Every finding on record at Lexington Healthcare and Rehabilitation Center

Based on observations, interviews, and record review, the facility failed to implement interventions and provide supervision to prevent accidents/injuries to residents related to: 1) failure to prevent a fall with injuries for one resident (#56) out of four residents reviewed for falls; and 2) failure to ensure a safe environment for residents to smoke for two residents (#21, #41) out of two residents who required the use of a wheelchair. Residents were expected to sign a leave of absence (LOA) form and then navigate off facility grounds, unassisted, through the parking lot approximately 350 feet, over a large speed bump, and across large potholes, despite being assessed to require supervision during ambulation or requiring the use of a wheelchair. Findings included: 1. A review of the medical record for Resident #56 revealed a progress note dated 07/02/2025 at 6:35 a.m. “Resident attempted to get oob (out of bed) without assistance, found with left leg stuck inside rail and face on the floor, noted moderate amount of blood to resident's facial/nose area, resident remained on floor, positioned on right side, pending arrival of emergency services, MD (Medical Doctor) made aware of resident's state, attempts to reach residents son unsuccessful, no answer at this time will attempt at a later time” Further review of the medical record revealed she was admitted to the facility on [DATE], with diagnoses to include cognitive communication deficit (4/29/25); hypertension (4/29/25); major depressive disorder (4/29/25); encephalopathy (6/1/25); dementia (6/19/25); fracture of base of skull (7/3/25); contusion of scalp (7/3/25); history of falling (7/3/25). A review of the resident’s care plan dated 05/07/2025 to 07/28/2025, revealed the “Resident is at risk for falls and/or fall related injury r/t [related to]: generalized weakness. Resident will minimize risk of fall related injuries with staff intervention thru next review date.” Interventions included, “Observe for unsteadiness/dizziness when changing positions; provide assist as needed”. “Utilize total mechanical lift with staff assist of 2 for transfers”. “Remind resident to request assistance prior to ambulation/transfers as needed”. “Keep call light within reach.” A review of the Determination of Capacity to Give Informed Consent form dated 5/22/25, revealed that the Psychiatric Mental Health Nurse Practitioner (PMHNP) attested “I have assessed [Resident #56] on a consult requested by attending physician and have found he/she”…The PMHNP marked with an “x” “Lacks the capacity to make medical decisions.” Further review of the record revealed an encounter note dated 06/19/2025 by the PMHNP that stated This is an [AGE] years old patient with a past psychiatric history of depression and dementia. Prior to last visit, patient had symptoms of depression. During last visit, patient was confused. Patient had symptoms of dementia. Patient stated no history of depression or anxiety. Patient denied any mood swings or behavioral outbursts. Sleep and eating habits were noted as good. No medication changes were done. Facility is requiring a detail cognitive assessment as patient is showing behaviors related to memory problems and there has been change in patient baseline requiring recommendation on the care plan. Today, I saw this patient to perform that cognitive assessment and form the care plan. As per collected information the patient is very confused with repetitive speech. Staff reports no concerns at this time. Patient can not tell me her birthday or where she currently is. No other psychiatric symptoms observed. Staff report patient has gotten agitated during hygiene care. No side effects to current psych medications reported.” The note documented a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severe cognitive impairment. On 6/26/25 the PMHNP documented on an encounter note, “Dementia with agitation: The history suggests that the patient had a gradual decline in memory, executive function, language, concentration, and fund of knowledge. These symptoms have caused distress and have affected the quality of life and activities of daily living. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. The memory loss has been followed by significant behavioral agitation as well.” The note documented a BIMS score of 7, indicating severe cognitive impairment. Review of the interdisciplinary team (IDT) notes dated 07/02/2025 at 9:03 a.m., “IDT reviewed 07/02/2025 with new intervention to apply bed bolsters to reduce the risk of future falls and enhance resident safety while in bed. This intervention will be added to the resident’s care plan and monitored for effectiveness.” A progress note dated 07/02/2025 at 2:16 p.m. This wroter [sic] called [Hospital] to get update on resident per Nurse[sic] she is admitted for non displaced skull FX [fracture], family notified. A review of the hospital speech-language pathology (SLP) evaluation note dated 07/02/25, “Assessment/Plan SLP Assessment Pt [patient] was cleared by nursing for SLP evaluation. Pt is A+OX1 [alert and oriented to self only], confused but cooperative. Pt presents from SNF [Skilled Nursing Facility], following GLF [ground level fall], with skull fx [fracture] and C-collar [cervical neck brace] in place. Strong and foul urine smell is noted in pt.'s room. Oral-facial examination is remarkable for reduced mandibular depression due to the presence of C-collar.” “Severe cognitive deficits are noted, however, pt is baseline mentation per notes.” On 7/16/25 at 5:07 p.m., an interview was conducted with the Director of Nursing (DON). She stated that the resident had a fall risk score of 10 (out of 20) on admission which was high but not “super high” She stated that when the resident returned to the facility they put bolsters in her bed (long cushions or pillows that provide support and can be used to prevent falls) and moved her closer to the nursing station. She stated prior to the fall they did not see the need to have any more interventions than those listed on the care plan. Offering that the resident should have called for assistance and she did not, so she fell. She further offered that the facility could not protect every resident at all times from falling. She was asked if there should have been more supervision of the resident due to her dementia and confusion she stated the resident was capable of calling for assistance and she did not. On 07/17/2025 at 9:59 a.m., an interview was conducted with the PMHNP, during which she stated she last saw the resident on 06/26/2025 and found her to be confused, alert to self only, very confused, garbled speech, dementia with agitation and exit seeking, She was not told the resident had a fall and if she had been she would have seen her for a follow up. In her opinion she was not able to request assistance or call for assistance. She stated she should have been notified of the resident’s fall, the hospital visit would make her “unstable” which would have required her to be seen the next day. On 07/17/2025 at 2:02 p.m., a telephone interview was conducted with the son of Resident #56, during which he stated that the facility called him and informed him that the resident was found alongside the bed and was sent to the Emergency Room. He reported that she is always confused and was confused at the time she fell. They called him that morning. He stated that they have given her a special mattress and moved her closer to the nursing station to keep a better eye on her. On 07/17/2025 at 4:38 p.m., a telephone interview was conducted with Staff G, Licensed Practical Nurse (LPN) who stated she was working with the resident the morning of her fall. She stated that the patient was very confused and would not have known what the call light was and would not have be able to use it to call for assistance. She stated that she did rounds every two hours and that the resident had been asleep the last she had checked on her. She said the CNAs (Certified Nursing Assistants) are in and out. The resident had not tried to get out of bed before and when she entered the room she was on the floor. 2. During an interview on 07/14/2025 at 5:05 p.m., Resident #41 was observed in a wheelchair in the parking lot of the facility. Resident #41 stated he was smoking. I have to sign out on a Leave of Absence (LOA) and go past the fence to smoke. Sometimes I go and hide in the cover patio area. I put my butts out in my pile. The lady at the front desk keeps my lighter and cigarettes.” No staff or smoking receptacles were observed in the area where Resident #41 was smoking. Review of Resident #41's admission record revealed an admission date of 04/21/2025. Resident #41 was admitted to the facility with diagnoses of muscle weakness (generalized), other abnormalities of gait and mobility, unsteadiness on feet, and nicotine dependence, unspecified, uncomplicated. Review of Resident #41's Quarterly MDS dated [DATE] revealed, Section C. Cognitive Patterns a Brief Interview Mental Status (BIMS) of 15 out of 15 showing intact cognition. Review of Resident #41’s Care Plan dated 04/22/2025 revealed: Focus: “[Resident #41] desires to smoke. [Resident #41] has been assessed as able to smoke: independently. Goal: [Resident #41] will adhere to the smoking policy daily thru the next review date. Resident will demonstrate safe smoking practices thru the next review date. Interventions: Monitor for signs of unsafe smoking practices; Return smoking material to designated staff upon re-entry to the facility from LOA; Maintain smoking materials in designated area; Provide redirection if resident is observed in any unsafe smoking practices. Seek the assistance of managers/supervisors if needed; Observe for decline in hand dexterity; decline in cognition; decreased alertness while smoking; inability to safely dispose of ashes, butts; new or worsening vision impairments; and decreased ability to safely hold cigarette, as needed.” Review of Resident #41’s smoking assessment dated [DATE] revealed: Does the resident use, or have a desire to use, tobacco products/e-cigarettes? Yes 3. Observation a. does the resident remain alert during smoking? Yes Can the resident safely light a cigarette or smoking product, or ignite an e-cigarette device? Yes c. Is the resident able to safely hold a cigarette/smoking product/e- cigarette device? Yes d. Can the resident dispose of ashes, butts, and e- cigarette devices properly? Yes Is the resident free of visible upper extremity tremors? Yes f. Is the resident free from contractures in their hands, wrist, or elbows that impair their ability to smoke? Yes g. Is the resident free from loss of mobility, reduced movement, weakness, or paralysis to the dominant upper extremity? Yes h. Is the resident free from vision issues that impair their ability to smoke? Yes i. Total score for observation 0. During an interview on 07/15/2025 at 3:59 p.m., Staff Z, Unit Manager, stated she completed the smoking assessment for Resident #41 at his admission in April. “I answer the questions on the smoking assessment by marking yes to the questions. I did not observe Resident #41 smoking. I see him smoking when I leave for the day and see him out on the sidewalk smoking. I was told to make sure that all the residents who smoke have a smoking assessment completed and created new smoking assessments for all the residents today (07/15/2025). She had not seen the smoking policy/guideline form and was unsure where it came from. 3. During an interview and observation on 07/14/2025 at 5:15 p.m., Resident #21 was observed on the edge of the facility driveway in between the main street and a yellow speed bump on the facility driveway. Resident #21 was observed holding onto her wheelchair, trying to move it across the speed bump. Resident #21 stated I am being punished because I am a smoker. We have to come all the way out here, off property to the sidewalk to smoke. I don’t understand why I can’t go right here underneath this tree. No staff or smoking receptacles were observed in the area where Resident #21 was smoking. Review of Resident #21's admission record revealed an admission date of 07/08/2025. Resident #21 was admitted to the facility with diagnosis to include other abnormalities of gait and mobility, unsteadiness on feet, other specified disorders of bone density and structure, and nicotine dependence, unspecified, uncomplicated. Review of Resident #21's physician orders revealed an order dated 07/10/2025, resident may go on LOA unsupervised. Review of Resident #21's Medicare 5 Day MDS dated [DATE] revealed Section C. Cognitive Patterns, a Brief Interview Mental Status (BIMS) of 14 out of 15 showing intact cognition. Review of section GG. Functional Abilities revealed, for mobility, Resident #21 requires partial/moderate assistance for sit to stand, chair/bed-to-chair transfer, walk 10 feet 1 step (curb). Resident #21 uses manual wheelchair for mobility. Review of Resident #21's care plan dated 07/09/2025 revealed: “Focus: [Resident #21] desires to smoke. [Resident #21] has been assessed as able to smoke: Resident /responsible party have been informed of the facility smoking policy. Goal: [Resident #21] will adhere to the smoking policy daily thru the next review date; Resident will demonstrate safe smoking practices thru the next review date. Interventions: Monitor for signs of unsafe smoking practices; Provide redirection if resident is observed in any unsafe smoking practices; Seek the assistance of managers/supervisors if needed; Observe for decline in hand dexterity; decline in cognition; decreased alertness while smoking; inability to safely dispose of ashes, butts; new or worsening vision impairments; and decreased ability to safely hold cigarette, as needed; Inform resident of smoking cessation options upon resident request prn[as needed].” Review of Resident #21’s smoking assessment dated [DATE] revealed: Does the resident use, or have a desire to use, tobacco products/e-cigarettes? Yes …3. Observation a. does the resident remain alert during smoking? Yes b. Can the resident safely light a cigarette or smoking product, or ignite an e-cigarrete device? Yes c. Is the resident able to safely hold a cigarette/smoking product/e-cigarette device? Yes d. Can the resident dispose of ashes, butts, and e- cigarette devices properly? Yes Is the resident free of visible upper extremity tremors? Yes f. Is the resident free from contractures in their hands, wrist, or elbows that impair their ability to smoke? Yes g. Is the resident free from loss of mobility, reduced movement, weakness, or paralysis to the dominant upper extremity? Yes h. Is the resident free from vision issues that impair their ability to smoke? Yes i. Total score for observation 0. During an interview on 07/16/2025 at 11:15 a.m., the Director of Therapy stated Resident #21 is in Physical Therapy (PT) and Occupational Therapy (OT) as of 07/08/2025. PT is working with her on bed mobility, transfers and ambulation. Resident #21 is a standby assist which is close supervision or contact guarding to make sure she is safe when standing. “She should have someone standing next to her when she is out of her wheelchair. Resident would not be considered safe to ambulate on her own.” During an interview on 7/15/2025 at 4:05 p.m., the Director of Nursing (DON) stated the policy is we are a nonsmoking facility. Residents are assessed to see if they are a safe smoker, “I would assume they are watching the resident smoke if they are documenting on the observation of the smoking assessment. I don’t have to see someone physically smoking to assess if they have a tremor. There are a couple of things on the smoking assessment under the observation that do not require them to watch the resident smoking.” During an interview on 07/17/2025 at 3:25 p.m., the Nursing Home Administrator (NHA) stated “We are a non-smoking facility and if residents want to smoke, they sign out LOA and go off the premises to smoke. No there are no smoking receptacles or anywhere for cigarettes to be discarded outside. The nurses do a smoking assessment with the residents. I have never looked at the smoking assessment. If it says observation I would expect there to be an observation of the residents smoking. I have never watched any residents travel through the parking lot to the sidewalk so I cannot say if the parking lot is safe. There are speed bumps, and holes in the parking lot.” Review of the facility’s undated policy titled Safety and Supervision of Residents, undated, revealed “Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision, and assistance to prevent accidents are facility-wide priorities…Facility-Oriented Approach to Safety: 1. Our facility-oriented approach to safety addresses risks for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through our combination of employee training, employee monitoring, and reporting processes; reviews of safety and incident/accident data; in a facility wide commitment to safety at all levels of the organization. 3. When accident hazards are identified, the QAPI [Quality Assurance and Performance Improvement]/safety committee shall evaluate and analyze the cause of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents. 5. The QAPI committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary. Individualized, Resident Centered Approach to Safety: 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the facility environment including adequate supervision and assistive devices…6. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach for safety, which considers the hazards identified in the facility environment and individual resident risk factors, and then adjust interventions accordingly. 7. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual residents assessed needs and physician order. 8. The type and frequency of resident supervision may vary among residents and over time for the same resident. 9. Due to their complexity and scope, certain resident risk factors environmental hazards are addressed and dedicated policy and procedures.”

Based on observation and interviews, the facility failed to ensure the kitchen was maintained in a clean, sanitary manner in one kitchen (Main) of one kitchens observed during survey.Findings included:During the initial tour of the kitchen conducted with the Certified Dietary Manager (CDM) on 07/14/2025 from 9:59 a.m. to 10:25 a.m., concerns were identified related to the following:The filter in the juice machine was observed with dirt and debris. An immediate interview with the CDM revealed she did not know how the filters can be cleaned. She stated they would have to order new filters and the vendor would install.The juice machine equipment was observed with brown - coloring and stains on the surface of the stainless-steel surfaces. The CDM stated the surfaces are rusted and there was no way to clean them.The ceiling filters were observed with stains, dust and dirt, located above food prep and food service areas.The light by the food prep area was observed with brown stains and bio-growth.An observation was made of water leaking close to the light fixture above the food service station. The CDM stated the maintenance department was aware of the issue.An observation was made of the kitchen mixer utensils with dust and sticky substances on the surfaces of the items. The utensils were stored on the top shelf above clean dishes. The CDM said, We do not use those anymore. They should be removed.A tour of the freezer revealed ice frozen on the freezer surfaces and chunks of ice observed on top of the food boxes. The CDM stated she was aware of the concern and maintenance would remove the ice-build up.An observation was made of an insect flying on top of the chicken which was in a mixing bowl. The [NAME] was preparing the chicken for lunch. The CDM stated some staff leave the back door open, which allows insects and flies to fly inside the kitchen. She immediately removed the chicken and threw it in the trash.Outside the back area of the kitchen, an observation was made of trash and standing water, near the kitchen door. The CDM stated they were expected to pick up trash daily. She stated the maintenance department was aware the water was leaking from an A/C (Air Conditioning) unit located on top of the kitchen roof. She stated it had been an ongoing problem, and it was breeding mosquitoes.Further observation of the trash area revealed trash around the dumpster grounds including used gloves, papers, and incontinence pads. The CDM stated the responsibility to clean the area was shared between nursing and maintenance departments. She stated it was hard for her to enforce compliance. She stated the expectation was they should keep the grounds clean.During an interview conducted with the CDM on 07/16/2025 at 11:30 a.m., the CDM stated they had an expectation to maintain the kitchen in a clean manner. She stated they had started cleaning, and the maintenance department would be working on the repairs.Review of a facility policy titled Environment, dated October 2019 showed a policy - It is the center policy that all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition.Action Steps showed: 1. The Dining Service Director will insure that the physical plant is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation.2. The Dining Services Director will insure that all employees are knowledgeable in the proper procedures for cleaning all food services equipment and surfaces.3. The Dining Services Director will insure that all food contact surfaces are cleaned and sanitized after each use.4. The Dining Service Director will insure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces.5. The Dining Service Director will insure that all dining areas are cleaned and sanitized after each use, including table surfaces, chairs, and floors.6. The Dining Services Director will insure that all trash is contained in covered leak proof containers that prevent cross contamination.7. The Dining Services Director will insure that all trash is properly disposed in external receptacles (dumpsters) and that the area is free of debris.(Photographic Evidence Obtained)

Based on observation, interviews and record review, the facility failed to ensure dependent residents received assistance with activities of daily living (ADLs) for five residents (#107, #86, #18, #43 and #102) of seven residents sampled.Findings included: 1. On 07/16/2025 at 9:13 a.m. Resident #107 was observed with long fingernails and hair on her chin. She stated she would like to be assisted with trimming her nails and shaving her face. She stated she preferred her nails short and clean. She stated the Certified Nursing Assistants (CNA’s) say they will help, but then they do not. Review of the admission record for Resident #107 revealed she was admitted to the facility on [DATE] with diagnoses to include dementia. Review of Resident #107’s quarterly Minimum Data Set (MDS) dated [DATE] revealed in section C the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating moderate cognitive impairment. Section GG - showed the resident required partial/moderate assistance (Helper does less than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). Review of a care plan for Resident #107 dated 03/11/2024 showed the resident has a self-care deficit with dressing, grooming, and bathing related to generalized weakness. Resident participates with ADLs with cues from staff. Interventions included gather and set up supplies for cares. Cue or encourage resident to participate in ADL tasks. Allow resident ample time to attempt or complete ADL tasks before intervening. Encourage/remind the resident to ask for assistance as needed and observe for decline in ADL function; report to the physician as indicated. 2. On 07/16/2025 at 9:18 a.m. Resident #86 was observed in his room. He was observed with long fingernails, embedded with black colored substances underneath the nails. The resident stated there used to be a nurse who used to trim his nails, but she does not trim his nails anymore. Resident #86 said, “I think they are just busy.” He stated he preferred his nails trimmed short. Review of the admission record for Resident #86 revealed he was admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis following cerebral infarction, affecting left dominant side and need for assistance with personal care. Review of Resident #86’s comprehensive MDS dated [DATE] revealed in section C the resident had a BIMS score of 15 out of 15 indicating intact cognition. Section GG- showed the resident required partial/moderate assistance (Helper does less than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). Review of a care plan for Resident #86 dated 12/09/2021 showed the resident has a self-care deficit with ADLs related to CVA (stroke), hemiplegia, impaired balance, limited mobility, and weakness. Interventions included - provide hands on assistance with dressing, grooming, bathing as needed. An interview was conducted on 07/16/2025 at 9:21 a.m. with Staff X, Licensed Practical Nurse (LPN)/ Unit Manager (UM). She stated the residents should be assisted with shaving on a daily basis, mostly during showers/baths. She stated the nail care should be done at the same time. She stated if a resident was refusing any type of care, the nurse should be notified. She stated the nurse would document, and interdisciplinary team (IDT) would discuss, and the care plan would be updated. 3. On 07/15/2025 at 10:46 a.m. Resident #18 was observed in her room, noted with facial hair on her chin. She stated it was a long time ago since she was shaved. On 07/16/2025 at 9:16 a.m. Resident #18 was observed in her room. She stated she still needed to be assisted with shaving. She stated it was “not lady like. Review of the admission record revealed Resident #18 was readmitted to the facility on [DATE] with a primary diagnosis of Parkinson’s disease without dyskinesia, without mention of fluctuations. Review of Resident #18’s quarterly Minimum Data Set (MDS) dated [DATE] revealed in section C the resident had a BIMS score of 7 out of 15 indicating severe impairment. Section GG- showed the resident required substantial to maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). Review of Resident #18’s care plan dated 02/08/2023 revealed the resident has a self-care deficit with dressing, grooming, bathing related to generalized weakness. Interventions included - gather and set up supplies for care, cue/encourage resident to participate in ADL tasks, allow resident ample time to attempt/complete ADL tasks before intervening, encourage/remind the resident to ask for assistance as needed, and to provide hands on assistance with dressing, grooming, and bathing. On 07/16/2025 at 11:50 a.m. an interview was conducted with Staff Y, CNA. She stated the residents are to be shaved during showers. She stated if a resident refuses, she would let the nurse know. She stated if they asked to have their nails trimmed, she would check if it was okay. She stated most of the time it is not a problem. On 07/16/2025 at 11:54 a.m. an interview was conducted with Staff S, Registered Nurse (RN). Staff S, RN stated if a resident had facial hair, the CNAs would shave the resident per preference during their shower. She stated she sometimes helps trim resident's nails. She stated if she got through her assignments today, she would assist the residents who needed to have their nails trimmed. 4. On 07/14/2025 at 11:32 a.m., an interview was conducted with Resident #43. The resident stated he had a bowel movement and had been waiting for an hour and a half to be assisted to the toilet. The resident stated he used the call light, and a nurse told him that they would get the CNA, responsible for his area. The resident stated staff came into the room and turned off the call light approximately an hour ago. Review of Resident #43’s medical records revealed he was re-admitted to the facility on [DATE], with diagnosis to include encephalopathy, need for personal care, epilepsy, and other specified disease of spinal cord. Review of Resident #43’s quarterly Minimum Data Set (MDS) Section C revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 that means intact cognition. Section H revealed the resident is always incontinent with bowel and bladder. Section GG showed for Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment, the resident requires Substantial/Maximal Assistance. Review of a care plan initiated on 06/08/2022, showed a focus of Resident #43, has a self care deficit with dressing, grooming, bathing r/t (related to), TBI (traumatic brain injury), spinal cord injury and seizures. Interventions included: provide total staff assistance with dressing, grooming, and bathing, and staff to anticipate resident needs with ADLs (activities of daily living). Review of a CNA Kardex (a document used by nursing staff describing a resident’s level of care), dated 07/04/2025 through 07/17/2025 revealed the resident did not receive toileting care consistently with the following dates missing documentation: 07/05/2025, 07/12/2025, 07/13/2025, 07/14/2025, 07/15/2025, 07/16/2025 and 07/17/2025. 5. On 07/14/2025 at 11:13 a.m., an interview was conducted with Resident #102. The resident explained that she had used her call light earlier, and the staff did not respond until over an hour later. During this time, the resident was left soiled in stool. She explained that she had not received a shower since 07/12/2025. She stated she would like showers at least three times a week, but she would like to shower more often if she could. On 07/15/2025 at 10:17 a.m. an interview was conducted with Resident #102 she said she had not received another shower since 07/12/2025. Review of Resident #102’s medical records revealed she was admitted to the facility on [DATE], with diagnosis to include unspecified heart failure, hyperlipidemia, unspecified, morbid (severe) obesity due to excess calories, essential (primary) hypertension, peripheral vascular disease, unspecified, lymphedema, and chronic obstructive pulmonary disease, unspecified. Review of Resident #102’s quarterly Minimum Data Set (MDS) Section C revealed the resident had a BIMS score of 15 out of 15, which means intact cognition. Section H revealed the resident was always incontinent with bowel and bladder. Section GG showed for toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment, the resident requires Substantial/Maximal Assistance. Review of a care plan initiated on 03/26/2021, showed a focus – Resident #102, has a self-care deficit with ADLs r/t: impaired mobility r/t lymphedema/morbid obesity diagnosis (dx) of; chronic pain. Interventions included: resident usually prefers a shower, however some days chooses to have a bed bath instead. Provide hands-on assistance with dressing, grooming, and bathing as needed. Review of a care plan dated 03/26/2021, showed a focus of Resident #102, is at risk for complications r/t alteration in health maintenance with a dx of: anemia, GERD, hypothyroidism. Interventions revealed, provide increased assist with ADLs as needed for c/o (complaints of) increased fatigue/weakness. Review of a care plan initiated 03/26/2021, showed a focus - Resident #102, has an alteration in elimination AEB (as evidenced by): is incontinent of bowel and bladder. The interventions were: provide hands-on assistance with toileting upon resident request and as needed. Check resident upon arising, before/after meals and at HS (hours of sleep) for incontinence; perform incontinence care prn (as needed). Initiate bowel protocol as needed. Review of a CNA Kardex, dates 07/04/2025 through 07/17/2025 revealed the resident did not receive toileting care consistently with the following dates missing documentation: 07/04/2025, 07/06/2025, 07/09/2025, 07/10/2025, 07/12/2025, 07/14/2025, 07/15/2025, and 07/16/2025. On 07/16/2025 at 2:32 P. M., an interview was conducted with Staff X, Licensed Practical Nurse who was the Unit Manager (UM), for the South Wing. Staff X, UM stated residents should be changed every two hours or less. She stated, charting should be documented in the electronic medical record. She stated the charting should be completed before leaving the building; otherwise, staff would be called back to the facility to complete the charting in the residents’ records. On 07/17/2025 at 1:41 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated that residents should be changed every two hours. The DON stated charting should be done at the time assistance is provided to a resident. Review of an undated facility policy titled, Activities of Daily Living (ADLs), Supporting, showed: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation showed: 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable… 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); b. mobility (transfer and ambulation, including walking); c. elimination (toileting)…

Based on observations, interviews, and record review, the facility failed to provide incontinence care and prevent a Urinary Tract Infection (UTI) for one resident (#150) out of three residents sampled.Findings Included: During a phone interview on 07/15/2025 at 5:15 p.m., Resident #150 Family Member (FM) stated Resident #150 has been in and out of the hospital related to UTI's, multiple times. When she picks up Resident #150's laundry it is soaking wet. Maybe if they changed her more often, she would not have so many UTI's. When she goes to the hospital and they do lab work it shows E. coli [Escherichia coli] in her urine. Review of Resident #150's admission record revealed an admission date of 06/01/2022. Resident #150 was admitted to the facility with diagnosis to include Unspecified Dementia, Unspecified Severity, With Other Behavioral Disturbance, Urinary Tract Infection, Site Not Specified, Major Depressive Disorder, Recurrent, Moderate, Parkinson's Disease Without Dyskinesia, Without Mention of Fluctuations History of Falling. Review of Resident #150's Quarterly MDS, dated [DATE], revealed, Section C. Cognitive Patterns, a Brief interview Mental Status (BIMS) of 01 out of 15 showing severe cognitive impairment. Review of Section GG. Functional Abilities revealed Resident #150 was dependent for all self-care and mobility. Review of Section H. Bladder and Bowel revealed, Resident #150 was always incontinent for bladder and bowel. Review of Resident #150's Orders revealed:7/11/2025, Nitrofurantoin Macrocrystal Capsule 100 milligrams (MG) Give 1 capsule by mouth every 12 hours for UTI for 5 Days. the medication was administered as ordered. 7/5/2025,Urinalysis (UA) Culture and Sensitivity (C&S) may straight catheter. one time only for increasing confusion, restlessness for UTI 6/25/2025-6/29/2025 Ertapenem Sodium Injection Solution Reconstituted 1 gram (GM) (Ertapenem Sodium) Inject 1 gram intramuscularly one time a day for UTI. 6/21/2025-6/24/2025 Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day for uti for 3 Days 6/20/2025-6/21/2025 Lab: UA with C & S ok straight cath every shift for 3 Days OK discontinue once UA collected and sent 6/3/2025-6/8/2025 Cefuroxime Axetil Tablet 500 MG Give 1 tablet by mouth two times a day for UTI for 5 Days 5/30/2025-5/30/2025 UA C&S may straight catheter. every shift for 3 Days May discontinue order once completed 5/31/2025-5/30/2025 UA C&S may straight catheter. one time only for anxiety for 2 Days discontinue when complete. Review of Resident #150's Care Plan dated 03/16/2019 revealed:Focus:Resident #150 has potential for complications related to has active infection as follows: UTI Goal:Resident #150 will be free of infection by completion of antibiotic therapy. Interventions: Vital signs as ordered and as needed; Observe site of infection for increased swelling, inflammation, tenderness, drainage, or necrosis; update physician if noted; Maintain isolation precautions as indicated/ ordered; Observe for signs/symptoms of recurring infection; notify physician if noted. Focus:Resident #150 has an alteration in elimination as evidence by (AEB): is incontinent of bowel and bladder related diagnosis: dementia Goal: Resident #150 will be clean, dry, and odor free daily thru the next review date.; Resident will remain free from sign/symptoms of UTI thru the next review date; Resident will have a regular bowel movement at least every 3 days thru the next review date. InterventionsAdminister medications as ordered; observe for effectiveness; Provide hands on assistance with toileting upon resident request and as needed; Check resident upon arising, before/after meals and at HS for incontinence; perform incontinence care as needed; Keep urinal readily accessible; empty and clean as needed; Maintain closed drainage system and keep drainage bag below level of the bladder. Provide a catheter privacy bag. Observe for sign/symptoms of UTI; report to physician if noted; observe for the presence of stool , amount of stool, color and consistency that might indicate constipation/infection; Encourage adequate fluid intake; Labs as ordered; report results to physician; Initiate bowel protocol as needed;;OT screen as indicated; Observe for changes in bowel/bladder function; update physician if noted Review of Resident #150's Labs Results revealed: 06/21/2025 Urine Culture Organism: Escherichia coli (E.coli) Review of Resident #150's task for Toileting Hygiene revealed no documentation for toileting hygiene for the 7 a.m.- 3:00 p.m., shift on 06/18/2025, 06/27/2025, 6/29/2025, 6/30/2025, 07/04/2025, 07/08/2025, 07/09/2025, 07/10/2025, 07/11/2025, 07/13/2025, and 07/16/2025. No documentation for toileting hygiene for the 3:00 p.m.- 11:00 p.m., shift on 06/21/2025, 06/22/2025, 06/28/2025, and 07/06/2025. No documentation for toileting hygiene for the 11:00 p.m.- 7:00 a.m., shift on 06/24/2025, 07/06/2025,07/11/2025 and 07/16/2025. Review of Resident #150's hospital records revealed:05/31/2025- Brought in by Emergency Medical Services (EMS) for altered mental status. Per EMS called in for concern for UTI. The patient family wanted her evaluated in the Emergency Department (ED). The patient complains of intermittent Right lower quadrant (RLQ) abdominal pain and is covered in foul-smelling urine upon arrival. UA shows bacteria. Continue intravenous (IV) Rocephin. Urine Culture was never sent will continue with current plan and discharge. During an interview on 07/16/2025 at 10:48 a.m., Staff AB, CNA stated she typically has 15-16 residents assigned to her. It is hard to get assignments done and you cannot spend a lot of time with the residents. Resident #150 is total care resident. You have to check on Resident #150 every 2 hours to see if she needs to be changed. During an interview on 07/16/2025 at 1:59 p.m., Staff J, CNA stated she typically has 10-11 residents assigned to her. There are more dependent residents on the south hall. It is time consuming when you have a lot of dependent residents. Some of the residents require 2 people to assist and you have to find help. This can take longer to provide care because everyone has their own workload and are busy doing their own tasks. Resident #150 can be confused and yells at staff. Her behaviors get really bad when he has a UTI. Resident #150 would refuse care at times, but this only happened when she had a UTI. During an interview on 07/16/2025 at 2:37 p.m., Staff Y, CNA sometimes she will 13 residents assigned to her at one time. It does get hard to complete her tasks because most of the residents on that side are dependent residents. It takes longer to answer the call lights on that side then other halls. Because you have a lot of dependent residents. Residents get left soiled because you have one resident with a blow out and you have to finish cleaning them up before you can go onto the next resident. Resident #150 is total care resident she requires assistance for all of her care. During an interview on 07/17/2025 at 5:37 p.m., Director of Nursing (DON) stated Resident #150 never clears the UTI. She has ESBL colonization. Resident #150's labs all show E.coli and ESBL. The CNA's should document when toileting hygiene is being provided for the resident.Review of the facility policy, dated 05/2023, titled Helping a Resident with Toileting Needs revealed, It is the practice of this facility to assist residents with toileting needs in order to maintain the resident's dignity as well as proper hygiene.Review of the facility policy undated titled Activities of Daily Living (ADLs), Supporting revealed, Policy Statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .2. Appropriate care and services will be provided for residents who are unable to carry out AOLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); b. mobility (transfer and ambulation, including walking); c. elimination (toileting); d. dining (meals and snacks); and e. communication (speech, language, and any functional communication systems).

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the transmission of communicable diseases and infections as evidenced by 1) failure of staff to provide appropriate incontinence care by two staff members (Staff A, Staff B); 2) failure to implement policies related to staff use of artificial fingernails and containment of long hair for two staff members (Staff K, Staff S); and 3) failure to ensure staff donned Personal Protective Equipment (PPE) in a contact isolation room for two staff members (Staff AA, Staff AB) out of six staff members observed. The findings included: On 7/16/25 at 9:51 AM, an observation was made of Staff B, Certified Nursing Assistant (CNA), providing incontinence care to Resident #7. The resident had a urinary catheter and had been incontinent of stool. The CNA was observed to use cleansing wipes to clean the resident's peri area, then using the same wipes, she cleaned the resident's penis and the tubing of the catheter. Staff B never changed the wipe, changed her gloves, or sanitized her hands. Staff B then rolled the patient onto the side and provided care to his buttocks to clean up the stool. She was not observed to change her gloves. After wiping a large amount of soft stool and changing the brief, she applied the new brief, changed the sheet under the resident, and covered him with a blanket. She did not change her soiled gloves. A dark soft substance was noted on the gloves, and was the same color and texture of the stool. Staff B, CNA at no point during the care was observed to change her gloves or perform hand hygiene. A review of the Competency Based Orientation CNA Skills Checklist for Staff B revealed the date of employment as 5/18/17, the date orientation was completed as 5/20/22. The form was signed by both the Director of Nursing (DON) and the Mentor. The form revealed there were 5 options: P=previous experience; D=demonstrated and/or instructed by the Dept. head, supervisor, or Mentor/Preceptor; RD=Return demonstration by the orienteer and/or meets performance objective; NE Needs further experience with performance objective; and NA Not Applicable. At the bottom of the page was a Note: All observers are to print their initial in the appropriate boxes and print their full name on the signature page (last page) at the time of their initial observation. Under section F. Specialized Equipment: Utilizes knowledge and skill with: items 3. Care of residents with catheter: i.e. indwelling, suprapubic. a P (previous experience) is indicated with a check mark. On 7/16/25 at 11:00 AM, an observation was made of Staff A, CNA, providing catheter care to the resident in room [ROOM NUMBER]-B. Staff A provided care using one wash cloth that she dipped into a water basin on the tray table next to the bed. She folded the washcloth into four sections and applied liquid soap to the cloth. She provided care to the resident’s penis using a circular motion, then without changing the washcloth she wiped down the catheter tubing. She then folded the corner of the cloth, used the cloth to cleanse the penis and tubing using the previous cleaning method, starting with the head of the penis and down the catheter tubing. She repeated this process two more times until all the corners of the washcloth had been used. She then obtained a new cloth and performed incontinence care. Staff A, CNA was not observed to change her gloves at any point during the care. On 7/16/25 at approximately 11:40 AM, an interview was conducted with Staff A, CNA. She stated she had been with the organization for about 6 years but had been at this location for about 2 years. She stated she received catheter care training during orientation at the other location but had not had additional training at this location. She stated there was on-line training but not really an observation of her providing care. A review of the Competency Based Orientation CNA Skills Checklist for Staff A, revealed the form was blank in the lines next to date of employment, date orientation completed, orientee, and the Director of Nursing. The name [Staff C, CNA] was printed using her first initial and last name, next to Mentor. Under comments was CNA did great. The form revealed there were 5 options: P=previous experience; D=demonstrated and/or instructed by the dept. head, supervisor or Mentor/Preceptor; RD=Return demonstration by the orienteer and/or meets performance objective; NE Needs further experience with performance objective; and NA Not Applicable. At the bottom of the page was a Note: All observers are to print their initial in the appropriate boxes and print their full name on the signature page (last page) at the time of their initial observation. Under section F. Specialized Equipment: Utilizes knowledge and skill with: items 3. Care of residents with catheter: i.e. indwelling, suprapubic. a P (previous experience) is indicated with a check mark. On 7/17/25 at approximately 2:30 PM, an interview was conducted with Staff A, CNA. She stated she did not know who [Staff C] was. She stated she could remember a form similar, but she had signed the form, motioning to the lack of signature on this sheet. She was unable to state when the form was completed for sure but she thought it may have been 6 months ago. On 07/17/25 at 11:42 AM, an interview was conducted with the Infection Preventionist (IP) and the Director of Nursing (DON). During this interview the IP was asked what her role was in staff education, she stated she talks about infection control during orientation but has not done visualization of staff in skills check-offs or return demonstration. The DON stated, We are not there yet. The IP stated she does visualizations of staff throughout the day and will offer spot re-education, but has no documentation of these efforts. She stated she does not observe staff providing care but will do so if asked. She stated their goal is 90% compliance rate, however, they are not able to state where they are at in reaching this goal, as they are not actually documenting their observations. On 7/17/25 at 3:08 PM, an interview was conducted with Staff C, CNA. Staff C stated she was a mentor for the CNAs. She stated anytime gloves become contaminated or soiled, staff are to change them and perform hand hygiene. She stated during catheter care, it is acceptable for the CNAs to use one washcloth as long as they do not contaminate the cloth in the area they are using to clean the catheter. She stated P” on the skills checklist form was for “Pass”, meaning they passed the observation. She said on the day the form is completed, she follows the staff all day, and they perform all items on the list. When shown the checklist and the instruction to initial the boxes and “P” meant previous experience, she stated she had not noticed this before and had not initialed the boxes; she thought she could place a check mark. Review of the handwashing/hand hygiene policy, revised August 2019, states that the facility considers hand hygiene the primary means to prevent the spread of infections. Under the section Policy Interpretation and Implementation under item #1 it states “All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Item #2 states all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Item 7 Use and alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:” item e, states “Before and after handling an invasive device (e.g. urinary catheters, IV access sites)”, items h. “Before moving from a contaminated body site to a clean body site during resident care;” Review of the undated Catheter Care, Urinary policy states “The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.” Under Infection Control it states, “Infection control standards maintained.” During a facility tour on 07/16/2025 at 12:37 p.m. two staff members (Staff AA, CNA and Staff AB, CNA) were observed going into room [ROOM NUMBER] (a contact isolation room) during lunch service. The staff members did not don PPE or gloves. Staff AA CNA stated he did not know the resident was on contact precautions. He stated he would make sure to read the sign next time. Staff AB, CNA was observed going into the same room, adjusted the resident in bed B, and taking the resident's tray. Staff AB, CNA did not don PPE. She stated she did not pay attention at the sign on the door. She stated she should have put on full PPE. The two staff members did not perform hand hygiene prior to entering the room. On 7/14/25 at 2:36 p.m. Staff K, Licensed Practical Nurse, (LPN) was observed with almond-shaped fingernails extending approximately ¼-½” past the fingertip. The nails were painted a mauve color with glitter. The staff member reported the nails were fake and the polish was new, “they” put a magnet over it and the glitter follows the magnet. The observation showed other fingernails were painted with larger pieces of glitter. The staff member reported being “addicted” to it and she has had it for a couple of months. The observation showed Staff K, LPN was the primary nurse on the unit multiple days of the 4-day survey. An interview was conducted on 7/17/25 at 3:13 p.m. with the Director of Nursing (DON). The observation of Staff K’s fingernails were described, the DON stated fingernails should be shorter than own (the DON’s fingernails extended minimally past fingertips). She stated fingernails should be nice, clean, short, and trimmed nicely, should not be fake. The DON reported the employee handbook did not identify whether the nails should be fake or real and ½” was not ideal. On 7/16/25 at 9:00 a.m. Staff J, Certified Nursing Assistant (CNA) was asked by Staff S, Registered Nurse (RN) to assist with repositioning Resident #36 prior to the administration of medication. Staff J was observed with untethered blonde braids hanging below buttocks. Staff J’s braids fell onto the resident and the bed linens as the staff member leaned over to lift the resident higher up in the bed. The staff member removed the resident’s teal and white blanket straightening it as the braids fell onto the blanket. Staff J left the area after assisting Staff S. On 7/16/25 at 12:25 p.m. an observation was made of an assignment board on the Rapid hallway showing Staff J had an assignment for the direct care of residents. The assignment was a different hallway than where Resident #36 resided. During an interview on 7/17/25 at 3:13 p.m. the Director of Nursing (DON) was informed of the observation with Staff J’s braids. The DON reported Staff J’s braids are usually tied up. Review of the policy – Employee Appearance, undated, revealed “Employees are expected to be neat and well-groomed at all times.” 1. Your supervisor will tell you what is appropriate attire for your position and department. Uniforms will be neat and clean at all times. 2. For safety reasons, employees, involved with resident care should limit jewelry. 3. Employees may also be instructed to appropriate footwear while on the job. 4. Nails should be clean and trimmed. 5. Nothing in policy is intended to interfere with any religious observance or medical condition requiring special clothing. Review of the Centers of Disease Control and Prevention guidance, dated 2/27/24 – Clinical Safety: Hand Hygiene for Healthcare Workers, located at https://www.cdc.gov/clean-hands/hcp/clinical-safety, revealed the key points were to “Protect yourself and your patients from deadly germs by cleaning your hands.” The CDC recommended: - Natural nails should not extend past the fingertip. - Do not wear artificial fingernails or extensions when having direct contact with hght-risk patients like those at intensive-care units or operating rooms. o Germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and handwashing. - Some studies have shown that skin underneath rings contain more germs than fingers without rings. o Further studies should determine if wearing rings increases the spread of deadly germs.

Based on observation, interview, and record review, the facility failed to ensure an assessment for self-administration of enteral nutrition was completed for one resident (#125) out of one resident reviewed.Findings included:On 07/16/2025 at 1:11 p.m. Resident #125 was observed in his room administering his enteral nutrition independently into his gastrostomy tube (g-tube). The resident's head of bed was observed to be flat. Resident #125 stated the nurses give him his enteral nutrition during the scheduled meal times. He stated he self-administers the enteral nutrition into his g-tube.Review of the admission record for Resident #125 revealed he was admitted to the facility on [DATE] with diagnoses to include malignant neoplasm of thyroid gland, unspecified severe protein calorie malnutrition, gastroesophageal reflux disease and gastrostomy status.Review of Resident #125's quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #125 had a brief interview for mental status (BIMS) score of 15 out 15 indicating intact cognition.Review of Resident #125's active physician orders summary dated 07/17/2025 showed: Nothing by mouth (NPO) diet, NPO texture, NPO consistency, dated 02/12/2025. House protein one time a day for malnutrition give 30 cubic centimeters (cc) via feeding tube. Enteral feed order five times a day related to gastrostomy status, dysphagia oropharyngeal phase. Jevity 1.5 eight ounces (237 cc) bolus 5 times per day via feeding tube. Flush with 100 cc water pre/post each bolus feeding. dated 02/14/2025. Review of the medical record showed there was no documentation of an assessment for Resident #125 to self-administer enter nutrition. There was no documentation of a physician order for Resident #125 to self-administer his enteral nutrition.Review of the care plan for Resident #125 did not show the resident was care planned to self-administer his enteral nutrition.An interview was conducted on 07/16/2025 at 5:35 p.m. with Staff T, Licensed Practical nurse (LPN)/MDS Coordinator. She stated if a resident was to self-administer his enteral nutrition, there should be an order. She stated the care plan would show a self-administering focus. She reviewed Resident #125's care plans and did not see a self-administering focus. Staff T, LPN/MDS Coordinator reviewed the physician orders and confirmed there were no physician orders for Resident #125 to self administer his enteral nutrition. She stated they would assess the resident and contact the physician to obtain orders and they would update the care plan. Review of a facility policy titled Resident Self- Administration of Medication, dated 12/2020 showed - it is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.Policy explanation and compliance guidelines:1. Each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team.2. Resident's preference will be documented on the appropriate form and placed in the medical record.3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following:a. The medications appropriate and safe for self-administration.b. The resident's physical capacity to: swallow without difficulty, open medication bottles, administer injections.c. The resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for.d. The resident's capability to follow directions and tell time to know when medications need to be taken.e. The resident's comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects, and when to report to facility staff.f. The resident's ability to understand what refusal of medication is, and appropriate steps taken by staff to educate when this occurs.g. The resident's ability to ensure that medication is stored safely and securely.14. The care plan must reflect resident self-administration and storage arrangements for such medications. and devices.Review of a facility policy titled Administering Medications, revised March 2023 showed a policy statement - Medications are administered in a safe and timely manner, as prescribed.Policy interpretation and implementation showed: 21. Resident may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary team has determined that they have decision-making capacity to do so safely.

Based on interviews and record review, the facility failed to report allegations of serious injury of unknown source and neglect for one resident (#56) of two residents sampled.Findings included: A record review for Resident #56 revealed she had an unwitnessed fall on 07/02/2025. Review of the nursing progress note dated 07/02/2025 revealed the resident had attempted to get out of bed without assistance and was found “face on the floor” with a moderate amount of blood on her facial/nose area. The resident was transferred to a local hospital via Emergency Medical Services (EMS) where she was diagnosed with a skull fracture. The resident was care planned for falls with interventions that included “Utilize total mechanical lift with staff assist of 2 for transfers”. “Remind resident to request assistance prior to ambulation/transfers as needed”. “Keep call light within reach.” Further review of the medical record revealed she was admitted to the facility on [DATE], with diagnoses to include cognitive communication deficit (04/29/2025); Hypertension (04/29/2025); Major Depressive Disorder (04/29/2025); Encephalopathy (06/01/2025); Dementia (06/19/2025); fracture of base of skull (07/03/2025); contusion of scalp (07/03/2025); history of falling (07/03/2025). A review of the Determination of Capacity to Give Informed Consent form dated 05/22/2025, revealed that the Psychiatric Mental Health Nurse Practitioner (PMHNP) attested, “I have assessed [Resident #56] on a consult requested by attending physician and have found he/she”…The PMHNP marked with an “x” “Lacks the capacity to make medical decisions. On 07/16/1025 at 5:07 PM, an interview was conducted with the Director of Nursing (DON). During this interview, she was asked about Resident #56’s fall and if she saw this event as an adverse incident or an injury of unknown source she stated, “No”. She offered that “There was no violation of the care plan” because the resident attempted to get out of bed without calling for assistance and fell. She offered that, since there was no violation of the care plan that she did not have to report this concern to the State Agency because it was out of their control. She stated that the resident had a fall risk score of 10 (out of 20) on admission which was high but not “super high”. She stated that when the resident returned to the facility they put bolsters in her bed (long cushions or pillows that provide support and can be used to prevent falls) and moved her closer to the nursing station. She stated prior to the fall they did not see the need to have any more interventions than those listed on the care plan. Offering that the resident should have called for assistance and she did not so she fell. She further offered that the facility could not protect every resident at all times from falling. She was asked if there should have been more supervision of the resident due to her dementia and confusion she stated the resident was capable of calling for assistance and she did not. She stated that she had investigated this incident but could not find the witness statements but felt the night supervisor would be able to locate them. On 07/17/2025 at 9:59 AM, an interview was conducted with the PMHNP, during which she stated she last saw the resident on 06/26/2025 and found her to be confused, alert to self only, very confused, garbled speech, dementia with agitation and exit seeking, She was not told the resident had a fall and if she had been she would have seen her for a follow up. In her opinion she was not able to request assistance or call for assistance. She stated she should have been notified of the resident’s fall, the hospital visit would make her “unstable” which would have required her to be seen the next day. On 07/17/2025 at 2:02 PM, a telephone interview was conducted with the son of Resident #56, during which he stated that the facility called him and informed him that the resident was found alongside the bed and was sent to the Emergency Room. He reported that she is always confused and was confused at the time she fell. They called him that morning. He stated that they had given her a special mattress and moved her closer to the nursing station to keep a better eye on her. On 07/17/2025 at 4:38 PM, a telephone interview was conducted with Staff G, Licensed Practical Nurse (LPN) who stated she was working with the resident the morning of her fall. She stated that the patient was very confused and would not have known what the call light was, and would not have be able to use it to call for assistance. She stated that she did rounds every two hours and the resident had been asleep the last she had checked on her. She said the CNAs (Certified Nursing Assistants) are in and out. The resident had not tried to get out of bed before and when she entered the room she was on the floor. Review of a facility policy titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, revised September 2022 showed, all reports of resident abuse (including injuries of unknown origin), neglect… are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents.

Based on record review and interviews, the facility failed to notify a resident and the resident's representative of a hospital transfer in writing prior to the transfer for one resident (#149) out of four residents reviewed.Findings included: During an interview on 07/14/2025 at 12:10 p.m., Resident #149 stated she just returned from a hospital stay. “The hospital wanted me to stay until Saturday, but I told them I had to be back to the facility on Friday so that my bed at the facility was not given away. I don’t remember being given anything explaining my options for holding my bed before I went to the hospital.” Review of Resident #149's Minimum Data Set (MDS), dated [DATE], revealed a brief interview for mental status (BIMS) score of 15 out of 15 indicating intact cognition. Review of Resident #149’s admission record revealed a readmission date of 07/11/2025 from an acute care facility. Resident #149 was admitted to the facility with diagnosis to include chronic obstructive pulmonary disease (COPD) with (Acute) exacerbation, primary insomnia, anemia, and type 2 diabetes mellitus with diabetic neuropathy. Review of Resident #149’s physician orders revealed as follows: Transfer to emergency room (ER) evaluate and treat; one time only for shortness of breath and chest pain for 1 day, dated 07/08/2025. Review of Resident #149’s Nursing Home Transfer and Discharge Notice form revealed notice of date given 07/14/2025. Physician/Designee Name and signature were blank. Resident or Representative Name and signature were blank. During an interview on 07/16/2025 at 10:14 a.m., Staff Z, Licensed Practical Nurse (LPN), Unit Manager stated if a resident needs to be transferred out the nurse would evaluate the resident, do a change of condition, call the physician for the order and go over the bed hold policy with the residents. I let the social services know when a resident transfers to the hospital and they complete the AHCA [Agency for Healthcare Administration] transfer form. During an interview on 07/16/2025 at 3:03 p.m., the Director of Nursing (DON) stated the Business Office and Nursing completes the AHCA Transfer form. The form should be filled out the same day the resident goes out. She reviewed the AHCA transfer form for Resident #149 and stated it is missing the physician and resident’s signature. Review of a facility policy dated 2/2025 showed - it is the policy of this facility to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Procedure: 1. The facility will support each resident in the exercise of his or her right to participate in his or her care and treatment, including planning for discharge. 2. The facility will determine the resident's expected goals and outcomes regarding discharge upon admission, routinely in accordance with the MDS assessment cycle, and as needed. a. Initial information and discharge goals will be included in the resident's baseline care plan. b. Subsequent assessment information and discharge goals will be included in the resident's comprehensive plan of care. 3. If discharge to community is determined to not be feasible, the facility will document in the clinical record who made the determination and why. 4. In cases where the resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the interdisciplinary team will treat this situation similarly to refusal of care: a. Discuss with the resident, (and/or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location. b. Offer other, more suitable, options of locations that are equipped to meet the needs of the resident. Document any discussions related to the options presented. c. Document refusals of other options that could meet the resident's needs. d. At time of discharge, follow policies regarding discharges Against Medical Advice, and refer to Adult Protective Services (or other state entity charged with investigating abuse and neglect), as necessary.

Based on interviews and record reviews, the facility failed to notify the state mental health authority/state intellectual disability authority after a significant change in the mental or physical condition of a resident who has mental illness for one resident (#3) of nine residents reviewed.Findings included:Review of Resident #3's electronic medical record revealed an original admission date of 02/10/2021 and a Preadmission Screening and Resident Review (PASRR) dated 02/08/2021 provided by the hospital pre-admission. In section 3, this is documented as a non-provisional admission, and section 4 is documented as no diagnosis or suspicion of serious mental illness or intellectual disability indicated. Level II PASRR not required. A PASRR Resident Review- Evaluation Request, dated 04/23/2023, was present with no signatures and no evidence of a level II request for evaluation from the state agency.Review of Resident #3's diagnoses list revealed a diagnosis of major depressive disorder on 10/29/2024. Further review revealed a request for a psychiatric meeting dated 10/29/2024, with diagnosis of major depressive disorder, recurrent, moderate. During an interview with the Director of Nursing (DON) on 7/16/2025 at 10:34 AM regarding the facility's PASRR process, when asked how the facility identifies residents with new mental disorders or intellectual disorder diagnoses, she stated the provider lets them know of any changes, and the Assistant Director of Nursing (ADON) arranges for a new PASRR. Additionally, she stated the Psychiatry and Psychology providers communicate directly with the ADON, DON, and Social Services Director. When asked who is responsible for making the referral to the appropriate state (designated) authority when a resident is identified as having an evident or possible mental disorders (MD), intellectual disability (ID) or related condition, the DON stated that the ADON makes that referral. When asked for a copy of the completed PASRR Resident Review Evaluation Request for Resident #3, the DON stated she would get it.During an interview on 7/16/2025 at 2:05 PM, the DON stated Resident #3 does have a completed PASRR Resident Review Evaluation Request completed after the major depression disorder diagnosis. The DON said it would be in the electronic medical record. The surveyor relayed lack of copy in electronic medical record. The DON stated she will get a copy. Resident #3's PASRR Resident Review Evaluation Request, dated 04/23/2023, was not signed by the preparer nor the resident's legal representative. No evidence of submission was provided. Additionally, a document was provided with no signature, letterhead, patient identification, source, or evidence of transmission (such as fax or email.)The facility did not provide a level II (evaluation and determination) for Resident #3 by the end of the survey. Review of the facility policy titled, Pre-admission Screening and Resident Review revised March 2019 revealed a policy statement, It is the policy of this facility to assure that all residents admitted to the facility receive a Pre-Admissions Screening and Resident Review, in accordance with State and Federal Regulations.Policy Interpretation and Implementation1. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process.b: If the level I screen indicates that the individual meets the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the level II (evaluation and determination) screening process.d: The state PASARR representative provides a copy of the report to the facility.

Based on observations, record reviews, and interviews the facility failed to implement patient-centered interventions related to adaptive dining equipment to promote independence while eating per occupational therapy and physician order for one resident (#13) out of one resident reviewed. Findings included: On 07/16/2025 at 12:29 p.m. Resident #13 was observed in the room wearing a clothing protector with an opened meal tray on the overbed table in front of the resident. The resident was observed holding a regular everyday eating fork. The resident stated a staff member was supposed to get weighted silverware, but they hadn't been sending one with the meals. Review of Resident #13s admission Record showed the resident was admitted on [DATE] and 02/05/2025. The record included diagnoses not limited to Parkinson's disease without dyskinesia without mention of fluctuations, unspecified convulsions, and type 2 diabetes mellitus with hyperglycemia. The resident's annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status score of 15/15, indicating an intact cognition. Review of Resident #13s physician orders revealed an order created by Staff N, Occupational Therapist (OT) on 6/24/25 and signed by the resident's primary care Physician on 07/04/2025 for the resident to receive Built-up handle utensils provided for all meals to promote independence with feeding tasks. Review of Resident #13's care plan with an initiated date of 07/25/2023 and a revision date of 06/18/2025 revealed the resident was at risk for an alteration in nutrition and/or hydration related to (r/t): receives a therapeutic diet, food intolerance/allergy: tomato products, Body Mass Index (BMI) indicates obesity, diagnosis (dx) myocardial infarction (MI), chronic obstructive pulmonary disease (COPD), sepsis, urinary tract infection (UTI)/ extended-spectrum beta-lactamase (ESBL), fall, left (L) tibia/ankle fracture (fx), ileostomy, gastrointestinal (GI) hemorrhage, diabetes mellitus (DM), anemia, Parkinsons, pain, gastroesophageal reflux disease (GERD), depression, bipolar, anxiety, genitourinary system surgery. Controlled carbohydrate diet (CCHO) added to dietary restrictions; 06/2025 weight stable, BMI 34.7. The goal revealed the resident would consume 75-100% of most meals through the next review date. The interventions showed dietary, Certified Nursing Assistants (CNAs), and nursing were to Provide adaptive equipment as ordered. An interview was conducted on 7/16/25 at 12:34 p.m. with Staff K, Licensed Practical Nurse (LPN) and Staff M, Certified Nursing Assistant (CNA). The staff members reported having never seen Resident #13 with built-up or weighted silverware. On 7/16/125 at 12:35 p.m. Staff K, LPN observed Resident #13 in the room eating with regular-style silverware. The staff member confirmed the silverware was not weighted or built-up. The resident reported spilling a lot of food. The staff member returned to the nursing station and reviewed Resident #13's physician orders and confirmed an order was revised on 06/24/2025 for the resident to have built-up silverware to promote independence. An interview was conducted on 07/16/2025 at 2:03 p.m. with Staff N, Occupational Therapist (OT) and the Director of Rehab (DoR). Staff N, OT stated Resident #13 had complaints of not being able to hold onto standard (eating) utensils and cut food, built-up utensils were trialed in two sessions, and an order was placed in the electronic record. Staff N, OT stated the expectation was to include (built-up) utensils with meals and was unaware the resident was not getting the utensils. Staff N, OT reported Resident #13 had not said anything about not getting them and Staff N, OT saw Resident #13 three times a week. The DoR provided an Occupational Therapy treatment note dated 6/24/25, written by Staff N, OT which read Therapist trialed use of built-up eating utensils to promote independence with feeding tasks. Patient (Pt) demonstrated increased ability to cut food and bring it to mouth without spilling/dropping utensils using built-up eating utensils. Review of the policy - Comprehensive Person-Centered Care Plans, revised December 2016, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The policy included the following:- 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.- 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.- . 8. The comprehensive, person-centered care plan will:a. Include measurable objectives and timeframes;b. Describe the services that are to be furnished to attain or maintain their resident's highest practicable physical, mental, and psychosocial well-being;.m. Aid in preventing or reducing decline in the residence functional status and/or functional leveln. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; [NAME]. Reflect currently recognized standards of practice for problem areas and conditions.- .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observations, record reviews, and interviews the medical physician failed to provide the facility with written, signed and dated progress notes following each visit for one (#13) of 34 sampled residents. Findings included:On 7/14/24 at 2:54 p.m. Resident #13 was observed and interviewed in the resident room. The resident was sitting in wheelchair and answered questions appropriately. The resident reported falling two weeks ago and required stitches and a second fall while using the door to maneuver in wheelchair. Review of Resident #13s electronic progress notes and the uploaded documents revealed the most recent Palliative Care - Follow up note was written for a service performed on 2/14/25. Review of the electronic practitioner notes showed psychiatry notes. The electronic Advanced Registered Nurse Practitioner (ARNP) notes revealed the last note was written 8/21/23. The electronic record did not include any specified MD Note and the last Physician Progress Note was dated 4/2/25 by the Physical Medicine and Rehabilitation physician for a service date of 2/27/25. An interview was conducted with Staff K, Licensed Practical Nurse (LPN) on 7/16/25 at 12:39 p.m. The staff member reviewed Resident #13s medical record, saying the physician's document in the electronic record. Staff K reviewed the resident's progress notes (encounter and standard) stating all that was seen was psych notes. An interview and record review was conducted with the Director of Nursing (DON) on 7/16/25 at 1:55 p.m. A review was conducted showing a Summary of Episode with the physician name listed. The DON asked if writer still wanted 3 months of physician notes as Attending Physician had a note for April (uploaded) in the electronic record. The DON stated not having physician notes for 3 months was not optimal and the notes were probably sitting in a pile somewhere not here, then asked if she should ask the doctor to type faster. An interview was conducted with the DON on 7/17/25 at 12:37 p.m. The previously requested physician notes were received. The DON stated the notes were found in Medical Records and the facility had a vacancy in that area. Review of another resident's Summary of Episode was reviewed and the DON confirmed there was no assessment information and the summary was not a physician note. When asked if it was acceptable for there not being a physician note in the medical record for 5 months, the DON stated no. The DON stated staff know the plan of care through (physician) orders. Review of the 10 physician notes received from the DON showed the physician and/or designated medical provider visited Resident #13 on 4/7, 4/21, 5/9, 5/19, 6/2, 6/9, 6/16, 6/23, 6/30, and 7/7/25. Review of Resident #13s uploaded documents on 7/17/25 at 1:02 p.m. revealed on 7/17/25 MD Progress notes April - July 2025 had been uploaded. Review of the policy - Physician Progress Notes, revised February 2008, showed Physician progress notes must be maintained for each resident. The interpretation and implementation revealed:1. Physician progress notes are maintained for each resident residing in this facility.2. Physician progress notes reflect the residents progress and response to his or her care plan, medications, etcetera (etc).3. The residents attending physician must write, sign, and date the physician progress notes reflecting each visit.4. Inquiries concerning physician progress notes should be referred to the attending physician, medical director, or director of nursing services. Review of the policy - Physician Visits, implemented 1/2025, revealed It is the policy of this facility to ensure the physician takes an active role in supervising the care of the residents. The compliance guidelines include the facility was to write a note to reflect the physician visit, an indication as to whether new orders were written or no new orders were received and any special discussions between the resident and/or family and physician during the visit. The Physician should: b. The resident must be seen at least once every 30 calendar days for the 1st 90 to calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by state law. d. Date, write, and sign 12a progress note reflecting each visit.

Based on interviews and record review, the facility failed to ensure medications were administered per physician orders and failed to document physician notification for missed medications for one resident (#110) of one dialysis residents reviewed.Findings included:Review of Resident #110's admission record revealed she was originally admitted to the facility on [DATE] with diagnoses to include end stage renal disease (ESRD) and dependence on renal dialysis.Review of Resident #110's Medication Administration Record (MAR) for the months of June and July 2025 revealed the resident was not receiving medications as ordered. The MAR showed numerous notes of a number 1 documented indicating Refused medications. The review showed the medications were not administered as prescribed in the months of June and July 2025 as follows: Lactobacillus capsule, Give 1 capsule by mouth one time a day for prophylactic was missed 31 times.House protein, one time a day, for at risk for malnutrition related to dialysis, offer 30 cc (cubic centimeters) was missed five times.Atorvastatin calcium 20mg (milligrams) one time a day for hyperlipidemia was missed one time.Ferrous sulfate 325 mg, one time a day for anemia was missed one time.Multivitamin one time a day for ARVD (Arrhythmogenic Right Ventricular Dysplasia) was missed one time.On 07/17/2025 at 12:11 p.m. an interview was conducted with Resident #110. The resident stated sometimes she did not receive her medications because she was at dialysis. The resident denied refusing medications.An interview was conducted on 07/17/2025 at 1:38 p.m. with Staff U, Licensed Practical Nurse (LPN). She stated a 1 meant the resident refused the medications. She stated the physician should be notified. She stated the nurse would input a progress note and also document educating the resident on the importance of taking their medications. Staff U, LPN stated the physician and responsible party/family should be notified.On 07/17/2025 at 1:41 p.m. an interview was conducted with the Director of Nursing (DON). She stated any refusals should be followed by physician notification and a progress note. She stated she would follow up.Review of a facility policy titled Administering Medications, revised March 2023 showed a policy statement - Medications are administered in a safe and timely manner, as prescribed.Policy Interpretation and Implementation showed:.4. Medications are administered in accordance with prescriber orders, including any required time frame.5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include:a. enhancing optimal therapeutic effect of the medication.b. preventing potential medication or food interactions; andc. honoring resident choices and preferences, consistent with his or her care plan.6. Medication errors are documented, reported, and reviewed by the QAPI (Quality Assurance Performance Improvement) committee to inform process changes and or the need for additional staff training.

Based on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-six medication administration opportunities were observed and two errors were identified for one (#23) of eight residents observed. These errors constituted a 7.69% medication error rate.Findings included:1.On 7/15/25 at 4:26 p.m., an observation of medication administration with Staff I, Licensed Practical Nurse (LPN), was conducted with Resident #23. The staff member removed a glucometer from the top drawer of the medication cart, and placed it in a clear plastic cup with a lancet and glucose testing strip. Staff I entered the resident's room, cleaned left index finger of resident with alcohol pad, lanced the finger and reported to the resident a blood glucose reading of 215. The staff member returned to the medication cart and cleaned the glucometer. Staff I documented in the medication record a blood glucose of 283, which the computer calculated a dose of insulin aspart of 6 units. This writer asked Staff I to review the blood glucose reading and the staff member confirmed from the glucometer memory a blood glucose reading of 215 for Resident #23. The staff member adjusted the blood glucose reading and stated it still showed the resident was to receive 6 units. The staff member was asked to read the order and confirm the dosage. Staff I refreshed the reading and the medication profile changed the dosage to 4 units for a glucose of 215.Staff I removed Resident #23's insulin glargine pen injector and insulin aspart pen injector. The staff member stated the resident was to receive 15 units of glargine and 4 units of aspart per sliding scale. Staff I dialed the dosage selector to 4 units on the insulin aspart pen and placed a needle then the staff member dialed the glargine pen to 15 units before applying the needle. The staff member re-entered the resident's room, verifying the dosages, and injected both insulins into the left lower abdominal quadrant. The staff member returned to the cart and dispensed one 500 milligram tablet of metformin, which was administered to the resident.An interview was conducted with Staff I on 7/15/25 at 4:46 p.m. The staff member stated, regarding not priming the insulin pens, nope, never been taught to prime the insulin pens.Review of Resident #23's admission Record showed the resident was originally admitted on [DATE] and re-admitted on [DATE]. The record included diagnoses not limited to Type 2 Diabetes Mellitus with hyperglycemia.An interview was conducted on 7/17/25 at 9:04 a.m. with the Director of Nursing (DON). The DON reported expecting medication errors. The insulin observation was revealed with findings of not priming the insulin pens prior to administration. The DON stated yes insulin pens were to primed prior to use and Staff I had been taught that (priming) but must have forgotten nerves. The medication error rate was disclosed and the DON nodded head stating ok, I will educate.Review of the undated procedure for Insulin Pen Administration, received by the facility, revealed:Step 1: Prepare your syringe- Take the cover cap off of your syringe.- Open an new needle by removing the paper tab.- Screw the needle onto your (name brand) Pen- Remove both the outer and inner needle caps.- After the needle is in place, do an air shot before taking your injections. Step 2: Do an air shot (Prime the Needle). Expiration: pen should be used within timeframe recommended by manufacturer.- Dial 2 units- Hold syringe with needle pointing up and tap reservoir gently to move air bubbles to top of needle.- Press the push button on syringe as far as it will go until a drop of insulin appears.Step 3: Dial your dose- Make sure your dose selector is set at 0.- Dial the number of units you need to inject. 1 click = 1 unit of insulin.- If you need to correct dose, dial the dose selector either up or down. Be careful not to press the push button while dialing or insulin will come.Step 4: Give the injection- When the needle is under your skin, inject the insulin by pressing the push button all the way in.- Leave the needle under your skin for a least 5 seconds after injecting your insulin. Keep the push button fully depressed until you withdraw the needle.Review of the manufacturer website, located at www. https://www.lantus.com/how-to-use/how-to-inject#solostar-pen, revealed the following instructions regarding the use of an insulin glargine pen.STEP 2. ATTACH THE NEEDLE Wipe the pen tip (rubber seal) with an alcohol swab. Remove the protective seal from the new needle, line the needle up straight with the pen, and screw the needle on. Do not make the needle too tight. If you have a push-on needle, keep it straight as you push it on. After you have attached the needle, take off the outer needle cap and save it (you will need it to remove the needle after your injection). Remove the inner needle cap and throw it away.STEP 3. PERFORM A SAFETY TEST Dial a test dose of 2 Units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test 2 more times. If there is still no insulin coming out, use a new needle and do the safety test again.! Always perform the safety test before each injection. Never use the pen if no insulin comes out after using a second needle.STEP 4. SELECT THE DOSE Make sure the window shows 0 and then select the dose. Otherwise you will inject more insulin than you need and that can affect your blood sugar level. Dial back up or down if you dialed the wrong amount. Check if you have enough insulin in the reservoir. If you cannot dial the dose you want, it may be because you don't have enough insulin left. You cannot dial more than 80 Units because the pen has a safety stop. If your dose is more than 80 Units, you will need to redial the rest of your dose. If you don't have enough insulin for the rest of your dose, you will need to use a new pen. Review of the manufacturers instructions for the use of an insulin aspart pen, located at www.novo-pi.com/novolog.pdf included the following instructions:Giving the airshot before each injectionBefore each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing:E. Turn the dose selector to select 2 units. (see diagram E).F. Hold your (name brand insulin aspart pen) with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. (see diagram F).G. Keep the needle pointing upwards, press the push-button all the way in (see diagram G). The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If you do not see a drop of insulin after 6 times, do not use the (name brand insulin pen) and contact (manufacturer with phone number).A small air bubble may remain at the needle tip, but it will not be injected.Selecting your doseCheck and make sure that the dose selector is set at 0.

Based on observation, record review, and interviews the facility failed to ensure food allergies were accommodated for one resident (#23) of one resident sampled for food allergies. Findings included: An observation and interview was conducted on 7/14/25 at 12:20 p.m. with Resident #23. The observation showed the resident lying in bed and able to answer questions intelligently and appropriately. The resident reported feeling the portion sizes had decreased and felt (pronoun) had lost weight. The resident reported the facility used mayonnaise made with mustard and was allergic to mustard seeds.Review of the admission Record showed Resident #23 was originally admitted on [DATE] and re-admitted on [DATE]. The record included diagnoses not limited to Type 2 Diabetes Mellitus, morbid (severe) obesity due to excess calories, and adult failure to thrive.Review of Resident #23s quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident scored 15 of 15 for a Brief Interview of Mental Status, indicating an intact cognition.Review of Resident #23s Interdisciplinary (IDT) Plan of Care Review Meeting Summary, dated 6/26/25 at 11:00 a.m., revealed lettered issues voiced during the meeting. The note showed letter A concerns related to Certified Nursing Assistant (CNA) scheduling with the UM directed the resident to question the Director of Nursing Services (DNS) and the lack of linens affecting shower/bathing schedule. The note listed letter B Resident notes allergy to mustard seed - facility may has it. The attendees of the meeting included the resident, Unit Manager (UM), MDS Registered Nurse (RN), and Activity Director. The attendees did not include a member of the Social Service (SS) or dietary department. The note showed letter D - SS discussed replacement to (?) cup lid - was broken by accident.Review of the grievance filed on behalf of Resident #23 by the IDT on 6/26/25 showed the residents hydration cups lid was broken and the facility replaced the cup. The grievance did not address the resident's report of being allergic to mustard seed. An interview was conducted on 7/15/25 at 3:31 p.m. with Staff O, Social Service Assistant (SSA). The SSA reported attending long-term care plan meetings. Staff O stated if there was no signature (on meeting summary) did not attend Resident #23s meeting on 6/26/25. The SSA stated if a resident voiced an allergy would definitely approach nursing staff. The meeting summary was reviewed and the SSA stated Staff P, MDS RN had written the meeting summary and dietary should have been notified of the reported allergy.An interview was conducted on 7/16/25 at 9:59 a.m. with the Certified Dietary Manager (CDM). The CDM stated she or assistant attended care plan meeting however for (the past) 2 weeks the facility hasn't had a morning cook so the IDT has a group chat and if she was unable to attend they will let her know if allergies or something significant regarding food service. The IDT will ask her to talk with the resident right then or will follow up with the resident. She stated at time of admission dietary was notified of allergies through the dietary communication forms and the electronic food service speaks with the electronic medical record system so when an allergy is listed it (the allergy) goes to the dietary tray ticket. The CDM stated she completes an audit of all changes done over the weekend. The staff member reviewed Resident #23s medical record and stated according to the record the resident did not have any allergies. The CDM reviewed the care plan meeting note and stated she had visited the resident one day and the resident had refused to speak with her, a second visit was attempted and the resident had not felt like talking. The CDM stated the resident's allergy would have been in a group chat and would have been put into the electronic medical record so the system would have alerted that the resident had voiced an allergy. The CDM stated the facility had been getting food from the same provider and some items have not been able to get because the provider had changed products. An observation was attempted with the CDM of the facility's open and unopened stock of mayonnaise. She looked in dry stock area and no mayonnaise was located, an observation of the refrigerator with condiments did not show any opened mayonnaise. A computer review of previously purchased mayonnaise showed the providers mayo did have mustard seed as an ingredient. The CDM was surprised mayonnaise had mustard in it.An interview was conducted on 7/16/25 at 10:40 a.m. with Staff P, MDS RN. The staff member confirmed being the person who took notes during the care plan meetings. If a concern (voiced), make notice of it and notify the relevant department unless they are in attendance. The staff member stated a concern depended if it could be handled right away would not write a grievance and would notify SS so they could write a grievance. The staff member remembered having a few care plan meetings with Resident #23. The staff member reviewed the care plan meeting note from 6/26/25 and stated he would have referred it to the kitchen and the CDM or Kitchen Manager (KM). He stated he had informed the CDM or KM immediately after the meeting as the kitchen was on the way to the office and was told the mayonnaise used in the faciltiy did not have mustard seed in it. Staff P stated it should have been noted and followed up on, sometimes an allergy we need to follow up on as it may be a preference or a dislike or an intolerance and not a true allergy. Staff P did not remember which kitchen staff he had spoken with due to it was awhile ago. The staff member confirmed he could write a grievance if its on 3-11 shift and SS was not there he would have filed a grievance and would have followed up on it.Review of Resident #23s Nutrition/Dietary note written on 7/16/25 at 11:37 a.m. by the Registered Dietician revealed a follow up (F/U) This resident has an allergy to mustard seed. I spoke with him in his room today - he stated that as a kid he broke out in hives after eating mustard. This has not happened since he was 12-[AGE] years old. This also has not happened here in this facility. Dietary will not serve this resident items with mustard seed.Review of Resident #23s meal tickets for 7/16/25 did not reveal any food likes, food dislike or any allergies. The mayonnaise product information, printed on 7/16/25 at 10:30 a.m. (received at same time as meal tickets) showed the mayonnaise ordered by the facility contained mustard seeds.Review of Resident #23s admission Record and Order Summary Report, printed on 7/17/25 at 1:50 p.m. revealed mustard seed had been added to the record.Review of the policy - Dining and Food Preferences, undated, revealed It is the center policy that individual dining, food, and beverage preferences are identified for all residents/patients. The action steps showed the following procedures:1. The Dining Services Director or designee will interview the resident or resident representative to complete a food preference interview within 48 hours of admission. The purpose of identifying individual preferences for dining location, meal times, including times outside of the routine schedule, food, and beverage preferences.2. The Food Preference interview will be entered into the medical record.3. Food allergies, food intolerance, food dislikes, and food and fluid preferences will be entered into the resident profile in menu management software system.4. The Registered Dietitian/ Nutritionist (RDN) or other clinically qualified nutrition professional will review, and after consultation with the resident, adjust the individual meal plan to ensure adequate fluid volume and appropriate nutritional content for residents that do not consume certain foods or food groups.5. The Dining Services Director, RDN or other clinically qualified nutrition professional, or designee, will enter information pertinent to the individual meal plan into the plan of care.6. The individual tray assembly ticket will identify allergies, food, and beverage preferences or special requests, and adaptive equipment as appropriate.7. Upon meal service, any resident/ patient with expressed or observed refusal of food and/ or beverage will be offered in an alternate selection of comparable nutrition value.8. The alternate meal and/ or beverage selection will be provided in a timely manner.

Based on observations, interviews, and record reviews, the facility did not ensure an effective infection prevention program was implemented for four out of four residents reviewed for on-going skin rashes. Findings included: An interview was conducted on 3/5/25 at 3:47 p.m. with a family member of Resident #8. The family member said in September/October 2024 the resident had scabies. She said no one in the facility noticed. The family member said she is a medical provider herself and had to tell them to call the doctor and have the resident treated. She said Resident #8 was treated and started getting better, but in the beginning of December the resident had the rash back again with itching all over. She said at that time she found out when the resident was treated for scabies previously, his room and personal items had not been cleaned properly. The family member said she spoke to someone higher up and they said a deep cleaning of the room and personal items were not completed because the facility didn't feel like it was scabies. The family member said Resident #8 had to be re-treated for scabies at the beginning of December and she asked the facility to do a deep cleaning of his room and his personal belongings. She said the resident's rash had gone away after the last treatment and cleaning. Review of Admission Records showed Resident #8 was admitted on [DATE] with diagnoses including convulsions, Parkinson's disease, and subdural hemorrhage. Review of Resident #8's physician order summary showed the following orders: -Permethrin External Cream 5%. Apply to entire body head to toe topically every evening shift for prophylaxis treatment for 1 day. Dated 10/7/24 -Permethrin External Cream 5%. Apply to body topically one time only for rash to body for 1 day wash off after 14 hours. Dated 11/29/24 -Permethrin External Cream 5%. Apply to entire body topically one time a day related to other specified disorders of the skin and subcutaneous tissue. Dated 12/5/24 -Ivermectin Oral Tablet 3 mg. Give 3 tablets by mouth one time a day every 7 days for scabies for 2 administrations. Dated 12/2/24 -Permethrin External Cream 5%. Apply to entire body topically one time a day related to other specified disorders of the skin and subcutaneous tissue. Dated 12/11/24. There were no orders for transmission-based precautions. Review of Resident #8's provider note, dated 12/2/24, showed, Pt [patient] also was noted to have rash on legs and abd. [abdomen]. Permethrin and Ivermectin orders are in place. There was noted to be pinpoint red sl [slightly] raised pruritic rash and scratches noted on Legs and abd. An interview was conducted on 3/5/25 at 1:05 p.m. with Residents #6 and #5, who are roommates. Resident #6 was lying in bed with the head of the bed elevated. He was observed to be scratching his neck and rubbing his arms against his sides. Resident #6 said he had been itching all over. He said he had been itching for over a month, and nothing had been done to help him. He said he had told multiple staff members, and he just wanted to find out what was wrong. Resident #5 spoke up from across the room and agreed stating he is also itching. Resident #5 said he had a rash on his sides and back. He said he was supposed to get medication for the itching but when he asked, he was always told it wasn't in. He said he was miserable. Both residents said their rooms had not had a deep cleaning and their personal items had not been bagged up and/or cleaned since the itching began. Review of Admission Records showed Resident #6 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease. Review of Resident #6's Annual Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating he is cognitively intact. Review of Resident #6's physician order summary showed the following orders: -Abdominal folds and groin: Clean area with soap and water, pat dry, apply Nystatin powder to area and leave open to air every shift for skin impairment/fungal. Dated 10/29/24 -Betamethasone Valerate External Cream 0.1% apply to back topically two times a day for rash for 14 days. Dated 2/24/25 -Diphenhydramine HCL Capsule 25 mg. Give 1 tablet by mouth every 6 hours for itching for 1 day. Dated 2/24/25. -Diphenhydramine HCL Capsule 25 mg. Give 1 tablet by mouth every 6 hours for itching. Dated 2/22/25. Discontinued 2/24/25. -Betamethasone Dipropionate External Cream 0.05%. Apply to upper arm and chest topically every night shift for 2 weeks. Dated 2/6/25. -Diphenhydramine HCL Capsule 25 mg. Give 1 tablet by mouth every 6 hours as needed for itching for 14 days. Dated 2/4/25. -Prednisone Oral Tablet 10mg. Give 4 tablets by mouth one time a day for dermatitis for 3 days and give 3 tablets by mouth one time a day for dermatitis for 3 days and give 2 tablets by mouth one time a day for dermatitis for 3 days and give 1 tablet by mouth one time a day for dermatitis for 3 days. Dated 1/22/25. -Diphenhydramine HCL Capsule 25 mg. Give 1 tablet by mouth every 6 hours as needed for itching. Dated 1/14/25. Discontinued 2/4/25. Nystatin Powder 100000 unit/gm. Apply to groin, abdominal fold topically every shift for skin impairment/fungal. Dated 12/10/24. Discontinued 12/22/24. There were no orders for transmission-based precautions. Review of Admission Records showed Resident #5 was admitted on [DATE] with diagnoses including syncope and collapse. Review of Resident #5's Quarterly MDS, dated [DATE], Section C, Cognitive Patterns, revealed a BIMS score of 15, indicated he was cognitively intact. Review of Resident #5's physician order summary showed the following: - Permethrin External Cream 5 %. Apply to back/body topically one time only for rashes for 2 Days apply on right under arm, back, body-shower following day. Dated 2/7/25 -Nystatin Powder. Apply to Apply to rash Under R Arm topically every day and evening shift for Rash Under Right Arm / Flank until 02/17/2025. Dated 2/5/25 There were no orders for transmission-based precautions. An interview was conducted on 3/5/25 at 2:35 p.m. with Resident #7. She stated she had a rash that was itching a lot. She said it started small and spread. Resident #7 said the rash and itching had been going on for a while. She said her room had been cleaned regularly but not a deep cleaning where the privacy curtains were changed and her personal items bagged up. Review of Admission Records showed Resident #7 was admitted on [DATE] with diagnoses including diverticulitis of intestine and adult failure to thrive. Review of Resident #7's Quarterly MDS, dated ,d+[DATE], Section C, Cognitive Patterns revealed a BIMS score of 15, indicating she was cognitively intact. Review of Resident #7's physician order summary showed the following: -Diphenhydramine HCL Capsule 25 mg. Give 1 tablet by mouth every 6 hours as needed for itching. Dated 2/21/25. -Hydrocortisone External Cream 1%. Apply to chest, arms, back topically one time a day for pruritus. Dated 2/12/25. -Permethrin External Cream 5%. Apply to entire body topically one time only for scabies for 2 days. Dated 2/5/25. -Triamcinolone Acetonide External Cream 0.5%. Apply to LT arm topically every day and evening shift for contact dermatitis for 10 days. Dated 12/27/24. There were no orders for transmission-based precautions. An interview was conducted on 3/5/25 at 12:25 p.m. with Staff A, Licensed Practical Nurse (LPN) and Staff B, Certified Nursing Assistant (CNA). They both said on the south unit, where they had been working, there were three residents that had rashes and are being treated or had been in the last few weeks. They both stated they each had also gotten a rash with itching and treated it themselves as well as at least one other CNA. They both said the Director of Nursing (DON) told them it was because someone was putting too much detergent in the laundry. An interview was conducted on 3/5/25 at 12:38 p.m. with Staff C, LPN. She said the north unit, where she had been working, had three resident that were being treated or had been treated in the last month or two for rashes and itching. Staff C said the Unit Manger had said it was an extensive case of eczema. Staff C said the three residents had rashes all over their bodies. She said she also contracted the rash and had it on her side. Staff C said she was treated outside of the facility for scabies. She said there was another staff member that had it and she treated herself for scabies as well. An interview was conducted on 3/5/25 at 12:45 p.m. with Staff D, LPN. She said the 100 unit, where she had been working, had three residents that had rashes and itching on that unit. She said the medical records showed pruritus. She said she was not aware of any staff on the 100 unit that had rashes or itching. An interview was conducted on 3/5/25 at 3:20 p.m. with Staff E, LPN. She said when a resident had a rash, the nurse should let the Unit Manager and DON (Director of Nursing ) know. She said typically housekeeping would do a deep clean of the room, clean the bed, and change the privacy curtains out. She said she doesn't know what the rashes were, but it is spreading. An interview was conducted on 3/5/25 at 2:56 p.m. with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP). She reviewed her infection tracking logs/line listing from October 2024 to current and confirmed the logs did not contain the recent outbreak of rashes in the facility. She said if the resident is not on an antibiotic, it was not being tracked. When asked about rashes in the facility she said she only knew about a couple of residents on the North unit. The ADON/IP said if there were multiple residents with rashes they should be tracking them. She said she had not been made aware any residents had been treated with Permethrin or Ivermectin for scabies and she did not know any staff members had contracted rashes/itching. She said had she been aware of these things, she would have been tracking and following up. The ADON/IP said if a resident was treated for scabies their roommate should have had a skin check and possible prophylactic treatment for scabies. She said housekeeping would have needed to be involved to ensure the room was deep cleaned and the residents personal items were bagged up. The ADON/IP was observed entering Resident #6's room and looking at his abdomen and sides. She said the rash looked like scabies to her and she felt like they needed to do a skin sweep of all residents in the facility. An interview was conducted on 3/5/25 at 5:30 p.m. with the DON. She said she was aware there were a couple of rashes on one unit, and it had been going on for 1 1/2 to 2 months. She said there was kind of a cluster on one hall. She said she saw orders for Ivermectin and Permethrin because the dermatologist was treating it like scabies. The DON said the medical director came in the beginning of February and looked at the rashes and said he didn't think it was scabies. The DON said also the beginning of February there was a person in laundry putting too much fabric softener in the wash, so the facility thought it may be contact dermatitis. She said they educated laundry staff and corrected that at the beginning of February. The DON said no skin scraping had been done on any residents to determine the cause of the rashes. She said she believed Resident #5's rash was only due to him not wanting to get up and shower. She said she thought Resident #6 had gotten better and she said what they did for Resident #8 was they, chalked it up to scabies. The DON asked, is it still an ongoing thing? The DON confirmed they were not tracking the rashes and said if they had considered it an infection outbreak they would have been tracking it. The DON said she did not know there were residents on three different units with rashes and itching. She said she was also unaware that staff had rashes and itching. She then said she did know that two staff members who helped the medical director do skin checks had some spots on their arms and wrists. The DON said when a rash comes up on a resident, it should be documented immediately and a skin assessment completed. She said the nurse should then call the doctor and document any new orders received. She said she would expect skin checks to be accurate in the medical record. An observation was conducted on 3/5/25 at 5:50 p.m. with the DON. She was observed entering Resident #6's room and doing a skin check. Resident #6 told the DON he was itching very badly and wanted it to stop. The DON confirmed his rash has spread and gotten worse. An interview was conducted on 3/5/25 at 6:05 p.m. with the Nursing Home Administrator (NHA). She had been aware they had a few residents with rashes. She said it was due to a laundry issues and that it was fixed the first week of February. She said they hadn't had many issues since then. The NHA said she was not aware they had residents currently itching with rashes, and she did not know any staff had contracted rashes. The NHA confirmed no skin scrapings had been done to diagnose the rashes. Review of a facility policy titled Surveillance for Infections, revised September 2017, showed: Policy Statement - The infection preventionist will conduct ongoing surveillance for healthcare-associated infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections, to guide appropriate interventions, and to prevent future infections. 2. The criteria for such infections are based on the current standard definitions of infections. 3. Infections that will be included in routine surveillance include those with: a. evidence of transmissibility in a healthcare environment. b. available processes and procedures that prevent or reduce the spread of infection. c. clinically significant morbidity or mortality associated with infection (e.g., pneumonia, UTIs, C. difficile); and d. pathogens associated with serious outbreaks. (e.g., invasive Streptococcus Group A, acute viral hepatitis, norovirus, scabies, influenza). 4. Infections that may be considered in surveillance include those with limited transmissibility in a healthcare environment; and/or limited prevention strategies. 5. Nursing staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections, and will document and report suspected infections to the charge nurse as soon as possible. 6. If a communicable disease outbreak is suspected, this information will be communicated to the charge nurse and infection preventionist immediately. 7. When infection or colonization with epidemiologically important organisms is suspected, cultures may be sent, if appropriate, to a contracted laboratory for identification or confirmation. Cultures will be further screened for sensitivity to antimicrobial medications to help determine treatment measures. 8. The charge nurse will notify the attending physician and the infection preventionist of suspected infections. a. The infection preventionist and the attending physician will determine if laboratory tests are indicated, and whether special precautions are warranted. b. The infection preventionist will determine if the infection is reportable. c. The attending physician and interdisciplinary team will determine the treatment plan for the resident. 9. If transmission-based precautions or other preventative measures are implemented to slow or stop the spread of infection, the infection preventionist will collect data to help determine the effectiveness of such measures. Review of a facility policy titled Scabies Identification, Treatment, and Environmental Cleaning, undated, showed: Purpose The purpose of this procedure is to treat residents infected with and sensitized to Sarcoptes scabiei and to prevent the spread of scabies to other residents and staff. Preparation 1. Obtain or verify the existence of a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. General Guidelines 1. Scabies is an itching skin irritation caused by the microscopic human itch mite, which burrows into the skin 's upper layers and eventually causes itching, tiny irregular red lines just above the skin and an allergic rash. 2. Secondary bacterial skin infections may result from untreated scabies. 3. Symptoms sometimes include severe itching, which worsens at night. 4. Common locations of scabies: a. Anterior axillary region or under breasts (b.) Around the waist; (c.) Between fingers and palm of hand; (d.) On the inner thigh, groin, buttocks; (e.) Anterior surfaces of wrists and elbows; (f.) On body parts which may come in contact with contaminated linens, bedding, or clothing; (g.) Upper backs of nursing home residents; and (h.) On hands of employees. 5. Scabies is spread by skin-to-skin contact with the infected area, or through contact with bedding, clothing privacy curtains and some furniture. 6. Diagnosis may be established by recovering the mite from its burrow and identifying it microscopically. 7. Affected residents should remain on precautions per CDC guidelines. 8. Family and friends of residents who have had close contact should be notified and given instructions regarding self-examination and treatment. 9. Staff members who may have been exposed should report any rashes developing on their bodies to the infection preventionist or director of nursing services. 10. A resident sharing a room with someone infected with scabies should be examined carefully for scabies. If signs and symptoms are present, the resident should be treated in accordance with these procedures. If symptoms are not present, assessments should be made until the case has resolved. I l. Individuals who come into contact with the infected resident or with potentially contaminated bedding or clothing should use precautions as established by the facility's infection and exposure control programs. 12. During a scabies outbreak among residents and/or personnel, the infection preventionist or committee will coordinate interdepartmental planning to facilitate a rapid and effective treatment program. 13. Control of an epidemic depends on treating all residents at risk. Specific drug selection for each resident will depend on that individual's risk factors, possible medication interactions, etc.

Based on observations, record reviews, and interviews the facility failed to facilitate timely care plan meeting notifications to allow the representative or resident to participate in the care plan meetings, and failed to provide care plan summaries of the meetings to the representatives and/or three residents (#6, #17, and #23) of three sampled residents. Findings included: 1. On 8/12/24 at 10:33 a.m. Resident #6 was observed lying in bed and reported having the ability to feed self, having a good appetite, and not having gone to the hospital recently. Review of Resident #6's Admission Record revealed the resident was admitted on [DATE], discharged [DATE] and readmitted on [DATE], with a hospital leave beginning on 7/7/24 and returning to the facility on [DATE]. The resident's primary diagnoses included unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The record included other diagnoses not limited to unspecified encephalopathy, and Parkinson's disease without dyskinesia without mention of fluctuations. Review of Resident #6's Admission Record revealed the resident's family member was the responsible party, essential caregiver, emergency contact #1, and Power of Attorney (POA) for Care and Finances. Review of Resident #6's Minimum Data Set (MDS) assessments revealed an Annual MDS, dated [DATE], that documented the Brief Interview for Mental Status (BIMS) score for Resident #6 as 03, showing a level of severe cognitive impairment. Review of Resident #6's MDS assessments showed the following comprehensive assessments had been completed: - Quarterly on 6/14/23. - Quarterly on 9/7/23. - Quarterly and modification on 12/5/23. - Annual on 3/6/24, completed on 3/19/24. - Quarterly and modification on 6/6/24, completed on 6/7/24. The facility provided the following care plan invitations and care plan summaries sent to Resident #6's family member/POA: - Invitation for care plan meeting 8/9/23 mailed to the POA on 7/28/23. The Interdisciplinary (IDT) Plan of Care Review Meeting Summary showed one attempt to contact the POA was done by mail on 7/28/23 and the meeting was held without the family member due to no reply. The summary had an area to document 3 attempts at contacting the resident and/or their representative which showed one mailed attempt on 7/28/23 was documented without any further attempts. The care plan meeting on 8/9/23 was held approximately six weeks after the Quarterly MDS assessment on 6/14/23 and approximately six weeks prior to the Quarterly MDS assessment on 9/7/23. - The IDT Plan of Care Review Meeting Summary, dated 3/14/24 at 10:15 a.m., did not reveal the type of review associated with the meeting, whether the meeting was held in person or by telephone conference, and did not reveal any attempt was made to contact either the resident and/or representative. The note showed no family present for care plan meeting (2) resident confused unable to participate. Review of the Invitation Letters and Care Plan Summaries provided and uploaded in the clinical record revealed no documentation of either in regard to comprehensive assessments completed in June 2023, September 2023, December 2023, and June 2024. Review of Resident #6's Interdisciplinary Narrative notes did not show any progress notes had been written, and review of the Care Plan notes showed the last one written was on 8/31/21. An interview was conducted with Staff A, MDS Coordinator on 8/13/24 at 12:03 p.m. Staff A stated a care plan meeting was conducted every 92 days, and if residents are confused the POA was called. The contact with representatives was done by telephone. Staff A stated Resident #6 was due for a care plan meeting this month and it was going to be scheduled for 8/22/24 but had to reschedule it for 8/29/24. Staff A confirmed not reaching out to the representative. The staff member stated sometimes the receptionist helps with calling the representatives. Staff A stated the last meeting was on 3/14/24 and the representative would have been called. Staff A reported trying to call the representatives the day of the meeting. Staff A stated the last time Resident #6's representative was involved was 4/23/23. An interview was conducted with the Regional MDS Coordinator on 8/13/24 at 12:17 p.m. The staff member provided a handwritten note of names of representatives contacted for the March 2024 care plan meetings and it showed the representative for Resident #6 had been notified of the meeting. The Regional MDS stated Staff A was going through papers to locate any other notifications or summaries and reported if it was not documented (it wasn't done). The staff member stated the facility had identified an issue with notifications during a mock survey two weeks prior. 2. On 8/14/24 at 12:09 p.m. Resident #17 was observed lying in bed and stated staff assisted with eating and hydration. Review of Resident #17's Admission Record revealed the resident was admitted on [DATE] and 9/21/23. The record included diagnoses not limited to Type 2 Diabetes Mellitus with hyperglycemia and oral phase dysphagia. The record showed the resident was self-responsible and had a POA. Review of the resident's census showed the resident was not active from 2/27/23 to 3/9/23 and 9/12/23 to 9/21/23. Review of Resident #17's Quarterly MDS, dated [DATE], showed the resident's BIMS score of 14 out of 15, indicating intact cognition. Review of Resident #17's MDS schedule showed the following comprehensive assessments were completed: - Quarterly on 4/25/23. - Quarterly on 7/20/23. - Quarterly and modification on 10/20/23. - Annual on 1/20/24. - Quarterly on 4/15/24. - Quarterly on 7/15/24. Review of Resident's Care Plan Meeting invitation letters and IDT Plan of Care Review Meeting Summaries revealed the following: - Letter of invitation was mailed to the POA of Resident #17 on 6/15/23 for a meeting to be held on 6/21/23 at 11:30 a.m., the letter was mailed six days prior to the meeting. The MDS schedule showed the April MDS targeted on 4/25/23, seven weeks prior to the meeting on 6/15/23 and the meeting was held five weeks prior to the quarterly assessment targeted on 7/20/23. - Letter for meeting on 8/1/24 at 10:45 a.m. did not show who received the letter, when or how it was delivered. The summary showed the resident declined to participate in the meeting which was attended by three staff members, the Unit Manager, Staff A, MDS Coordinator, and an unknown staff member. The facility did not provide either a letter of invitation or a care plan meeting summary related to the resident's MDS dated [DATE]. The review of Resident #17's clinical record did not reveal any care plan documentation had been uploaded from 1/25 to 7/9/24 and the facility did not provide any documentation related to the comprehensive assessment done on 4/15/24. During an interview on 8/14/24 at 1:17 p.m. the Staff A, MDS Coordinator stated Resident #17 did not normally participate (in the meetings) and only reaches out to family members if they wanted. The staff member reported even though the resident did not normally participate they would still invite the resident. 3. On 8/14/24 at 12:14 p.m. Resident #23 was observed lying in bed, with a family member at the bedside. The resident was able to make their needs known. Review of Resident#23's Admission Record showed the resident was admitted on [DATE] and again on 2/27/24. The diagnoses included but was not limited to dementia in other disease classified elsewhere mild without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified schizophrenia, Type 2 Diabetes mellitus, and unspecified bipolar disorder. The record revealed the resident was the responsible party and did not show a Power of Attorney (POA) or Healthcare Surrogate (HCS). The census for the resident also showed a period of no billing from 1/26/24 to 1/31/24. Review of Resident #23's MDS assessments revealed a BIMS score on 3/31/24 of 9 out of 15, indicating a moderate cognitive impairment, and on 4/11/24 a BIMS score of 10, continuing to indicate a moderate cognitive impairment. Review of Resident #23's MDS schedule revealed the following comprehensive assessments: - Quarterly on 1/23/24. - Quarterly on 3/31/24 and 4/11/24 - Quarterly on 7/8/24. Review of the facility provided Care Plan summaries on 11/16/23 showed Resident #23 had participated and on 8/6/24 the resident and family member participated along with Hospice and the facility's IDT. Review of Resident #23's uploaded documents showed a baseline signature page on 10/20/23, and Care Plan Meeting Summaries dated 11/20/23 and 8/6/24. The documents provided did not show an invitation or summary related to the Quarterly assessments done on 3/31 and 4/11/24. Review of Resident #23's Care Plan Notes and IDT Narrative notes showed no notes were included in the clinical record. During an interview on 8/14/24 at 1:11 p.m. Staff A, MDS Coordinator stated the last care plan was conducted with Resident #23, [family member], and Hospice. The staff member reported the resident does participate in care plan meetings. Staff A reported not writing a progress note regarding the care plan meetings, he uses the IDT summary, which was uploaded into the resident's electronic records and the staff member uploads the summaries. He stated a summary was done with every (care plan) meeting. Staff A stated he would have to look into why summaries were not uploaded and reported being in the facility during the time of Resident #23's care plan meetings. Review of the facility policy titled, Resident Participation - Assessment/ Care Plans, revised February 2021 revealed, The resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. The interpretation in implementation of the policy included of the following: 1. The resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan . 3. The resident/ representatives right to participate in the development and implementation of his or her plan of care includes the right to: -a. Participate in the planning process; -b. Identify individuals to be included in the planning process; -c. Request meetings; -d. Request revisions to the plan of care; -e. Participate in establishing his or her goals and expected outcomes of care; -f. Participate in the type, amount, frequency and duration of care; -g. Receive the services and/ or items included in the care plan; -h. Be formed, in advance, of changes to the plan of care; -i. Refuse, request changes to and/ or discontinue care or treatment offered or proposed; -j. Be informed, in advance (by physician, practitioner, or professional), of the risk and benefits of the care or treatment proposed; -k. Have access to and review the care plan; and -l. Review & the care plan after any significant changes are made. 4. The care planning process: -a. Facilitates the inclusion of the resident and/ or representative 5. Facility staff supports and encourages resident/ representative participation in the care planning process by: -a. Ensuring that residents, representatives, and families understand the care planning process; -b. Holding care plan meetings at times of day when the resident, representative, and family members can attend and are functioning at their best; -c. Providing sufficient notice in advance of the meeting; and -d. Planning for enough time for exchange of information and decision making. 7. A comprehensive care plan is developed within seven (7) days of completing the resident assessment. 8. A seven (7) day advance notice of the care planning conference is provided to the resident and his or her representative. Such notices made by mail and/ or telephone. 9. The social service director or designee is responsible for notifying the resident/ representative and for maintaining records of such notices. Notices include: -a. The date, time, and location of the conference; -b. The name of each person contacted in the date he or she was contacted; -c. The method of contact (e.g. Mail, telephone, e-mail, etc.); -d. Input from the resident or representative if they are not able to attend; -e. Refusal of participation, if applicable; and -f. The date and signature of the individual making the contact.

Based on interviews, record reviews, and the facility's policy, titled COVID-19 Vaccination Mandate Policy, the facility failed to ensure 100% of staff were fully vaccinated against COVID-19 or had approved exemptions for seven (7) of 11 sampled staff, which resulted in a 95.6% vaccination rate. The findings include: Review of the facility's Covid-19 Staff Vaccination Status for Providers matrix revealed 183 total direct hire, contracted, and other staff. Of the eleven staff sampled, two (2) were fully vaccinated against COVID-19 and two (2) had approved exemptions. Seven (7) were partially vaccinated against COVID-19 - Certified Nurse Aide (CNA) #s 1 and 3; Licensed Practical Nurse (LPN) #s 1, 3, and 4; Registered Nurse (RN) #2 and Dietary Aide (DA) #1. The seven partially vaccinated staff had received one (1) dose of the Moderna or Pfizer COVID vaccine series. None had received the one-shot Johnson and Johnson vaccine. Review of the facility's policy, titled COVID-19 Vaccination Mandate Policy, (undated) revealed, .By March 14, 2022 all Covered Individuals must be Fully Vaccinated against COVID-19 or receive an exemption .Fully Vaccinated is defined as two or more weeks since the administration from the last date of the final or last dose of a COVID-19 vaccine . During an interview on 04/21/23 at 9:15 AM, the Corporate RN confirmed seven (7) employees were partially vaccinated with only one dose. The Corporate Nurse, pointing to the COVID-19 policy stated, Everyone should have been fully vaccinated. During an interview on 04/21/23 at 12:00 PM, LPN #1 confirmed she was partially vaccinated with having received only one shot in the Pfizer series. LPN #1 stated, I got the first Pfizer COVID shot in 2021, before I started work here April 11th, 2023. I know I gotta [sic] take the second shot to be completely vaccinated; but I got COVID and just haven't rescheduled. They said I had to be vaccinated or exempted. They told us, to wear mask a mask all the time and a N95 mask when needed . when the community level is high. During an interview on 04/21/23 at 12:10 PM, CNA #1/Receptionist confirmed she was partially vaccinated with having received only one shot in the Moderna series. CNA #1 stated, I started work here December 2021. I got my Moderna vaccination in February 2023 but have not rescheduled my second one yet. Yes, I know I had to have the second shot; and I do plan on getting it, I just haven't. I think they have my vaccination card, but I don't remember if they told me I had to have it before I started work. Nobody asked me again for it. During an interview on 04/21/23 at 12:30 PM, with the Corporate RN and Director of Nursing (DON) present, the Administrator stated, All staff should have been fully vaccinated or requested an exemption. The Corporate RN stated, The new hires should have not have started work until they were fully vaccinated. We have notified Human Resources (HR) of this.

Based on interview and record review, the facility failed to include the resident representative in all aspects of the person-centered care planning and the right to participate in the care and treatment planning and process for one (Resident #72) out of fifty-one sampled residents. Findings included: On 3/19/2023 at 10:20 a.m., Resident #72 was observed in her room and seated upright in her bed, with her over the bed table positioned in front of her. During an attempt to interview resident #72, it was noted she had low cognitive functions and was not able to speak with relation to her medical care and services. She was able to answer basic yes and no questions and indicated she was feeling fine and having a good morning. Resident #72 was not aware if she or anyone in her family were involved with the quarterly care plan meetings/conference. On 3/20/2023 at 1:30 p.m., an interview with Resident #72's Power of Attorney (POA), who was also a family member, revealed Resident #72 was at the facility for long term care. Resident #72's POA revealed she visited the resident almost daily and knew many of the staff who took care of her. Resident #72's POA was asked if she was involved with the resident's daily routines and plan of care. She was not aware of exactly what that meant. When she was asked if she participated in the quarterly care plan conference team, which included many of the medical and service department staff, she revealed she had not and she did not ever remember being offered or invited to those meetings. She confirmed she did not receive any mail documentation to support she was ever invited. Resident #72's POA revealed this would be something that she would like to be a part of as she was involved daily with the resident. On 3/21/2023 at 8:00 a.m., an interview with the North Unit Manager, Staff A, revealed she was not sure if Resident #72's POA attended the care plan conference/meetings, and was not sure if she had ever been invited to participate. Staff A knew Resident #72's POA/family member, and felt she was involved with the resident when she was present daily. A review of Resident #72's electronic medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the Advance Directives revealed Resident #72 had a Power of Attorney (POA) in place to make her medical and financial decisions. The POA was noted as a family member and was involved with daily visitation. A review of the Diagnosis sheet revealed Diagnoses to include but not limited to: Dementia and Depression. A review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed: Cognition/Brief Interview Mental Score or BIMS score not scored, but indicated resident had Short Term/Long Term memory problems, and with Severely Impaired Decision Making skills. A review of the nurse progress notes dating back from 6/1/2022 through to current date 3/20/2023 did not indicate any notes that Resident #72's POA was involved with any part of the care planning process. There were no notes that indicated Resident #72's POA was invited to any quarterly care plan conferences. A review of the following Care Plan Conference sheets, revealed: 1. The Care Plan Quarterly Conference sign in sheet dated 6/14/2022, revealed no documentation that the Responsible Party, Family Member attended. The sheet was checked indicating Resident #72 was invited to participate, and declined; and also checked that the Responsible Party was notified by mail of review and POA declined. The conference sheet was signed by five departmental staff members. 2. The Care Plan Quarterly Conference sign in sheet dated 9/20/2022, revealed no documentation that the Responsible Party, Family Member attended. The sheet was checked indicating Resident #72 was invited to participate, and declined. The sheet did not indicate if the Responsible party was notified by mail or phone to attend the conference/meeting. The conference sheet was signed by one departmental staff member, Staff L, Registered Nurse (RN), Registered Nurse Assessment Coordinator (RNAC). 3. The chart did not contain quarterly care plan conference/meeting sheets for months 12/2023, and 3/2023. In an interview with the North Unit Manager, Staff A confirmed the chart and other records did not contain the last two quarterly care plan conference/meeting sign in sheets. On 3/22/23 at 9:45 a.m., in an interview with Staff L, he explained he was responsible for coordinating the care plan meetings. He stated he determined who was the responsible party, resident or loved one. He would verbally invite the resident and maybe give them a letter. If the loved one was the responsible party he sent a letter, calls and/or emails. He stated he documented attempts in the past but not anymore. The care plan meeting might include the resident/family member, Interdisciplinary Team (IDT), sometimes a CNA or a nurse. When we have care plan meetings there was a signature sheet that indicated who participated. Staff L recalled Resident #72 and that she did not usually speak to him and he was able to communicate with her. He indicated she was not responsible for herself and her responsible party would be invited. He did not recall if he invited her or not. He indicated there was no documentation of invite. He reviewed the Care Plan Meeting Signature page from 6/14/22 and 9/21/22 and confirmed only his signature was present on the form. On 3/22/2023 at 3:00 p.m. the Nursing Home Administrator provided the following Policy and Procedure for review. The facility policy for Resident Participation - Assessment/Care Plans dated (revised February 2021) Policy Statement states that the resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. The Policy Interpretation and Implementation states: 1. The resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan. 3. The resident/representative's right to participate in the development and implementation of his or her plan of care includes the right to: a. participate in the planning process; e. participate in establishing his or her goals and expected outcomes of care; f. participate in the type, amount, frequency and duration of care; 4. The care planning process: a. facilitates the inclusion of the resident and/or representative; 5. Facility staff supports and encourages resident/representative participation in the care planning process by: a. ensuring that residents, representatives and families understand the care planning process; c. providing sufficient notice in advance of the meeting; and 9. The social services director or designee is responsible for notifying the resident/representative and for maintaining records of such notices. Notices include: a. the date, time and location of the conference; b. the name of each person contacted and the date he or she was contacted; c. the method of contact (e.g., mail, telephone, email, etc.); d. input from the resident or representative if they are not able to attend; e. refusal of participation, if applicable; and f. the date and signature of the individual making the contact.

Based on observation, record review, and interview, the facility failed to provide one (Resident #134) of 51 residents with a written notification for a room change. Findings include: On 03/19/2023 at 10:00 am., Resident # 134 was observed lying down in bed under her covers. Resident #134's call light was observed within her reach. A review of the Admission Record revealed Resident #134 was admitted to the facility on [DATE] with diagnoses included but not limited to Nontraumatic Intracerebral Hemorrhage, Unspecified, Acute Embolism and Thrombosis of Unspecified Femoral Vein, and Type 2 Diabetes Mellitus without Complications. A review of the admission Minimum Data Set (MDS) dated , 2/22/2023, Section C- Cognitive Patterns, Brief Interview for Mental Status, (BIMS) revealed Resident #134's BIMS score was 15, which indicated intact cognition. A review of the Electronic Medical Record, (EHR) revealed Resident #134 was admitted to [room number] on 3/15/2023, then moved to [room number] on 3/16/2023. A review of the EHR showed Resident #134 was not provided with an advance notice of the room transfer and a reason why the move was recommended. During an interview with Resident #134 on 3/19/2023 at 10:00 a.m., she reported she was moved from her room yesterday into another room without her knowledge or consent. She said the facility did not discuss with her and her daughter the reason why she had to relocate to a different room. Resident #134 expressed a desire to return to her original room. On 03/21/2023 at 3:40 p.m., an interview was conducted with Staff P, the admissions coordinator. She said she was helping the facility because they did not have a social worker. Staff P admitted she was unaware that Resident #134 and/or her representative should have been notified of a room change. Staff P acknowledged she did not know the facility's policy and procedure for room change notification. On 03/ 21/ 2023, at 3:00 p.m., an interview was conducted with the interim Nursing Home Administrator (NHA). The NHA said when a resident was transferred to a different room, the staff should first determine what the issues were that were connected to the reason the resident needed to be moved. After that, during the morning meeting, the interdisciplinary team (IDT), which consisted of the NHA, Director of Nurses, unit managers, and the admission coordinator, would decide which room the resident should be moved into. The NHA said since the facility did not currently have a Social Services representative, the NHA advised that someone from the IDT team should contact the resident and/or their family to inquire about whether they agreed to the room change or not. The NHA stated when a room change occurred, residents or their representative should be informed, and it should be noted in the resident's medical record. A review of the facility Admission Room Change Policy, showed where feasible the facility will make room to room transfers when requested by the resident or as may become necessary to meet the resident's medical and nursing care needs. 2) Unless medically necessary or for the safety and well-being of the resident(s), a resident will be provided with an advance notice of the room transfer. 3) Such notice will include the reason (s) why the move is recommended

Based on observation and interview, the facility failed to ensure the walls were maintained in two (Rooms #10 and #16) of 22 rooms on the South Unit. Findings included: 1. An observation was made on 03/19/23 at 2:50 p.m. of room South-16. The wall next to bed B was observed to have missing paint and black scuffs on the wall. The resident stated his wall had been that way for a while it's probably from my wheelchair hitting the wall (photographic evidence obtained). An interview was conducted with Staff O, Certified Nursing Assistant (CNA) on 03/19/23 at 2:50 p.m. She stated, I noticed the wall this morning but I was so busy getting everyone up. I can put it in [maintenance work order system] but I go as far as finding the maintenance person because if you just put the information in [maintenance work order system] it doesn't get done. 2. An observation was conducted on 03/19/23 at 10:45 a.m. of the wall surrounding the window in room South-10. The wall was observed to be soft, pushed in, cracked, paint was peeled away from the wall, and the wall itself was lifted away from the building structure. There was also a rust-like substance on the blinds. The resident who resided in room South-10 stated, It has been that way for a while, I don't know exactly how long but, a while, they know about it they just haven't fixed it yet (photographic evidence obtained). An interview was conducted with the maintenance director on 3/22/23 at 2:52 p.m. He indicated he only had three open work orders at the time and none of them were on the South unit. He stated his expectations were work orders were completed as soon as possible and addressed immediately as they come in. There were two maintenance workers for the building including himself. He said room inspections were completed upon angel rounds which occurred daily, and he expected the staff doing angel rounds to put in work orders if they noticed maintenance concerns. He also indicated maintenance was not involved in the angel rounds. The maintenance director stated We have a checklist we address whenever we go into the rooms. Water intrusion is a big problem not only for damage to the building but also it attracts pests. Painting is a challenge because we prioritize other things over painting. He confirmed room South-16 should not look like that and he confirmed the room had dry wall damage. When there is dry wall damage, I have to patch it, let it dry, sand it, then paint it so it takes time to do it correctly. There's no question that it should be painted. Further interview was conducted with the Maintenance Director on 3/22/23 at 3:13 p.m. He went into room South-10 and observed the wall damage. He indicated he was not aware of the wall damage and stated that was a concern and the wall needed to be removed. He said there needed to be further investigation on where the damage came from because that is wall damage with water intrusion. A policy was requested for maintaining a clean, sanitary and home like environment and one was not provided by the end of the survey. 46498