palsy, dysphagia, oropharyngeal phase, anorexia nervosa. R1's Annual MDS (minimum data set) dated November 06, 2024 showed that R1 was moderately impaired in cognition and was dependent on staff for all ADL's (activities of daily living) including eating. R1's diet order on POS (Physician Order Summary) showed Pureed diet (start date January 09, 2025). R1's weight (in lbs/pounds) history in EMR included as follows: 81.8 lbs (January 16, 2025), 89.8 lbs (December 17, 2024), 88.8 lbs (November 25, 2024), 89.6 lbs (October 18, 2024), 88.6 (September 18, 2024), 89.9 (July 14, 2024). Dietitian progress notes dated January 16, 2025 included the following information in summary: R1's diet order was pureed texture diet with thin liquids and super cereal at breakfast. Weight: 81.8 lbs (January 16, 2025). BMI [Body Mass Index]: 16 which is underweight. Weight loss of 8.9% since December 17, 2025 and 8.7% since October 18, 2025 and is not desired or planned. On January 16 at 2025 at 10:52 AM, R1 was seen lying in bed in hospital gown. R1 made eye contact and some sounds but did not respond to queries. On January 16, 2025 at 11:02 AM, V4 CNA (Certified Nursing Assistant) was called to the room to ask about R1's oral intake. V4 stated I am from Agency. I don't know anything about her. The (CNA) students were in here this morning to feed her. On January 16, 2025 at 12:44 PM, V9 (Student Instructor) stated that she watched the students feed R1, and R1 ate some of the eggs and most of the oatmeal and drank the orange juice. V9 stated She (R1) did not eat the potatoes (hash brown) and sausage. On January 16, 2025 at 12:36 AM, R1 received a room tray (served by V4) of mechanical soft consistency chicken, regular consistency coleslaw and cornbread and pudding for dessert, and 4 oz/ounces of juice in a glass and 8 oz carton of 2% milk. R1's diet card showed Mechanical Soft consistency. V4 spoon fed R1 and R1 ate 100% of the pudding and drank 100% of juice and most of milk via a straw. On return to the room a few minutes later, V4 remarked that R1 ate all of the pudding and if she (R1) would have received a pureed diet, she would have eaten better. On January 16, 2025 at 1:00 PM, R1's diet order on POS was checked in the EMR and it showed Pureed diet. On January 16, 2025 at 1:02 PM, V3 ADON (Assistant Director of Nursing) was shown R1's tray consisting of mechanical soft diet received and relayed that diet order on EMR showed pureed diet and V1 DON (Director of Nursing) was subsequently notified of the same. On January 16, 2025 at 1:58 PM, V6 (Dietary Manager) stated I got the form today to change the diet from mechanical soft to pureed. Prior to today resident [R1] was getting mechanical soft diet. The nurse brings the diet order change form and put's it in my mailbox and I will update it in the system [computer] before printing the diet cards. V6 stated that he does not recall receiving the diet change slip [from mechanical soft to pureed diet] prior to today. On January 16, 2025 at 3:00 PM, V2 (DON) stated that if nursing is downgrading the diet, the Physician is notified and then referred to the Speech Therapist. V2 stated that once the diet is downgraded in the POS, the diet order is printed and brought down to the kitchen. V2 stated that she does not know what happens after that. V2 stated that V3 ADON (Assisted Director of Nursing) had put the diet change in the EMR/POS and brought the diet order down to the kitchen. On January 16, 2025 at 3:04 PM, V3 (ADON) stated that [sometime beginning in the month of January/unknown date] the nurse on duty had come to her office with the V10 NP (Nurse Practitioner) and stated that R1 was not swallowing her medications and feels that the diet should be downgraded. V3 stated that she used her judgement and downgraded the diet to pureed and printed the diet order and placed it on V6's desk. V3 added that she also sent V6 a What's App message (about the diet change) as that is the mode of communication for managers. On January 16, 2025 at 2:34 PM, V7 (Speech Therapist) stated that she was aware that the nursing downgraded R1's diet to pureed in the beginning of the month. V7 stated that she works three days a week at the facility and sees patients that V8 (Rehab Director) refers her to. V7 stated that V8 put R1 on her schedule to be seen today (January 16, 2025) and she did a swallow evaluation for R1 at the bedside this afternoon. V7 stated that she recommended to keep R1 on the current diet order of pureed consistency with thin liquids. V7 stated that R1 is at risk for aspirating on a mechanical soft diet because of suboptimal positioning. V7 added that while evaluating R1, R1 told her that she had a lot of pain while swallowing. On January 17, 2025 at 12:24 PM, V12 (Medical Director) stated that he is R1's Primary Care Physician and the staff have been updating him about R1's recent concerns about eating. V12 stated that recently R1 has been eating less as her dysphagia was progressing and the diet was downgraded from mechanical soft to pureed diet. V12 stated that the facility should carry out the order for diet change within the day in 24 hours. V12 stated that R1's oral intake can be affected by dysphagia and pain medications (Morphine). V12 stated that he was notified of R1's weight loss which can be affected by declined oral intake. Nursing progress notes dated January 15, 2025 included that R1 was not able to tolerate medication and holding her medication in her mouth and the family and MD (Medical Doctor) notified. NP progress notes dated January 13, 2025 included the following information It was reported by the nurse that the patient was unable to swallow his medications and the patient was ordered speech evaluation and treatment. Her pain medication (Norco by mouth) was discontinued due to swallowing difficulties and Morphine liquid 0.25 ml[Milliliters] q [every] 4 hours was ordered for pain and her diet was downgraded to puree Nursing progress notes dated January 09, 2025 included R1 holding medication and food in her mouth not swallowing NP, DON and relieving nurse made aware. New order given by NP for speech consultation. Resident Listing Reports dated January 16, 2025, with current diet orders served in the facility kitchen showed R1's diet order as Mechanical Soft. Speech Language Pathologist Plan of Treatment bed side swallow evaluation for R1 dated January 16, 2025 for trials of diet consistencies included as follows in summary : Patient reporting severe pain and unable to reposition to upright position, thus trials completed at about 20-30 degrees. Suspect reduced laryngeal elevation Thin liquids via straw: mildly delayed oral transit time and no overt signs and symptoms of aspiration, however patient reports pain swallowing and motions to her neck. Mechanical soft trials noted with prolonged mastication and transit time, as well as observed inadequate mastication of trials and minimal trials attempted due to patient's increased risk of aspiration. Puree trials via teaspooon: moderately delayed oral transit time .with no overt signs and symptoms of aspiration, however patient continues to report pain swallowing and motions to her neck. Recommendations for Pureed diet with thin liquids for patient to swallow safetly. R1's Nutrition care plan revised October 06, 2024 included that R1 benefits from a mechanically altered diet due to dysphagia with interventions for the same included to provide and serve diet as ordered and goal to adhere to diet as ordered by physician through next review 3/11/25. On January 17, 2025 at 1:59 PM, V2 (DON) stated that the facility does not have a policy for the process of diet order implementation.

Based on observations, interview and record review, the facility failed to provide personal hygiene to a resident that was dependant on care. This applies to 1 of 3 residents (R1) reviewed for improper nursing in the sample of 6. The findings include: R1's face sheet included diagnoses of osteomyelitis, pressure ulcer of sacral region, stage 4, pressure ulcer of right buttock, stage 4, unspecified severe protein-calorie malnutrition, adult failure to thrive, other cerebral palsy, dysphagia, oropharyngeal phase, anorexia nervosa. R1's Annual MDS (minimum data set) dated November 06, 2024 showed that R1 was moderately impaired in cognition and was dependent on staff for all ADL's (activities of daily living) including personal hygiene. On 1/16/25 at 10:52 AM, when viewed through the door, R1 was seen lying in bed in hospital gown. Signage on R1's door showed Contact Isolation. V4 (Registered Nurse) who was in the hallway stated that R1 is on contact isolation for MRSA [Methicillin- resistant Staphylococcus Aureus) of wounds and gown and gloves are needed prior to room entry. On entry, R1 made eye contact and some sounds but did not respond to queries. There was a stale odor coming from R1. R1's hair appeared greasy and uncombed. R1's hands appeared contracted and R1 had long jagged fingernails that had blackish substance underneath some of the nails. R1's chin and pillow had remnants of food particles and stains. R1's neck under her chin and upper chest had powdery blackish substance on it. On January 16, 2025 at 11:02 AM, V4 (Certified Nursing Assistant) was called to the room and shown above observations. V4 stated that she is from agency and not regular staff and has not taken care of R1 before. V4 stated that the student nurses were in R1's room earlier and fed her. V4 stated that she is not sure when the facility staff last cut R1's nails. V4 stated I will get a towel and clean her up and comb her hair. On January 16, 2025 at 12:44 PM, V9 (Student Instructor) stated that she watched the student feed R1 and had wiped her mouth. V9 added that a towel was placed on R1's chest prior to feeding R1 and therefore did not notice anything on her neck. Nurse Practitioner's progress notes dated January 13, 2025 included that R1 has contractures and she is dependent on staff for all ADLs. R1's restorative care plan initiated May 03, 2023 included that R1 is at risk for deterioration in ADL related to medical diagnosis of Cerebral palsy, osteomyelitis, lack of coordination, adult failure to thrive, and weakness. Interventions included : do not rush resident, allow extra time to complete ADLs, have consistent approach among caregivers. On January 16, 2025 at 3:02 PM and on January 17, 2025 at 9:27 AM, V2 (Director of Nursing) stated that the CNA's provide ADL care and should provide personal hygiene daily for the residents. V2 stated that R1 is contracted and therefore it is difficult to cut her nails. V2 stated that staff should wipe R1's face off after providing feeding assistance. Facility policy for ADL effective February, 2023 (2/2023) included as follows: Guideline: In accordance with the comprehensive assessment, together with respect for individual resident needs and choices, our facility provides care and services for the following activities: Hygiene: bathing, dressing, grooming and oral care Our collaborative professional team, together with the resident and/or resident representative: 2. Develop and implement interventions in accordance with the resident's evaluated need, goal for care and preferences and will address the identified limitation in an ability to perform ADLs.

Based on observations, interview and record review, the facility failed to serve pureed diet as ordered by a Physician to a resident (R1) that has had a recent history of swallowing problems. This applies to 1 of 3 residents (R1) reviewed for improper nursing in the sample of 6. The findings include: R1's EMR (electronic medical records) included diagnoses of osteomyelitis, pressure ulcer of sacral region, stage 4, pressure ulcer of right buttock, stage 4, unspecified severe protein-calorie malnutrition, adult failure to thrive, other cerebral palsy, dysphagia, oropharyngeal phase, anorexia nervosa. R1's Annual MDS (minimum data set) dated November 06, 2024 showed that R1 was moderately impaired in cognition and was dependent on staff for all ADL's (activities of daily living) including eating. R1's diet order on POS (Physician Order Summary) showed Pureed diet (start date January 09, 2025). R1's weight (in lbs/pounds) history in EMR included as follows: 81.8 lbs (January 16, 2025), 89.8 lbs (December 17, 2024), 88.8 lbs (November 25, 2024), 89.6 lbs (October 18, 2024), 88.6 (September 18, 2024), 89.9 (July 14, 2024). Dietitian progress notes dated January 16, 2025 included the following information in summary: R1's diet order was pureed texture diet with thin liquids and super cereal at breakfast. Weight: 81.8 lbs (January 16, 2025). BMI [Body Mass Index]: 16 which is underweight. Weight loss of 8.9% since December 17, 2025 and 8.7% since October 18, 2025 and is not desired or planned. On January 16, 2025 at 11:02 AM, V4 CNA (Certified Nursing Assistant) was called to the room to ask about R1's oral intake. V4 stated I am from Agency. I don't know anything about her. The (CNA) students were in here this morning to feed her. On January 16, 2025 at 12:44 PM, V9 (Student Instructor) stated that she watched the students feed R1, and R1 ate some of the eggs and most of the oatmeal and drank the orange juice. V9 stated She (R1) did not eat the potatoes (hash brown) and sausage. On January 16, 2025 at 12:36 AM, R1 received a room tray (served by V4) of mechanical soft consistency chicken, regular consistency coleslaw and cornbread and pudding for dessert, and 4 oz/ounces of juice in a glass and 8 oz carton of 2% milk. R1's diet card showed Mechanical Soft consistency. On January 16, 2025 at 1:00 PM, R1's diet order on POS was checked in the EMR and it showed Pureed diet. Resident Listing Reports dated January 16, 2025, with current diet orders served in the facility kitchen showed R1's diet order as Mechanical Soft. On January 16, 2025 at 1:58 PM, V6 (Dietary Manager) stated I got the form today to change the diet from mechanical soft to pureed. Prior to today resident [R1] was getting mechanical soft diet. The nurse brings the diet order change form and put's it in my mailbox and I will update it in the system [computer] before printing the diet cards. V6 stated that he does not recall receiving the diet change slip [from mechanical soft to pureed diet] prior to January 16, 2025. On January 16, 2025 at 3:00 PM, V2 (DON) stated that if nursing is downgrading the diet, the Physician is notified and then referred to the Speech Therapist. V2 stated that once the diet is downgraded in the POS, the diet order is printed and brought down to the kitchen. V2 stated that she does not know what happens after that. V2 stated that V3 ADON (Assisted Director of Nursing) had put the diet change in the EMR/POS and brought the diet order down to the kitchen. On January 16, 2025 at 3:04 PM, V3 (ADON) stated that [sometime beginning in the month of January/unknown date] the nurse on duty had come to her office with the V10 NP (Nurse Practitioner) and stated that R1 was not swallowing her medications and feels that the diet should be downgraded. V3 stated that she used her judgement and downgraded the diet to pureed and printed the diet order and placed it on V6's desk. V3 added that she also sent V6 a What's App message (about the diet change) as that is the mode of communication for managers. On January 16, 2025 at 2:34 PM, V7 (Speech Therapist) stated that she was aware that the nursing downgraded R1's diet to pureed in the beginning of the month. V7 stated that she works three days a week at the facility and sees patients that V8 (Rehab Director) refers her to. V7 stated that V8 put R1 on her schedule to be seen today (January 16, 2025) and she did a swallow evaluation for R1 at the bedside this afternoon. V7 stated that she recommended to keep R1 on the current diet order of pureed consistency with thin liquids. V7 stated that R1 is at risk for aspirating on a mechanical soft diet. Nursing progress notes dated January 15, 2025 included that R1 was not able to tolerate medication and holding her medication in her mouth and the family and MD (Medical Doctor) notified.

Based on observation, interview and record review the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness. This applies to 128 residents in the facility receiving dietary services. Findings include: On [DATE] 10:06 AM V1 Administrator confirmed 128 residents were being served from dietary services on [DATE]. 1. On [DATE] at 10:01 AM, the dry storage contained: An opened one- gallon jar of mayonnaise dated [DATE] labeled refrigerate after opening. An opened one-gallon bottle of barbeque sauce dated [DATE] labeled refrigerate after opening. An opened 793-gram bag of chocolate pudding and a 24-ounce bag of butterscotch pudding without use by or opened on dates. Two 6-pound 9-ounce dented cans of yellow cling peaches. One 6-pound 3-ounce dented can of sauerkraut. On [DATE] at 01:15 PM, V21 (Dietary Director) stated the barbeque sauce and mayonnaise should be refrigerated once opened to prevent the growth of bacteria. Dented cans should be separated and not use because we don't know how deep the dent is or if the can was punctured and leaking. The food could be contaminated, and rust could develop inside of the cans if exposed to air causing illness or medical issues. The shelving in dry storage V21 identified as the location for dented cans did not have dented can signage. 2. On [DATE] at 10:13 AM, the plate warmer which was stacked with clean plates, was dirty and covered with crumbs and food splatters. On [DATE] at 01:15 PM, V21 stated, kitchen equipment should be kept clean to prevent cross contamination. The facility policy Storage and Handling of Cleaned Equipment and Utensils dated [DATE] states the food contact surfaces of equipment are protected from splash, dust and other contamination. 3. On [DATE] at 10:14 AM, the walk-in cooler contained: An opened 25-pound bucket of hard-boiled eggs delivered on [DATE]. Eggs did not have an opened on or use-by date. Two pitchers identified by V21 as orange juice, one pitcher identified as cranberry juice and five-liter container identified as fruit punch- none had a label to identify contents or use-by dates. A 16-quart container with sliced pickles did not have a label to identify contents or any dates. Five small facility serving cups identified by V21 as vanilla yogurt did not have any labels or dates. A large piece of meat identified by V21 as a ham roast (which was rewrapped in plastic wrap dated [DATE]) and a large raw pork loin in factory packaging, were both stored over a box of bagged shredded cabbage and a stalk of celery. Three 10-ounce packages of corn tortillas and a bottle of pinot grigio. V21 stated the tortillas and wine belongs to staff. On [DATE] at 01:15 PM, V21 stated, employee food items should not be stored with the facility food because we cannot verify the vendor, where it came from or what is in it, and it could be inadvertently served to residents. Meat products should not be stored over vegetables because they could drip blood or juice on them causing illness. 4. On [DATE] at 10:37 AM, the walk-in cooler contained: Two bags of brown liquid without labels or dates. A bag identified by V21 as chicken patties did not have a label or dates. An opened bag identified as French fries did not have a label or dates. An opened 40-ounce bag of onion rings did not have an opened on or use by date. On [DATE] at 01:15 PM, V21 stated it is important to label food items with the contents and dates so that expired food items aren't being served and so that we know what the items contains. Residents who have food sensitivities may have an allergic reaction if they are served food which contents aren't verified. 5. On [DATE] at 10:47 AM, a shelf near the stove contained a 32-ounce bottle of disinfectant spray, a 4-ounce bag of disinfectant spray, a four-ounce bag of fryer cleaning pucks, a four-ounce bottle of hand sanitizer and a four- ounce bottle of hand sanitizer. On a seasoning shelf, an opened 20-ounce bottle of mustard labeled refrigerate after opening. A large bin of flour with no opened-on or use-by date. A large bin of sugar with no opened-on or use-by date. The toaster oven was crusty and greasy. Stored on a shelf under the toaster ovens was a 26-ounce bottle of disinfectant cleaner and a 32-ounce bottle of surface sanitizer. Four 3.5-gallon containers with items V21 identified as flakes of corn, bran with raisins, crisped rice and O's cereals that were not labeled or dated. On [DATE] at 01:15 PM, V21 stated, cleaning products should not be stored in the food preparation areas when food is being prepared because they could contaminate the food and cause illness or send someone to the hospital. The facility policy Food Storage dated [DATE] states Refrigerator and freezer temperatures will be monitored twice daily and recorded on temperature monitor logs by culinary personnel. Food and non-food supplies are to be clearly labeled. Leftover foods are labeled, dated immediately placed under refrigeration and used within 72 hours or discarded. No personal food items will be stored with food items. 6. On [DATE] at 10:55 AM, V21 tested the sanitizer level in the three-compartment sink. V21 stated the multi-quat sanitizer is automatically measured out and should measure at 50ppm (parts per million). When tested , sanitizer solution in the three-compartment sink measured at 10ppm with test strips with max range of 200ppm. V22's (Dishwasher) documentation for the sanitizing solution concentration in the three-compartment sink done on [DATE] measured 400ppm. V22 stated he turns the dial on the sanitizing solution and let it run until the water's color turns pink. V22 stated he wrote down the result on the log located in the office. V21 stated no red disinfecting buckets were in use during the survey. V21 stated they were using no-rinse food safe surface wipes. On [DATE] at 1:15 PM, V21 stated, he purchased the kitchen disinfectant wipes being used in the kitchen instead of the red sanitization bucket. V21 stated there is no facility policy that covers the uses of the disinfecting wipes, and his supervisor did not clear him to use the wipes. 7. The kitchen logs for food temperature, freezer, walk in cooler, sanitizer solution concentration, and dishwasher were reviewed from [DATE] - [DATE]. The logs reviewed had incomplete documentation daily. On [DATE] at 01:15 PM, V21 stated, food temping is important to make sure food being served is fully cooked and have documentation if someone says it's cold or raw. Checking the cooler and freezer log assures food items are held at the proper temperatures. Assuring the sanitization level makes sure we are cleaning properly. The facility policy Sanitation and Infection Control dated [DATE] states, monitoring of food temperatures will be recorded throughout food production and delivery. Wiping cloths shall be clean, rinsed frequently in an approved sanitizing solution and shall only be used to wipe food spills and dining tables. Utilize and fill red buckets with sanitizing solution and replace every 2 hours. Sanitizer should read at 200ppm. Three-sink sanitizing method- use a test kit or other device that accurately measures the concentration of the sanitizing solution. The concentration for a multi quat sanitizing solution is 200- 400 ppm. All chemicals and toxic materials shall be stored separately from each other in a place used for no other purpose and away from all food or food contact equipment.

Based on observation, interview and record review, the facility failed to maintain infection control practices that prevent the spread illness and disease. This applies to 6 of 7 residents (R20, R25, R29, R30, R32, R64 and R387) reviewed for infection control in a sample of 29. Findings include: 1. R32 admitted to the facility with diagnoses that includes Parkinson's, dementia, congestive heart failure, arthritis, left artificial hip joint and dysphagia. R32 physician's orders includes hospice care services and enhanced barrier precautions related to wounds. On 01/07/25 at 04:05 PM, R32's bedroom door had EBP (Enhanced Barrier Precautions) signage. There was no PPE (Personal Protective Equipment) located outside of the room or anywhere nearby for entering R32's bedroom. V17 Hospice CNA (Certified Nursing Assistant) was bathing R32 without wearing an isolation gown. V17 had thrown soiled linens on the floor near R32's bed. V17 stated there was no isolation gown available for her use. V17 stated she informed facility staff the prior week that there were no isolation gowns available. On 01/07/25 at 04:10 PM, V16 (CNA) entered R32's room to assist with bathing and repositioning and did not put on an isolation gown. V16 stated PPE should be located outside of R32's room and she should have worn gloves and a mask for EBP to assist with care. On 01/07/25 at 04:58 PM, V12 LPN (Licensed Practical Nurse) assigned to R32 stated R32's EBP are related to her wounds. Staff are only required to wear an isolation gown when they are doing a dressing change. If the wound is covered and the dressing is intact staff are not required to wear an isolation gown. V12 stated PPE is in the medication room. The medication room is locked, and CNA's do not have access. On 01/07/25 at 05:03 PM, V18 CNA assigned to R32 stated PPE gown is not required for R32 because although EBP signage is on the door, there were no supplies outside the room for her use and no red biohazard bin near the room door. On 01/09/25 at 02:22 PM, V2 DON (Director of Nursing/DON) stated R32 in on EBP for her wound and staff should have worn a gown to give her bed bath. V2 stated anytime care is being provided a gown should be worn. V2 stated if there are no supplies available outside the room, the nurse should be giving the CNAs the PPE to use. 34410 2. R64 is an [AGE] year-old female admitted with an admitting diagnosis including Gastrostomy Tube (GT) feeding. A review of R64's physician order sheet (POS) documented administering feeding with Jevity 1.2 at 50 milliliters per hour (ml/hr) from 7:00 PM to 10:00 AM. On 1/7/25 at 10:18 AM, R64's entry door was observed with an EBP sign to wear gloves, gown, and mask to provide high-contact resident care activities. No PPE (Personal Protection Equipment) box is available at the door side. On 1/7/25 at 10:25 AM, observed V4 (CNA) providing incontinent care to R64 without wearing a gown. At 10:27 AM, V5 (LPN) stated that R64 was on EBP due to GT feeding and that staff should wear gloves and a gown while changing the EBP resident. On 1/8/25 at 10:40 AM, V2 (DON) stated, The CNA (V4) should have worn gown while changing an EBP resident. On 1/9/25 at 10:30 AM, during an infection control interview, V3 (Infection Preventionist) stated that the staff should wear gloves and a gown when providing high-contact resident care activities to EBP residents. A review of the facility presented Enhanced Barrier Precaution Guidelines revised on 3/21/24 document: Enhanced Barrier Precaution refers to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with MDRO (Multi-Drug Resistant Organism) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). 2. Initiation of Enhance Barrier Precaution b. Implement enhanced barrier precautions for residents with any of the following: ii indwelling medical devices (eg., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. 3. On 1/9/25 at 11:09 AM, R387 was observed in a contact isolation room with signage indicating to wear gowns and gloves to go inside the room. R387 was observed with two visitors sitting in chairs without wearing gowns. A review of R387's Physician Order Sheet (POS) document: Maintain contact precaution due to ESBL (Extended Spectrum Beta-Lactamase) every shift. On 1/9/25 at 11:19 AM, V3 (Infection Preventionist) stated that the visitors are supposed to wear a gloves and gown and she will educate the visitors/family. The facility presented Isolation - Categories for Transmission Based Precaution (effective date: 01/20/24) document: Contact Isolation: Use PPE appropriately, including gloves and gown. Wear a gown and gloves for all interactions involving contact with the resident or the resident environment. Donning PPE upon room entry and properly discarding before exiting the resident room is done to contain pathogens. 44387 4. On 1/7/25 at 10:59 AM, during initial rounds on the 1st floor, V7 (Housekeeping) was observed cleaning R25's room. V7 had on mask and gloves and was going in and out of R25 room while she was cleaning and getting supplies from her cleaning cart outside the room. R25 had Contact Isolation sign on his door, with a PPE (Personal Protective Equipment) supply bin right outside the door. V7 said R25 was on isolation for MRSA (Methicillin Resistant Staphylococcus Aureus); V7 said she should be wearing full PPE while cleaning the resident's room. On 1/8/25 at 10:31 AM, V6 (Wound Care Nurse) was providing wound care treatment to R25's left and right foot. V3 (Infection Preventionist/IP) was assisting V6 with the wound care; during the wound care, V24 (R25's wife) came into the room without full PPE. Review of R25's Electronic Medical Record (EMR) shows the following diagnoses of sepsis, pneumonitis due to inhalation of food and vomit, ESBL resistance, MRSA, unspecified Escherichia Coli (E. Coli), pressure ulcer of sacral region stage 2, and pressure ulcer of left heel stage 4. On 1/8/25 at 10:17 AM, V3 (IP) said R25 was on contact isolation for ESBL (enzymes that make some bacteria resistant to many antibiotics) and MRSA in his sputum. V3 said staff should be wearing full PPE (gown, gloves, mask) when they enter R25's room. On 1/8/25 at 11:22 AM, V3 said resident's family members should also be wearing full PPE when they are in contact isolation rooms. 5. On 1/7/25 at 12:03 PM, V4 (CNA) provided incontinent care to R30. V4 informed R30 of the incontinent care, washed hands, put on gloves and gathered supplies. V4 raised R30's bed up, then moved the garbage can from the left side of the bed to the right side of the bed, and informed R30 to turn to her left side, facing the window. V4 removed R30's soiled brief, R30 had a bowel movement. V4 used wipes to clean R30 buttocks, removed the soiled brief and threw the soiled brief in the trash can. The trash can did not have a trash bag. The soiled brief stained the trash can with bowel movement, there was brown streaks in the trash can. V4 changed gloves, used wet wash clothes to clean R30's perineal area and buttocks. V4 changed gloves again and used a dry towel to dry R30's perineal area and buttocks. V4 then repositioned R30 in bed, then put the soiled brief and wipes from the trash can in a trash bag and took the trash out. The trash can still had brown streaks from the soiled brief. V4 did not perform hand hygiene with each glove change. On 1/9/24 at 9:01 AM, V2 (Director of Nursing/DON) said there should be trash bags in the trash cans for infection control reasons; also there should be hand hygiene with each glove change. 41384 6. On 1/7/25 at 12:56 PM, V11 CNA (Certified Nurses' Assistant) was observed feeding R20 and R29 at the same time, using the same hand, and never cleaning her hands in-between residents. V11 sat in-between R20 and R29. R29 was on V11's right side, and R20 was on V11's left side. V11 used her right hand to feed both R20 and R29 alternating bites between residents, but never cleaning her hands in-between residents. On 01/09/25 at 09:53 AM, V2 (DON) said that staff should clean their hands in-between feeding residents for infection control. The facility's Hand Hygiene Guideline dated 08/2024 showed that appropriate hand hygiene is essential in preventing transmission of infectious agents. The policy showed that hand hygiene is essential to prevent the spread of infection from resident to resident. The policy shows that hand hygiene is recommended immediately before touching a resident, after touching a patient or patient surroundings, after contact with blood, bodily fluids, or contaminated surfaces.

Based on observations, interviews, and record reviews, the facility failed to provide grooming and hygeine cares for residents who require staff assistance. This applies to 5 of 7 residents (R64, R66, R76, R114, and R125) reviewed for activities of daily living (ADL) in a sample of 29. The Findings include: 1. R64 is an [AGE] year-old female admitted with severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. The MDS also documents that R1 is dependent for eating, toileting hygiene, oral hygiene, and personal hygiene. On 01/07/25 at 10:18 AM, R64 was observed in her bed with contracted hands, fingers curled, and nails about 7 millimeters (mm) past the fingertip, that were dirty with a brownish deposit underneath the nails, which were touching her palm. R64 stated that she wanted to trim her nails, but she couldn't do it alone, and nobody was helping her. On 1/8/25 at 9:37 AM, R64 was in her bed with a dry, crusty lip peeling off, and the resident was observed licking her dry lips. 2. R66 is a [AGE] year-old male admitted with an admitting diagnosis, including cerebral infraction and hemiplegia affecting the right dominant side. A review of the MDS dated [DATE] documents that R66 has cognition intact. The MDS also documents that R1 requires set-up assistance with eating, partial/moderate assistance with toileting hygiene, and supervision or touching assistance with personal hygiene. On 01/07/25 at 12:03 PM, R66 was observed with the contracted right hand, having a dirty long nail about 6-8 millimeters past the fingertip with a blackish deposit underneath the nails on the third and fourth fingers. R66 stated that nobody was helping him to cut his fingernails. On 1/8/25 at 10:40 AM, V2 (Director of Nursing/DON) stated, Certified Nursing Assistants (CNAs) should be doing nail trimming and grooming at least on shower days and as needed. The long nails with contracted hands can cause ulcers. CNAs are also supposed to provide oral care. A review of the ADL policy (effective 02/2023) document: Guideline: In accordance with the comprehensive assessment, together with respect for individual resident needs and choices, our facility provides care and services for the following activities: Hygiene: Bathing, dressing, grooming, and oral care. The facility presented the Nail Care Guidelines (effective 02/23) document: Nail care includes routine cleaning and regular trimming. Proper nail care can help prevent skin problems around the nail bed. 41384 3. On 1/7/24 at 11:10 AM, R114 was observed with long jagged fingernails. R114's 12/26/24 MDS showed that R114 needs substantial/maximal assistance from staff for personal hygiene and that R114's cognition is severely impaired. On 01/09/25 at 09:42, AM V2 (DON) said that the staff should be clipping residents nails every day and the residents' nails should be short for infection control and safety, so they don't scratch themselves or others. 4. On 01/07/25 at 01:29 PM R76's nails were observed long, up to 1 inch in length, jagged, nails curling under tips of fingers, and with a brown substance under the nails. R76's 11/6/24 MDS showed R76 needs substantial/maximal assistance from staff for personal hygiene. On 01/09/25 at 09:43 AM V2 said that residents should receive nail care as needed. The facility's Activities of Daily Living (ADL) policy dated 2/2023 showed that the facility provides necessary care and services to ensure that the residents abilities in activities of daily living (ADL) do not diminish . The policy showed that in accordance with the residents' comprehensive assessment the facility provides care and services for: hygiene, mobility, elimination The facility's professional team will implement interventions in accordance with the resident's evaluated needs . 44387 5. On 1/7/25 at 11:34 AM, R125 was in bed watching TV. R125 was noted with several white hair on her chin and her fingernails were long and dirty with black/brownish substance. On 1/9/25 at 11:38 AM, R125 was resting in bed, fingernails still long with black/brownish substance in nail bed. R125 said she would need assistance with getting her nails trimmed. Review of R125's Electronic Medical Record (EMR) shows the following diagnoses of cerebral infarction, cognitive communication deficit, and lack of coordination. R125's MDS of 12/24/24 shows that R125's cognition is moderately impaired and needs substantial/maximal assistance with personal hygiene.

Based on observation, interview, and record review, the facility failed to safely and securely store all resident medications. This applies to 11 residents (R64, R108, R74, R120, R37, R43, R72, R82, R5, R287, and R238) reviewed for medication storage in a sample of 29. Findings include: On 1/9/25 at 11:34 AM, the medication storage room on V14's (LPN/Licensed Practical Nurse) unit was checked in her presence. Upon entrance into the medication storage room, the medication refrigerator holding resident narcotics was found unlocked (narcotics were not double-locked) and the key to the refrigerator was hanging on a hook inside the medication storage room. V14 (LPN) said that is where the narcotic key is always kept. The following resident narcotics were found in the unlocked medication refrigerator: 1. R64's 2 vials of Lorazepam 2 mg/mL oral solution. 2. R108's Lorazepam 2 mg/mL oral solution. 3. R74's Lorazepam 2 mg/mL oral solution. 4. R120's Lorazepam 2 mg/mL oral solution. 5. R37's Lorazepam 2 mg/mL oral solution. On 1/9/25 at 11:41 AM, the medication storage room on V15's (LPN) unit was checked in her presence. Upon entrance into the medication storage room, the medication refrigerator holding resident narcotics was found without a lock on it. The narcotics were not double-locked. The following resident narcotics were found in the medication refrigerator without a lock on it: 6. R43's Dronabinol 5 mg capsules. 7. R72's Lorazepam 2 mg/mL oral solution. 8. R82's Lorazepam 2 mg/mL oral solution. 9. R5's Lorazepam 2 mg/mL oral solution. On 1/9/25 at 12:33 PM, V2 (DON/Director of Nursing) said all resident narcotics/controlled substances should be double-locked. V2 said medication refrigerators in medication storage rooms should have a lock on them because they hold controlled substances. V2 said the medication storage room is to be kept locked as well as the medication refrigerator inside the medication storage room. V2 said only nurses should have access to the keys for the medication storage room and the medication refrigerator. V2 said the key in V14's medication storage room is kept hanging on the wall because they only have one key to the refrigerator and never made copies of it for each nurse to have a key. The facility's policy titled, Controlled Substance Storage effective 10/25/14 states, Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. Procedures: A. The director of nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Only authorized licensed nursing and pharmacy personnel have access to controlled substances. B. Schedule II- V medications and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other medications or per state regulation . If a key system is used, the medication nurse on duty maintains possession of the key to controlled substance storage areas. Back-up keys to all medication storage areas, including those for controlled substances, are kept by the director of nursing or designee . 44387 10. On 1/7/25 at 12:38 PM, R287 was observed in bed; R287 had just finished his lunch. On R287's bedside table, there was tube of Glutose 15 (raises low blood sugar), a bottle of Refresh liquid gel (lubricating eye drops), and a bottle of Fluticasone Propionate nasal spray. R287 said the medications were his and he uses them daily. Review of R287's Electronic Medical Record (EMR) shows the following diagnoses of Chronic Obstructive Pulmonary Disease with acute Exacerbation, dysphagia, Type 2 Diabetes Mellitus, allergic rhinitis and dependence on supplemental oxygen. R287's Minimum Data Set (MDS) of 12/27/24 shows that his cognition is moderately impaired. Review of R287's current physician order shows that he has an order for Fluticasone Propionate Nasal Suspension 1 spray in both nostrils one time a day. R287 does not have an order for the eye drops, or the Glutose 15. R287 does not have an order that states the medications can be stored in the residents' rooms. On 1/9/25 at 8:49 AM, V2 (Director of Nursing/DON) said they do not have residents that can self-administer their medications and there are no residents that can store medications at their bedside. V2 said there is a risk that residents could be double medicating, or there could be an interaction with the medications that they are providing for the residents, hence they need to be aware of the medications the residents are taking. V2 said there should be a physician order for residents to have medications stored at the bedside, and the residents needs to be assessed in order to store medications at the bedside. The medications would also need to be locked. The facility's Storage of Medications policy (effective date 10/25/2014) states that medications and biologicals are stored safely, securely, and properly. The medication supply is accessible only by licensed personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 41384 11. On 1/7/25 at 2:02 PM, R238 was in her room and on her bed side table was 1 prescription bottle of Miconazole nitrate 2% powder (Antifungal) and 1 prescription bottle of Sodium Chloride 0.65% nasal spray. R238 said that she uses the nasal spray twice a day. A review of R238's Order Summary report did not show any orders for Miconazole Nitrate 2% powder or Sodium Chloride 0.65% nasal spray. On 1/9/25 at 09:56 AM V2 (DON) said that medications should not be at the residents' bedside

Based on interview and record review, the facility failed to provide resident and/or their family/power of attorney (POA) in writing the reason residents were transferred to the hospital, and the facility failed to notify the ombudsman of resident hospital transfers. This applies to 3 of 3 residents (R25, R108 and R136) reviewed for hospitalization in a sample of 29. The findings include: 1. R108's Emergency Department (ED) hospital record of 11/21/24 shows that R108 was seen at the hospital for Altered Mental Status and Leukocytosis. R108's progress notes of 11/21/24 at 6:12 PM states that resident was confused and unable to acknowledge nursing staff. Resident's POA was notified and requested for resident to be sent to the hospital. Nurse informed the provider and the Director of Nursing (DON), orders received to send to the ED. 2. R25's ED hospital record of 1/3/25 shows that R1 was seen at the hospital for abdominal pain, ascites, and pneumonia. R25's progress notes of 12/31/24 at 4:45 PM states that R25 was complaining of severe abdominal and chest pain; R25's abdomen was distended and firm. The physician was notified and ordered to send R25 to the ED. R25' wife was notified of the transfer. On 1/9/25 at 9:10 AM, V2 (DON) said resident's family are notified of the transfers to hospital, however, there is no written documentation of reason of transfer and that the bed hold policy was provided to the residents and/or their POAs. V2 said that they do not notify the ombudsman of residents' transfers to the hospital. V2 stated the facility does not have a bed hold policy; they have an assessment that is done in the EMR and that is presented to the resident when they leave the facility. The facility's ECC Bed Hold Policy (undated) states that this form serves as a written information and notice to the resident or legal representative at the time of admission, and in advance of any transfer, and at the time of transfer that specified the duration of the bed hold policy under the Medicare and Medicaid state plan of the facility. The facility permits private pay residents, Medicare-eligible residents and Medicaid-eligible residents whose leaves have exceeded the Medicaid-reimbursed 10 day bed hold period who wish to pay from their own income to hold the bed. 45906 3. R136's Face sheet shows she was admitted to the facility on [DATE]. R136's Change in Condition Evaluation documented on 11/1/24 at 13:33 shows R136 was transferred to the hospital after an unwitnessed fall. On 1/9/25 at 2:13 PM, V2 (DON) said the facility does not have documentation showing R136 or her family were notified in writing of the reason for R136's transfer to the hospital. V2 said the facility did not notify the Ombudsman of R136's transfer to the hospital because V2 stated she did not know the facility was supposed to notify the Ombudsman.

Based on observation, interview and record review the facility failed to protect residents' privacy. This applies to 2 of 2 residents (R61 and R32) reviewed for dignity in a sample of 29. Findings include: 1. R61 admitted to the facility with diagnoses that includes effusion of the left knee, poly-osteoarthritis, acute kidney disease, dysphagia, anemia, hypertension, gout, and pulmonary edema. R 61's current care plan states he has an ADL (Activities of Daily Living) self-care performance deficit related to impaired gait and requires substantial staff assistance with transfers, bed mobility, and toileting. R61's MDS (Minimum Data Set) dated 1/5/25 shows he is cognitively intact. On 01/07/25 at 12:21 PM, R61's urine collection bag was hanging on the right side of his bed visible to the hallway. On 01/07/25 at 12:44 PM, V23 CNA (Certified Nursing Assistant) and a therapist came into room to put R61's pants on. R61's room blinds were left open and visible from the parking lot on the first floor as he was dressed. On 01/08/25 at 03:14 PM, R61's urine collection bag was hanging on the right side of his bed visible to the hallway. R61 stated he prefers to have his urine collection bag protected from the view of others. On 01/08/25 at 03:28 PM, V19 CNA removed R61's incontinence brief and left the room to obtain staff assistance to reposition R61 and reapply his incontinence brief. V19 walked out of room, leaving the door open, with R61 naked and exposed from his waist to his ankles. V19 turned back less than a minute later closed the room door but did not cover R61. R61 stated he is left exposed often. He would like to have been covered and not left exposed. On 01/08/25 at 03:43 PM (15 minutes later), V19 returned with assistance to finish assisting R61. 2. R32 admitted to the facility with diagnoses that includes Parkinson's, dementia, congestive heart failure, acute, left artificial hip joint and dysphagia. R32 physician's orders includes hospice care services and enhanced barrier precautions related to wounds. R32's MDS dated [DATE] indicates she has severe cognitive impairment and is completely dependent on staff for assistance with ADL's. On 01/07/25 at 04:05 PM, V17 (Hospice CNA) was providing bathing assistance to R32 with the room door opened and no curtain closed around the bed to protect R32 from view. R32, who has severe cognitive impairment, did not verbalize concern with the curtain not being pulled to protect her privacy, but a reasonable person would want their naked body protected from the view of passersby. On 01/09/25 at 02:22 PM, V2 DON (Director of Nursing) stated curtains should be closed during cares to block the residents from view; urine collections bags should be covered from view; blinds should be closed when care is being provided to residents; and when staff walk away from residents, they should cover them and not leave their genitals exposed. The facility Resident Rights Guideline states residents have the right to be treated with respect and dignity.

Based on interview and record review the facility failed to notify the physician of an elevated White Blood Cell Count. This applies to 1 of 4 residents (R1) reviewed for change in condition in a sample of 4. This failure resulted in R1 being admitted to the hospital Intensive Care Unit for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R1's Resident Progress Notes dated [DATE] documents R1 with increased confusion and cloudy urine. The Physician was notified, and orders were received to obtain a urinalysis and urine culture. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's final Laboratory Report dated [DATE] at 5:07 PM documented a White Blood Cell Count (WBC) of 20.8 (normal range 4.,d+[DATE].8). R1's Resident Progress Notes [DATE] at 2:04 PM documents R1 with a poor appetite for breakfast and lunch. This note documents the Nurse Practitioner was notified of R1's poor appetite and the preliminary urinalysis and urine culture results. R1's Internal Medicine Progress Note dated [DATE] documents R1 with elevated WBC's and a positive urine culture (preliminary result) without a fever. [MEDICATION(S)] 1 gram intravenously every 12 hours was indicated for a Urinary Tract Infection ([CONDITION(S)]). R1's final Laboratory Report dated [DATE] at 2:39 PM documents a final urine culture result showing Morganella Morganii and Staphylococcus Aureus organisms. R1's Resident Progress Notes [DATE] documents R1 was sent to the hospital for evaluation for decreased urine output and a swollen scrotum. R1's hospital emergency room Provider Notes [DATE] documents R1 admitted to the Intensive Care Unit with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Discharge Summary dated [DATE] documents R1's hospital admission due to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 expired on [DATE] after being placed on Hospice Care by his family due to his advanced age and do not resuscitate order. On [DATE] at V12 (Physician) stated the facility failed to notify me or my Nurse Practitioners of R1's elevated white count on [DATE]. We started R1 on antibiotics on [DATE] even before the sensitivity report was completed because he was symptomatic and had a high white count. R1 did not die because of the [CONDITION(S)], he was improving with treatment; hospital notes clearly show he was improving and stabilized. R1 died because he was made comfort care and treatment was withdrawn. The failure to notify us of the elevated white count did delay his treatment and starting the antibiotics quicker may have prevented his hospitalization and decline at the facility. I cannot say this delay would have changed the outcome of the Scrotum/Penile [CONDITION(S)], because he had a catheter. The facility policy, Notification of Resident Change in Condition Policy dated [DATE] documents the facility is to notify the physician promptly of any changes in a resident's health condition.

Based on interview and record review, the facility failed to ensure a resident was transferred in a safe manner using a mechanical total transfer lift device. This failure resulted in R1 sustaining a fractured fibula of the left lower leg. This applies to 1 of 3 residents (R1) reviewed for falls in a sample of 3. The findings include: The Face Sheet shows R1 had multiple admissions and readmissions to the facility. R1 was originally admitted to the facility for short term rehabilitation on 01/08/2013. R1's readmission to the facility for long term placement was on 09/01/2020. The POS (Physician Order Sheet), dated December 2021, shows R1 as an [AGE] year-old resident with diagnoses including Acute and Chronic Respiratory Failure with [CONDITION(S)], Urinary Tract Infection, Chronic Obstructive Pulmonary Disease, [CONDITION(S)], unspecified-site Osteopenia, Polyarthritis, pain in unspecified shoulder, pain in right and left knee, Dorsalgia (back pain), and Congestive Heart Failure. The restorative assessment dated [DATE] shows R1 was alert and oriented times 2-3, was able to verbalize her needs and required total assistance of two people physically assisting R1 when transferring using a mechanical total transfer lift device. R1 was also assessed as high risk for falls. The care plan dated 09/02/2020 showed that R1 had an intervention for proper utilization of the mechanical total transfer lift device and the need for two staff members for safe transfers. V3's (Licensed Practical Nurse) note dated 01/03/2021 at 3:40 PM, shows that V3 was summoned to R1's room because R1 was lying on the floor. R1 slid out from the sling of the mechanical total transfer lift device. The note shows R1 hit her head and had vomited. R1 was sent out to the hospital for further evaluation, treatment and CT (Computerized Tomography) of the head. R1 returned to the facility on same day. There was no abnormal finding on CT of the head. On 01/11/2022 at 2:30 PM, V3 stated she remembers very well when R1 fell on [DATE] around 3:40 PM. V3 stated R1 fell because V4 (CNA/ Certified nurse Assistant from an agency) had transferred R1 by himself without assistance. V3 added R1 had slid from the sling of the transfer lift device while R1 was being lifted up from her wheelchair in route for transfer from wheelchair to the bed. V3 reiterated that while R1 was being hoisted up, R1 slid down from the sling because one of the attachments of the sling was not attached to the hook of the transfer lift device. V3 also stated the sling has four attachments and all attachments must be attached to the hooks of the transfer lift device to ensure safety and to prevent resident from falling. V3 further stated with R1, one of attachments was not attached to the hook and this caused R1 to slide from the sling during transfer. V3 also stated that R1 was found on the floor when she entered R1's room. V3 then repeated the above statements during the interview when V2 (Director of Nursing) and V5 (Nurse Consultant) were present and reminded V2 You even gave an in-service to (V4/CNA-Certified Nurse Assistant) to ensure safety during transfer when using a mechanical lift device because he (V4) transferred (R1) by himself instead of using two staff to transfer. V6's (Nurse Practitioner, NP) notes dated 01/04/2021, shows R1 was seen on 01/04/2021 for a follow up due to the fall incident on 01/03/2021. The note shows during this visit, R1 was complaining of pain of 10 out 10 to her LLE (left lower extremity) (Pain of 10 out of 10 means excruciating pain and is described as worst pain unimaginable). The note also shows R1 stated she hit her left leg when she slid down from the sling of the transfer lift device. It was also documented that R1 had developed a blood blister with swelling to the left lower extremity. V5 ordered X-Rays to left shoulder, knee and leg. The portable X-Ray result dated 01/05/2021 shows there was a suspicious fracture of the left leg. The nurse's notes dated 010/5/2021 shows that R1 was sent to the hospital on 01/05/2021 for further evaluation. X-Ray of the left extremity was inconclusive, and an MRI (Magnetic Resonance Imaging) was recommended for follow up. R1 returned to the facility the same day with a CAM (Controlled Ankle Movement) boot (leg immobilizer) in place to the left leg. Review of the hospital ER (emergency room ) report dated 01/5/2021 showed ER reason for visit; abnormal findings; diagnoses; closed fracture of ankle. Ankle fracture is when one or more of the bones in your ankle break. The clinical documentation showed that MRI was not done. On 01/12/2022 at 1:30 PM, V2 (Director of Nursing) stated she cannot find any documentation to show that MRI was done. V6's (NP) notes dated 01/20/2021, showed a follow up evaluation was done by V6 and R1 had an ankle fracture. The nurse's notes dated 01/08/2021 showed that R1 was scheduled for an Orthopedic consultation on 01/11/2021. On 01/12/2021 at 2:30 PM V6 (Nurse Practitioner) stated R1 was having excruciating pain to her left leg on 01/05/2021 due to R1 hitting her leg during the fall on 01/03/2021. V6 also stated that the fracture left fibula must have been determined during the Orthopedic consultation. Again on 01/13/2022 at 9:45 AM, V6 was further interviewed after she had reviewed R1's clinical chart. V6 stated that she has to defer to Orthopedic regarding R1's fracture. V6 stated from my professional standpoint, when I saw (R1) on 01/04/2021, the pain to her left leg was excruciating, it was something unusual, an acute and new onset. During my previous examination (R1) had not complained of any new onset of pain that was severe, no left leg swelling and no blood blister prior to the fall. I saw (R1) on 12/30/2020 prior to fall. This pain, swelling, and blood blisters were caused from the fall that occurred on 01/03/2021. On 01/12/2022 at 3:30 PM, V7 (R1's Attending Physician) stated that R1 was referred to an Orthopedic consultation on 01/05/2021 for fracture management when R1 was at the hospital. The Orthopedic consultation notes by V8 (Orthopedic Surgeon) dated 01/11/2021 showed that R1 had fracture of left fibula, WBAT (weight bearing as tolerated), CAM (Controlled Ankle Movement) boot while out of bed and returned to clinic for orthopedic follow in 6 weeks for another X-Ray of the left ankle. The information regarding CAM boot obtained from website (myfootdr.com) shows that it works by both keeping foot and ankle fixed in place, and offloading (removing) some of the weight off the foot, so that fracture can heal more effectively. The information regarding fibula from a website (childrenshospital.org) shows that fibula is called the calf bone, is smaller than tibia, and runs beside it. The top end of the fibula is located below the knee joint but is not a part of the joint itself. The lower end of the fibula forms the outer part of the ankle joint. The facility's policy with a revision date of August 2008 shows the total lift machine should be used by two staff members.

Based on interview and record review, the facility failed to complete a comprehensive assessment and develop intervention to prevent further weight loss for a resident who had significant weight loss; failed to obtain weights as per the facility policy; and failed to develop a plan of care to avoid drastic weight changes. This failure resulted in R2 losing 27.9 pounds in less than six weeks. This applies to 1 of 5 residents (R2) reviewed for weight loss in the sample of 10. The findings include: The facility's admission/transfer/discharge log dated May 2020 through November 2020 showed R2 was discharged to another facility on 9/18/20. The review of R2's electronic health record (EHR) showed R2 was [AGE] years old and was originally admitted to the facility on [DATE]. R2 was sent out to the hospital on [DATE] due to stage 4 [MEDICAL CONDITION] with worsening kidney function related to acute diastolic heart failure. R2's EHR showed R2 was in the hospital from 6/26/20 through 7/17/20. R2 was noted with [DIAGNOSES REDACTED]. R2's re-admission observation detail report dated 7/17/20 showed R2 with bruises on the right arm and right thumb. The report also showed R2 with open areas 2 cm (centimeters) under the right breast, and on the coccyx (0.5cm). The coccyx wound was healed on 7/29/20. R2's EHR showed an order dated 7/23/20 for Multivitamin and Prostat 30ml twice a day for wound healing. R2's MAR (Medication Administration Record) dated 7/17/20 showed R2 was on fluid restriction of total 1200ml per day. R2's Minimum Data Sets ((MDS) dated [DATE] showed R2 required extensive assistance of one staff for eating. R2's POS (Physician order [REDACTED]. On re-admission, R2's diet order dated 7/17/20 was Mechanical soft with skim milk, low cholesterol egg, no liver, no sausage, no bacon, NCS, thin liquids. R2's diet order dated 8/13/20 showed Regular diet with skim milk, low cholesterol egg, No liver, no sausage, no bacon, NCS, thin liquids. Review of R2's weight record at the facility showed the following: Initial weight dated 6/25/20= 190.08 lbs (Taken 3 days after admission) Readmission weight 7/20/20=134.96 lbs (Taken 3 days after re-admission) The Dietitian failed to review R2's chart until 7/23/20 (6 days after re-admission) and ordered Multivitamin with minerals. 8/1/20= 126lbs 8/10/20= 118lbs ([MEDICATION NAME] ordered) 8/20/20= 112.12 lbs 9/1/20= 107.04 lbs. On 12/4/20 at 12:15pm, V20 (Physician) stated R2 was sent to the facility initially in June 2020 for rehabilitation. V20 stated R2's baseline weight prior to initial admission at the facility was between 135-140 pounds in March-April 2020. V20 stated R2 went to the hospital and spent about 3 weeks due to [MEDICAL CONDITION]. V20 stated R2 was [MEDICATION NAME] at the hospital and was discharged back to the facility in good condition in July 2020. V20 further stated he was not made aware of R2's drastic weight loss at the facility. V20 stated subsequent weight loss after re-admission was not desired for R2. V20 stated if he was notified, he would have ordered closer monitoring of R2's weight and discussed with the family for further interventions. The review of facility's grievance/complaint form log dated 9/14/20 showed (V22) (Family member) has concerns regarding the lack of communication from the facility about (R2) and (R2's) status. The form also showed (V22) has concerns about (R2's) weight and many other concerns and would like a call back. The grievance/complaint form was filled out by V14 (Admission Director). Review of facility's grievance/complaint form log dated 9/15/20 filled out by V12 (MDS Coordinator) showed family was not notified of weight loss and the rate at which weight was lost. On 12/3/20 at 8:39am, V12 (MDS Coordinator) stated she notified the dietitian about R2's weight loss on 9/14/20 after V22's complaint. V12 stated she sent an email to V3 (Dietitian) on 9/14/20 regarding R2's weight loss. On 12/3/20 at 9:51am, V3 (Dietitian) stated she reviews residents' records weekly. V3 stated she reviews records for new admission, re-admission, [MEDICAL TREATMENT] residents, residents with weight changes and residents on Gastrointestinal Tube (GTube). V3 stated she did not review R2's chart on 6/22/20 when R2 was initially admitted to the facility because R2's height and weight were not available. V3 stated she reviewed R2's chart on 7/23/20 and added Multivitamin with minerals. V3 stated she reviewed R2's chart in August 2020 with no recommendations and wanted to wait until September 2020. V3 stated she did not know R2's base line weight and thought the weight loss was desired based on hospital records. There was no dietary notes and no interventions for R2 in August 2020. The next dietary note was dated 9/14/20 after family complained of weight loss. On 12/3/20 at 11:56am, V19 (Restorative Nurse) stated she was in charge of weight monitoring in the facility. V19 stated resident's weight must be taken on admission, weekly times 4, then monthly. V19 stated residents with eating issues, GTube placement, or [MEDICAL CONDITIONS] should have more frequent weight monitoring. V19 stated if weight loss is noticed, family, dietitian, speech and physician should be involved and supplements should be added. On 12/3/20 at 11:10am, V2 (Director of Nursing) stated R2's weight should have been obtained on the day of admission or readmission in order for the facility to have a baseline weight record. V2 further stated V3 (Dietitian) has remote access to all residents records and R2's weight loss should have been addressed. Review of R2's EHR showed no plan of care to address R2's weight loss nor was there any comprehensive assessment of R2's condition related to weight loss. Facility's policy titled, Weight Assessment and Intervention with a revised date August 2008, showed: 1. The nursing staff will measure resident's weight on admission, and weekly for three weeks thereafter .If no weight concerns are noted at this point, weights will be measured monthly thereafter. 3. Any weight change of greater than or less than 5 pounds within 30 days will be retaken for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. 4. The dietitian will respond within 24 hours of receipt of written notification. 5. The Dietitian will also review the unit Weight Record to follow individual weight trends over time. Negative trends will be assessed and addressed by the Dietitian whether or not the definition of Significant Weight Change is met. 8. If a weight loss or gain meets the definition of Significant, the Dietitian should discuss with the Interdisciplinary Team if a Significant Change MDS is necessary. 11 The Dietitian will discuss the weight issue with the resident and or family. 12. Resident's Physician, Nursing Supervisor and resident's family/responsible party should be notified of any significant weight loss or gain. Facility's policy titled, Nutrition (Impaired)/Unplanned Weight Loss with a revised date August 2008, showed: Asses the individual's current nutritional status and identify individuals with anorexia, recent weight loss, and significant risk for subsequently impaired nutrition; for example, high risk residents with acute systems such as vomiting, diarrhea, fever, and infection, or those taking medications that may be causing or increasing the risk of anorexia or weight loss.