Every finding on record at Lincoln Meadows Care Center

Based on interview and record review the facility failed to ensure a resident's personal item was safeguarded and that appropriate process or protocol was implemented to locate the missing item for one of three sampled residents (Resident 1).This failure resulted in the loss of Resident 1's inventoried dentures and financial loss for Resident 1.Review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility in July 2026 with several diagnosis including Cerebral Infarction (a condition that causes blocked blood to parts of the brain, causing brain tissue to die), Type 2 Diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and chronic kidney disease.Review of Theft and Loss Record document dated 7/15/26, indicated Resident 1 reported his dentures were missing today after lunch.Review of Resident 1's Inventory of Personal Effects on admission dated 7/10/26, indicated Upper dentures are in Resident 1's possession. The same document on discharge date d 8/10/26 indicated that Resident 1's dentures were missing.Review of the Inventory/Theft and Loss Agreement dated 7/10/26, indicated, The facility will investigate any loss and participate in a resolution, up to replacement if responsible for the loss. Under the Administrative Action section, the document was blank.During an interview on 8/25/26 at 11:07 a.m. with Social Service Director (SSD), the SSD stated that she was first made aware Resident 1's dentures were missing on 7/15/26. SSD stated that Resident 1's family called after discharge asking if the dentures were found and requesting re-imbursement for the dentures. No documented evidence of process or protocol implemented to locate Resident 1's missing dentures.During an interview on 8/25/26 at 12:10 p.m. with Certified Nursing Assistant (CNA) 1, CNA1 stated she had not been asked to help locate Resident 1's dentures.During an interview on 8/25/26 at 11:57 a.m. with the Administrator (ADM), the ADM stated that he would re-imburse for the dentures. The ADM further stated that he did not call the family.Request for the procedure for finding resident's lost items was requested but not given.

Based on interview and record review, the facility failed to ensure medications were administered in accordance with manufacturer guidelines and prescriber instructions for one (1) of ten (10) sampled residents (Resident 47), when the facility failed to identify and correct the inappropriate administration times for glipizide, a medication requiring administration approximately 30 minutes before meals for effective blood sugar control. Glipizide doses were instead scheduled at standardized times that did not align with mealtimes or manufacturer recommendations. This failure created the potential for uncontrolled blood sugar and disease related complications. Findings:A review of the clinical record showed Resident 47 was admitted on [DATE] with diagnoses including primary hypertension (high blood pressure) and atrial fibrillation (irregular heartbeat). In 2024, diagnoses were updated to include uncontrolled type 2 diabetes mellitus. Physician orders for glipizide included:- Glipizide 5 mg (milligram, strength) oral tablet, give 1 tablet by mouth twice daily for type 2 diabetes mellitus, Do not give more than 30 minutes before meal. Start date 5/2/2026; discontinued 5/19/2026; scheduled at 8:00 a.m. and 8:00 p.m.- Glipizide 5 mg tablet, 1 tablet by mouth twice daily for type 2 diabetes mellitus, Do not give more than 30 minutes before meal. Start date 4/4/2025; discontinued 5/2/2026; scheduled at 8:00 a.m. and 8:00 p.m.During a medication observation on 5/18/2026 at 8:24 a.m., Licensed Nurse (LN 1) prepared and administered multiple oral medications to Resident 47, including glipizide 5 mg, after the start of breakfast, not prior to the meal as ordered.During an interview and concurrent record review on 5/18/2026 at approximately 1:30 p.m., LN 1 read the glipizide order and acknowledged the medication was not administered before the meal. LN 1 stated the medication could be given after eating and that the 8:00 a.m. dose had a one hour before and one hour after administration window.During a phone interview on 5/19/2026 at 2:22 p.m., the Consultant Pharmacist (CP) stated glipizide should be administered 30 minutes before meals. The CP acknowledged the order instructions reflected this requirement. After reviewing Resident 47's clinical record, the CP confirmed glipizide was scheduled at 8:00 a.m. and 8:00 p.m., which are not before mealtimes and acknowledged the resident had an order dating back to 2025. The CP acknowledged he did not make a recommendation to correct the administration times. He stated the facility does not have standard administration times for medications intended to be given before meals or with meals and relies on medication specific instructions. He stated that in 2024 he requested comments be added to reflect glipizide administration before meals for this resident.During an interview and concurrent review of physician orders, the May 2026 Medication Administration Record (MAR), and the facility's meal schedule on 5/20/2026 at 11:04 a.m., the Director of Nursing (DON) stated that glipizide should be administered 30 minutes before meals. The DON acknowledged that mealtimes are staggered by resident room location, with start times of 7:10 a.m. for breakfast, 12:10 p.m. for lunch, and 5:10 p.m. for dinner.The DON reviewed Resident 47's glipizide orders and MAR dated 4/4/2025 through 5/19/2026 and 4/4/2026 through 5/2/2026, which were scheduled for 8:00 a.m. and 8:00 p.m. The DON acknowledged the Consultant Pharmacist did not identify the medication timing issue. The DON confirmed these administration times were not appropriate for a medication intended to be given before meals and stated that administering glipizide outside of manufacturer guidelines could lead to uncontrolled blood sugars.A review of the prescribing information for glipizide, revised December 2023, indicated: .glipizide was more effective when administered about 30 minutes before, rather than with, a test meal in diabetic patients. Further review indicated: Dosage and Administration: glipizide should be given approximately 30 minutes before a meal to achieve the greatest reduction in post prandial (after eating) hyperglycemia. (high blood sugar)During a review of the facility's., Medication Administration [Times], not dated, indicated the following times for medication administration: twice daily: 8 a.m. and 4 p.m.; three times daily: 8.m., 2 p.m. and 8 p.m. or 8 a.m. 2 p.m. and 10 p.m.During a review of the facility's policy and procedure titled, Consultant Pharmacist Services Provider Requirements, version 3 (not dated), indicated, The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility. In collaboration with facility staff the consultant pharmacist helps to identify, communicate, address, and resolve concerns and issues related to the provision of pharmaceutical services. This includes: .2. Evaluating the process of receiving and interpreting prescribers' orders; acquiring, receiving, storing, controlling, reconciling, compounding, dispensing.administering, monitoring responses to and using and/or disposing of all medications, biologicals and chemicals. Further review indicated, Specific activities that the consultant pharmacist performs includes: 1) Reviewing the medication record (medication regimen review) pf each resident at least monthly. incorporating federally mandated standards of care in addition to other applicable professional standards .and documenting the review in the resident's medical record. 2) Communicating to the responsible prescriber and the facility leadership potential or actual problems detected and other findings relating to medication therapy orders as well as recommendations for changes in medication therapy and monitoring of medication therapy at least monthly.During a review of the facility's policy and procedure titled, Administering Medications, revised date October 2025, indicated, . 2. Medications are administered in accordance with prescriber orders, including any required time frame. 3.Medications re administered within (1) hour of their prescribed time, unless otherwise specified (for example before and after meal orders).

Based on observation, interview, and record review, the facility failed to ensure its medication error rate remained below 5%. The facility's medication error rate was 6.67%, with two errors identified during 30 medication administration opportunities. Errors were observed for two of five sampled residents (Resident 47 and Resident 16) when Resident 47 received glipizide, a medication used to control blood sugar, at the wrong time, which was not in accordance with the physician's orders or the manufacturer's specifications and Resident 16 did not receive her as needed (PRN) dose of hydralazine, a medication prescribed for the treatment of high blood pressure, despite having an elevated blood pressure reading that met the parameters for administration per the physician's order. These failures resulted in residents being placed at risk for complications related to uncontrolled blood sugar and uncontrolled high blood pressure.Findings:1. During a medication observation on 5/18/2026 at 8:24 a.m. at the 1 B medication cart, Licensed Nurse (LN 1) prepared eight oral medications for Resident 47, including one tablet of glipizide 5 mg (milligram, strength) Resident 47 was observed taking all her medications with water.A review of Resident 47's clinical record indicated the following physician order:-Glipizide oral tablet 5 mg, (milligram, mg, strength) give one tablet by mouth two times a day for Diabetes Mellitus Type II (DM2, chronic condition, high blood sugar). Do not give more than 30 minutes before meal. Order start date: 5/2/2026.Scheduled administration times, 8 a.m. and 8 p.m.During an interview and concurrent clinical record review on 5/18/2026 at approximately 1:30 p.m., LN 1 read Resident 47's glipizide order, including, 'do not give more than 30 minutes before meal.' LN 1 acknowledged the medication was not given before the meal and breakfast was approximately at 7 a.m. She stated the medication could be given after eating that the 8 a.m. dose had a one hour before and one hour after administration window.During a phone interview on 5/19/2026 at 2:22 p.m. with the Consultant Pharmacist (CP), the CP stated that glipizide should be given 30 minutes before meals. The CP reviewed Resident 47's clinical record and acknowledged the order instructions indicated, do not give more than 30 minutes before meal. The CP reviewed the prescribing information and read that glipizide should be given approximately 30 minutes before a meal to achieve the greatest reduction in high blood sugar after eating.During an interview and concurrent clinical record review of physician orders and the May 2026 Medication Administration Record on 5/20/2026 at 11:04 a.m. with the Director of Nursing (DON), the DON stated that glipizide should be administered 30 minutes before meals. The DON acknowledged Resident 47's glipizide was not given before breakfast and that this could contribute to uncontrolled blood sugar levels.A review of the prescribing information for glipizide, revised December 2023, indicated: .glipizide was more effective when administered about 30 minutes before, rather than with, a test meal in diabetic patients. Further review indicated: Dosage and Administration: glipizide should be given approximately 30 minutes before a meal to achieve the greatest reduction in post prandial (after eating) hyperglycemia (high blood sugar).During a review of the facility's policy and procedure titled, Administering Medications, revised date October 2025, indicated, . 2. Medications are administered in accordance with prescriber orders, including any required time frame. 3.Medications re administered within (1) hour of their prescribed time, unless otherwise specified (for example before and after meal orders).2. During a medication observation on 5/18/2026 at 8:57 a.m. at the 2A medication cart with Licensed Nurse (LN 2), LN 2 stated she needed to take Resident 16's blood pressure before administering her morning medications. LN 2 was observed taking Resident 16's blood pressure on her left arm while the resident was sitting at the side of her bed; the reading was 164/78 mmHg (millimeters of mercury, pressure measurement). LN 2 then prepared seven oral medications for the resident, who was observed taking them with water.A review of Resident 16's clinical record indicated the following physician order: Hydralazine oral tablet, give 1 tablet by mouth every 12 hours as needed for hypertension (HTN, high blood pressure); give if systolic blood pressure (SBP-the top number of a blood pressure reading, measuring the maximum pressure exerted on artery walls when the heart beats and pumps blood to the body) is greater than 150 mmHg. On 5/18/2026 at 9:03 a.m., the resident's blood pressure was documented as 164/78 mmHg, with an SBP of 164 mmHg, exceeding the ordered parameter requiring administration of PRN hydralazine.During an interview and concurrent clinical record review on 5/18/2026 at approximately 12 p.m. at the 2A medication cart with LN 2, when asked about Resident 16's hydralazine order, LN 2 stated the medication is given on the evening shift. After reviewing the order further, LN 2 acknowledged that hydralazine was ordered as needed for SBP greater than 150 mmHg, confirmed that the resident's SBP earlier that morning was 164 mmHg, and acknowledged that the PRN hydralazine was not administered as ordered.During an interview and concurrent clinical record review of Resident 16's physician orders, progress notes, blood pressure readings, and the May 2026 Medication Administration Record (MAR) on 5/20/2026 at approximately 11:50 a.m. with the Director of Nursing (DON), the DON stated she expects nursing staff to follow provider orders for as needed blood pressure medications. The DON acknowledged the resident's blood pressure that morning was above the ordered parameter and that the as needed hydralazine should have been given. She confirmed the medication was not administered and acknowledged the resident was at risk for complications related to untreated elevated blood pressureDuring a review of the facility's policy and procedure, titled, Physician Orders, revised October 2025, indicated, The licensed staff shall carry out physician/nurse practitioner's orders as prescribed. Further review indicated, Orders for medications may include: a. Name and strength of the drug. b. Number of doses, start and stop date, and/or specific duration of therapy. c. Dosage and frequency of administration. d. Route of administration. e. Clinical condition or symptoms for which the medication is prescribed.

Based on observation, interview, and record review, the facility failed to ensure one of ten sampled residents (Resident 16) was free from a significant medication error when staff did not administer a prescribed as needed (PRN) antihypertensive medication as ordered by the physician.This deficient practice placed the resident at risk for complications associated with uncontrolled high blood pressure, including stroke, heart attack, and kidney damage.Findings:A review of Resident 16's clinical record, indicated she was admitted to the facility on [DATE] with some of the following diagnoses: high blood pressure (hypertension), atrial fabulation (irregular heartbeat), diastolic heart failure (decreased blood flow to the body) and chronic kidney disease stage 3 (moderate kidney damage).A review of Resident 16's clinical record indicated a physician's order, dated 4/28/26, for hydralazine oral tablet 50 mg (milligram, strength), give 1 tablet by mouth every 12 hours as needed for hypertension, give if systolic blood pressure (SBP, the top number of a blood pressure reading, measuring the maximum pressure exerted on artery walls when the heart beats and pumps blood to the body) is greater than 150 mmHg (millimeters of mercury, measurement of pressure).During an interview and concurrent clinical record review on 5/18/2026 at approximately 12 p.m. at the 2A medication cart with Licensed Nurse (LN 2), LN 2 was asked about Resident 16's hydralazine order. LN 2 initially stated that the medication is given on the evening shift. After reviewing the order further, LN 2 acknowledged the medication was to be administered as needed when the systolic blood pressure (SBP) exceeded 150 mmHg. LN 2 confirmed that Resident 16's blood pressure earlier that morning was 164/78 mmHg-above the ordered SBP threshold requiring administration. LN 2 acknowledged the PRN hydralazine was not given as prescribed.A review of Resident 16's blood pressure readings, physician orders, nursing notes and the May 2026 Medication Administration Record (MAR), conducted with the Director of Nursing (DON) on 5/20/2026 at approximately 11:50 a.m., identified over 15 missed opportunities to administer PRN hydralazine within the required 12 hour dosing intervals. In each instance, the resident's systolic blood pressure (SBP) exceeded the physician ordered parameter of greater than 150 mmHg, yet hydralazine was not administered. The untreated elevated SBP readings were:5/20 at 6:57 a.m. (161/78 mmHg),5/19 at 6:56 a.m. (160/80 mmHg) and 3:54 p.m. (160/77 mmHg),5/18 at 6:40 a.m. (185/75 mmHg) and 9:03 a.m. (164/78 mmHg),5/14 at 9:00 p.m. (177/81 mmHg),5/13 at 7:37 a.m. (170/90 mmHg),5/12 at 6:33 a.m. (176/89 mmHg),5/11 at 3:35 a.m. (158/81 mmHg),5/10 at 6:47 a.m. (158/72 mmHg),5/8 at 7:29 a.m. (155/87 mmHg) and 4:56 p.m. (161/73 mmHg),5/7 at 3:20 p.m. (157/72 mmHg),5/6 at 6:41 a.m. (153/73 mmHg),5/5 at 6:28 a.m. (168/62 mmHg),5/4 at 5:23 p.m. (182/81 mmHg) and 5:34 p.m. (153/73 mmHg),5/3 at 6:36 a.m. (172/80 mmHg), and5/2 at 6:43 a.m. (153/74 mmHg).During an interview on 5/20/2026 at approximately 11:50 a.m., the Director of Nursing (DON) stated she expects nursing staff to follow provider orders for all as needed blood pressure medications. The DON acknowledged that Resident 16 had repeated elevated systolic blood pressure readings that were above the ordered parameter on numerous occasions and were not treated. She confirmed that the PRN hydralazine should have been administered when the resident met the required SBP threshold, and acknowledged the medication was not given. The DON further acknowledged that failing to administer the ordered PRN antihypertensive medication placed the resident at risk for complications related to untreated elevated blood pressureDuring a review of the facility's policy and procedure, titled, Physician Orders, revised October 2025, indicated, The licensed staff shall carry out physician/nurse practitioner's orders as prescribed. Further review indicated, Orders for medications may include: a. Name and strength of the drug. b. Number of doses, start and stop date, and/or specific duration of therapy. c. Dosage and frequency of administration. d. Route of administration. e. Clinical condition or symptoms for which the medication is prescribed.

Based on observations, interview, and record review, the facility failed to ensure that two out of 19 sampled residents (Resident 7 and Resident 85) received an ongoing activity program that met their psychosocial needs (a combination of mental health, emotional, spiritual, or behavioral needs important to a person), as required by their comprehensive plans of care. The facility did not maintain documentation showing that either resident received ongoing activities.This failure placed both residents at risk for psychosocial, emotional, spiritual, and mental decline and prevented them from achieving their highest practicable well being.Findings:1a. A review of Resident 7's clinical record indicated Resident 7 was admitted March of 2026 and had diagnoses that included metabolic encephalopathy (a condition where the brain does not receive enough nutrients or oxygen to function properly, leading to altered brain function), cerebral infarction (damage to a part in the brain due to a disrupted blood flow), dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities), and muscle weakness.A review of Resident 7's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 3/26/26, indicated Resident 7 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 10 out of 15 which indicated Resident 7 had a moderately impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 7's MDS Preferences for Customary Routine and Activities, dated 3/26/26, indicated it was very important for Resident 7 to do his favorite activities, and it was somewhat important for Resident 7 to listen to music he like. A review of Resident 7's care plan, dated 3/25/26, indicated, Activities- Customary Routine: [Resident 7] has preferences for customary routine and activities including Watching TV, Game shows, and phone to talk tofamily .Provide activity materials like books, magazines, TV, radio, arts and crafts .in accordance with resident's interest .Support [Resident 7] choices for preferences regarding customary routine and activities.A review of Resident 7's ACTIVITY ASSESSMENT, dated 3/24/26, indicated, [Resident 7] prefers independent leisure activities in his room due to his illness. Watch TV, Watching Game shows with his wife. Talking on his cell phone .During an observation on 5/18/26 at 8:54 a.m. of Resident 7, in Resident 7's room, Resident 7 was observed awake and lying on his bed. Resident 7 did not respond to greetings. There was no music playing in the room, the TV was off, and there were no books, magazines, radio, or phone noted in the room.During an observation on 5/19/26 at 10:17 a.m. of Resident 7, in Resident 7's room, Resident 7 was observed lying on his bed, eyes closed, and breathing was unlabored (something natural, flowing, or relaxed, and doesn't require effort). There was no music playing in the room, the TV was off, and there were no books, magazines, radio, or phone noted in the room.During another observation on 5/19/26 at 3:36 p.m. of Resident 7, in Resident 7's room, Resident 7 was observed lying on his bed, eyes closed, and breathing was unlabored. There was no music playing in the room, the TV was off, and there were no books, magazines, radio, or phone noted in the room.During an observation on 5/20/26 at 9:45 a.m. of Resident 7, in Resident 7's room, Resident 7 was observed lying on his bed, eyes closed, and breathing was unlabored. There was no music playing in the room, the TV was off, and there were no books, magazines, radio, or phone noted in the room.During a concurrent interview and record review on 5/20/26 at 12:21 p.m. with the Activities Director (AD), Resident 7's activity records were reviewed. The AD confirmed that there were no records that Resident 7 was provided with any ongoing activity that meets his psychosocial needs. The AD stated that Resident 7's preferred activities should have been provided to maintain his psychosocial wellbeing.1b. A review of Resident 85's clinical record indicated Resident 85 was admitted December of 2022 and had diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions causing memory loss and confusion), dementia, and muscle weakness.A review of Resident 85's MDS Cognitive Patterns, dated 1/8/26, indicated Resident 85 had a BIMS score of 5 out of 15 which indicated Resident 85 had a severely impaired cognition. A review of Resident 85's MDS Preferences for Customary Routine and Activities, dated 1/8/26, indicated it was very important for Resident 85 to have books, newspapers, and magazines to read, to listen to music she likes, to do her favorite activities, to participate in religious services or practices, and it was somewhat important to be around animals such as pets.A review of Resident 85's care plan, revised 4/7/25, indicated, ACT [activity] 1:1 [one-on-one]: [Resident 85] prefers to engage in activities such as: watching TV in bed, 1:1 in room visits. Dx [diagnosis] of Alzheimer's . A further review of Resident 85's care plan goals and interventions, revised 1/2/25, indicated, [Resident 85] has Dx Alzheimer's, she needs reminders for activities, 1;1 in room visits are in place .Offer one-to-one activity visits and ask reminiscing/open-ended questions about: Encourage to attend a group activities of interest .Offer supplies and equipment needed.A review of Resident 85's ACTIVITY PARTICIPATION REVIEW, dated 4/7/26, indicated, [Resident 85] enjoys art work, crafting and watching movies.During an observation on 5/18/26 at 10:19 a.m. of Resident 85, in Resident 85's room, Resident 85 was observed awake and lying on her bed. The TV was off, and there were no art or crafting materials noted in the room.During an observation on 5/19/26 at 10:10 a.m. of Resident 85, in Resident 85's room, Resident 85 was observed awake and lying on her bed. The TV was off, there was no music playing in the room, and there were no books, magazines, radio, art or crafting materials noted in the room.During an observation on 5/20/26 at 9:50 a.m. of Resident 85, in Resident 85's room, Resident 85 was observed awake and lying on her bed. The TV was off, there was no music playing in the room, and there were no books, magazines, radio, art or crafting materials noted in the room.During a concurrent interview and record review on 5/20/26 at 12:21 p.m. with the AD, Resident 85's activity records were reviewed. The AD confirmed that there were no records that Resident 85 was provided with any ongoing activity that meets her psychosocial needs. The AD stated that Resident 85 would be at risk for psychosocial decline and activity decline which may lead to depression if an ongoing activity program was not provided.During an interview on 5/20/26 at 2:58 p.m. with the Director of Nursing (DON), the DON stated that an ongoing activity program should be provided to the residents. The DON further stated that residents would be at risk for isolation, psychosocial decline, and mental health concerns if an ongoing activity program was not consistently provided.A review of the facility's policy and procedures (P&P) titled, Activity Programs, revised 10/2025, indicated, Activity programs are designed to meet the interests of and support the physical, mental and psychosocial wellbeing of each resident .2. Activities offered are based on the preferences of residents. 3. The Activities Program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities .6. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting of the programs .9. Activities are documented in the resident's medical record .11. Individualized and group activities are provided that: a. Reflect the choices of the residents .A review of the facility's P&P titled, Individual Activities and Room Visit Program, revised 10/2025, indicated, Individual activities will be provided for those residents whose situation or condition prevents participation in other types of activities, and for those residents who do not wish to attend group activities. Residents who are able to maintain an independent program will have supplies available to them .1. Individual activities are provided for individuals who have conditions or situations that prevent them from participating in group activities, or who do not wish to do so. 2. For those residents whose condition or situation prevents participation in group activities, and for those who do not wish to participate in group activities, the activities program provides individualized activities consistent with the overall goals of an effective activities program. 3. Individualized activities offered are reflective of the resident's activity interests, as identified in the activity assessment, progress notes and the resident's comprehensive care plan. 4. It is recommended that residents with in-room activity programs receive, at a minimum, three in-room visits per week. A typical in-room visit is ten to fifteen minutes in length, but may be longer if appropriate for the resident .6. Residents who choose not to attend group activities are encouraged to participate in independent activities. It is the responsibility of the facility and the activity staff to make regular contact with residents who choose to pursue independent activities, maintain appropriate records and offer supplies, as needed.

Based on interview and record review, the facility failed to provide treatment and services necessary to maintain or improve range of motion (ROM) and mobility for one of 19 sampled residents (Resident 10) when the facility did not follow the physician ordered Restorative Nursing Program (RNA program-program- interventions that actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning) frequency for active range of motion (AROM) and bed mobility exercises.This failure had the potential for Resident 10 to experience decline in ROM, decreased mobility, and failure to achieve her highest practicable well being.Findings:A review of Resident 10's clinical record indicated Resident 10 was admitted in December 2025 with diagnoses that included metabolic encephalopathy (a condition where the brain does not receive enough nutrients or oxygen to function properly, leading to altered brain function), cerebral infarction (damage to a part in the brain due to a disrupted blood flow), absence of left leg below knee, and muscle weakness.A review of Resident 10's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 5/8/26, indicated Resident 10 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 12 out of 15 indicating moderately impaired cognition. The MDS Functional Abilities dated 5/8/26 indicated Resident 10 was dependent for toileting hygiene, shower/bathing self, lower body dressing, putting on/taking off footwear, and personal hygiene, and needed substantial/maximal assistance with oral hygiene and upper body dressing. The MDS also showed substantial/maximal assistance was needed for rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, and chair/bed to chair transfers.A review of Resident 10's care plan, dated 2/22/26, indicated, Restorative Nursing- Range of Motion: Resident [Resident 10] at risk for decline and/ or complications with range of motion in joints, decreased mobility and movement, decreased muscle strength, decreased functional use of extremity, pain, deformity, contracture, and/or skin breakdown. Requires a restorative nursing range of motion program to lower extremities, upper extremities.A review of active physician's orders dated 4/22/26 indicated the following: RNA for AROM Program: BUE (bilateral upper extremities) & BLE (bilateral lower extremities) 3x/wk or as tolerated. as needed 3x/wk. RNA for Bed Mobility Program: Supine <> Sitting EOB (edge of bed) 3x/wk or as tolerated. as needed 3x/wk.During an interview on 5/18/26 at 8:22 p.m., Resident 10 stated she was very upset because she was not receiving the RNA program she had been referred to. She stated she only received one exercise last weekend, although she was supposed to receive exercises three times a week. She stated she needs to get her exercises so she could get better.During a concurrent interview and record review on 5/19/26 at 11:55 a.m. with Restorative Nurse Assistant (RNA) 1, Resident 10's RNA flowsheet for the past 30 days were reviewed. RNA 1 confirmed that Resident 10 only received AROM of BLE and LUE on 4/20, 4/21, 4/25, 4/26, 4/27, 4/30, 5/5, 5/6, and 5/17. RNA 1 also confirmed that Resident 10 only received bed mobility exercise one time on 5/17. RNA 1 further confirmed that Resident 10 did not get his exercises in accordance with the ordered RNA program frequencies which were three times a week and there were no documented refusals of Resident 10. RNA 1 stated the RNA frequency order should have been followed in order for Resident 10 to maintain and improve her mobility function. RNA 1 further stated there would be a risk for decline in range of motion if Resident 10's RNA program frequency was not followed.During an interview on 5/20/25 at 1:30 p.m. with the Director of Staff Development (DSD), the DSD stated RNA program frequency should have been followed and there should always be documentation if the resident refused. The DSD further stated Resident 10 would be at risk for contracture and decline in mobility if the RNA program was not followed.During an interview on 5/20/26 at 2:58 p.m. with the Director of Nursing (DON), the DON stated that she would expect that RNA program frequency would be followed. The DON further stated that the resident would be at risk for functional decline if the RNA program frequencies were not followed.A review of the facility's policies and procedures titled, RNA Program, dated 8/2025, indicated, 1. Facility should have designated certified and trained RNA staff to fully provide the RNA treatment as recommended for each resident based on current RNA caseload .4. Upon completion of the screen, if therapy identifies that there is a need for a restorative program, nursing staff will obtain order for therapy evaluation. 5. RNA to be provided per physician's order .

Based on observation, interview, and record review, the facility failed to ensure emergency kits (e kits) were replaced within the facility's required timeframe and failed to prevent staff from removing medications from previously opened e kits. This deficient practice had the potential to result in medications not being available when needed for residents.Findings:During an observation, inspection, and concurrent interview on 5/18/2026 at 9:34 a.m., I inspected the medication room with Supervisor Nurse (S LN). I observed three refrigerated e kits stored in the white medication refrigerator labeled Station 2. Two of the e kits had red plastic ties, indicating they had been opened, and one e kit remained sealed. I opened the two e kits with the red plastic ties for inspection. One e kit contained a log indicating it had been opened that morning. The second e kit contained two logs documenting medication removal on 5/6/26 at 2:00 p.m. and 5/17/26 at 4:16 p.m. S LN confirmed the observations and stated that e kits were required to be replaced and returned to the pharmacy within 72 hours of being opened. During an interview on 5/20/2026 starting at 11:04 a.m., with the Director of Nursing (DON), the DON stated that e kits needed to be replaced within 3 days of being opened. The DON acknowledged that medication might not be available to residents in need when opened e kits were not returned to the pharmacy in a timely manner. The DON also acknowledged that staff must not access or obtain medications from a previously opened e kit. During a review of the facility's policy and procedure titled, Emergency Kits, reviewed October 2025, indicated, .E. When an emergency or starter dose of a medication is needed, the nurse breaks the container seal and removes the required medication. F. As soon as possible, the nurse records the medication use on the medication order form and notifies the pharmacy for replacement of the kit. The nurse flags the kit with a red color-coded lock to indicate the need for replacement of kit.H. If exchanging kits, when the replacement kit arrives, the receiving nurse gives the used kit to the pharmacy personnel for return to the pharmacy. I. If exchanging kits, opened kits are placed with sealed kits within 72 hours of opening.

Based on observation, interview, and record review, the facility failed to ensure an opened foil medication pouch containing budesonide ampules (an inhaled medication used to reduce airway inflammation) for Resident 28 which was observed stored in 2B Medication Cart (one of two medication carts sampled) was labeled with the date it was opened, as required by manufacturer specifications and the facility's policies and procedures. This failure created the potential for administering expired or ineffective medication to Resident 28.Findings:During an inspection of the 2B Medication Cart on [DATE] at approximately 10:20 a.m. with Licensed Nurse (LN 3), an opened and undated foil pouch of budesonide prescribed for Resident 28 was observed stored in the cart. LN 3 reviewed the manufacturer's labeling on the pouch which indicated, once the foil envelope is opened, use the ampules within two weeks. Date Opened______ He stated he would discard the medication because he did not know when it expired. He acknowledged the pouch had not been dated when it was opened.During an interview with the Director of Nursing (DON) on [DATE] starting at 11:04 a.m. the DON reviewed pictures of the opened foil pouch with the manufactures labeling instructions. The DON acknowledged the medication pouch should have been dated when it was opened.During a review of the facility's policy and procedure, titled, Medication Storage and Labeling, reviewed [DATE], indicated, Medications are labeled in accordance with applicable federal and state requirements and currently accepted pharmacy practices.Review of the prescribing instructions for budesonide, revised [DATE], indicated, How should I store budesonide inhalation suspension? Budesonide inhalation suspension vials can be stored for 2 weeks after opening the protective aluminum foil envelope. Further indicated, Patient Instructions for Use: 1. Budesonide inhalation solution comes in a sealed protective aluminum foil envelope.Record the date that you opened the foil in the space provided on the envelope

Based on observation, interview, and record review, the facility failed to follow the prepared menu and did not meet the nutritional needs of two out of 19 sampled residents (Resident 21 and Resident 5) when staff did not serve Resident 21 and Resident 5 an 8 fl oz (fluid ounce- unit of volume used to measure liquids) of milk during 5/18/26 lunch meal. This failure had the potential to result in Resident 21 and Resident 5 not meeting and maintaining their nutritional needs and achieving their highest practicable wellbeing. Findings:1a. A review of Resident 21's clinical record indicated Resident 21 was admitted May of 2024 and had diagnoses that included diabetes (elevated sugar in the blood), severe protein-calorie malnutrition (PCM- a severe nutritional deficiency where inadequate intake of protein and calories leads to dangerous changes in body composition, function, and weight loss), and dementia (memory loss that interferes with daily functions).A review of Resident 21's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 2/24/26, indicated Resident 21 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 7 out of 15 which indicated Resident 21 had a severely impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 5's MDS Functional Abilities, dated 2/24/26, indicated Resident 21 needed set-up or clean-up assistance with eating.A review of Resident 21's active physician's order, dated 11/24/25, indicated, Regular diet .Minced and Moist texture [of food] .Thin consistency [of liquids] .A review of Resident 21's NUTRITIONAL RISK REVIEW (QUARTERLY), dated 2/23/26, indicated, Regular diet .Minced and Moist texture .Thin consistency .continue current plan of care .A review of Resident 21's Care Plan Report, revised 2/24/26, indicated, Nutritional Risk: [resident 21] is at [x] at risk for .nutritional imbalance related to malnutrition, mechanically altered diet, therapeutic diet .A review of Resident 21's Care Plan Report, revised 2/24/26, indicated, Malnutrition: Resident has a diagnosis of protein calorie malnutrition .Intake is variable, limited by cognitive andfunctional deficits. h/o [history of] wt [weight] loss .increased needs for wt gain/v. protein repletion .altered nutrition .During a concurrent observation and interview on 5/18/26 at 12:19 p.m. with Resident 21 in the dining room, Resident 21's lunch meal was observed which included a glass of pinkish beverage. Resident 21's meal ticket was checked and indicated, Standing Orders: > 8 fl oz. Beverage > 8 fl oz. Milk. Resident 21 confirmed that she did not receive a glass of milk and stated she wanted her milk, but it was not given to her.During a concurrent observation and interview on 5/18/26 at 12:23 p.m. with the Certified Nurse Assistant (CNA) 2 in the dining room, CNA 2 confirmed that Resident 21 was not served with an 8 fl oz of milk. CNA 2 checked Resident 21's meal ticket and stated that if it was indicated in the meal ticket, then Resident 21's milk should have been provided from the kitchen.1b. A review of Resident 5's clinical record indicated Resident 5 was admitted December of 2025 and had diagnoses that included hemiplegia (complete loss of the ability to move one side of the body) and hemiparesis (partial weakness of one side of the body) following cerebral infarction (damage to a part in the brain due to a disrupted blood flow) affecting left non-dominant side, congestive heart failure (a serious condition in which the heart does not pump blood as efficiently as it should), and dementia.A review of Resident 5's MDS Cognitive Patterns, dated 4/11/26, indicated Resident 5 had a BIMS score of 4 out of 15 which indicated Resident 5 had a severely impaired cognition. A review of Resident 5's MDS Functional Abilities, dated 4/11/26, indicated Resident 5 needed set-up or clean-up assistance with eating.A review of Resident 5's Care Plan Report, revised 12/17/25, indicated, Nutritional Risk (Moderate): Resident is at moderate nutritional risk related to dysphagia [difficulty swallowing] diet .A review of Resident 5's active physician's order, dated 12/23/25, indicated, Regular diet .Pureed texture [smooth, pudding-like consistency of food requiring no chewing] .Thin consistency [of liquids], for Pt [patient] approved for meltable snacks .A review of Resident 5's Care Plan Report, revised 1/7/26, indicated, Malnutrition: Resident is at risk for malnutrition due to end of life processes .A review of Resident 5's NUTRITIONAL RISK REVIEW (QUARTERLY), dated 4/10/26, indicated, Regular diet .Pureed texture .Thin consistency, for Pt approved for meltable snacks .Continue to honor food preferences as arise. Allow adequate time for meals, Assist with meals/fluids as needed, Encourage adequate nutrition and hydration .During a concurrent observation and interview on 5/18/26 at 12:35 p.m. with Resident 5 in Resident 5's Room, Resident 5's lunch meal was observed which included a glass of brownish beverage. Resident 5's meal ticket was checked and indicated, Standing Orders: > 8 fl oz. Beverage > 8 fl oz. Milk. Resident 5 confirmed that he did not receive a glass of milk. Resident 5 stated he wanted some milk, but he was not given any milk.During a concurrent observation and interview on 5/18/26 at 12:37 p.m. with CNA 3 in Resident 5's room, CNA 3 confirmed that Resident 5 was not served with an 8 fl oz of milk. CNA 3 checked Resident 5's meal ticket and stated the milk should have been provided since it was in Resident 5's meal ticket. CNA 3 further stated Resident 5's meal ticket should have been followed. During an interview on 5/20/26 at 1:35 p.m. with the Food Services Director (FSD), the FSD stated standing orders in the resident meal tickets should be followed and be given with the meal. The FSD further stated there would be a risk that residents could not meet their desired intake and supplement for the day if the meal tickets are not followed.During an interview on 5/20/26 at 2:58 p.m. with the Director of Nursing (DON), the DON stated that resident meal tickets should be followed. The DON further stated that the residents would be at risk of nutritional problems if the meal contents are not complete. A review of the facility's policies and procedures titled, DIET ORDERS, dated 2023, indicated, POLICY: Diet orders as prescribed by the Physician will be provided by the Food & Nutrition Services Department. PROCEDURE: Nursing will send a Diet Order Communication slip to the Food & Nutrition Services Department. The FNS Director or [NAME] in charge will make or adjust the diet profile and tray card as prescribed .

Based on observation, interview, and record review, the facility failed to provide the appropriate assistive eating utensil to one out of 19 sampled residents (Resident 85) when staff did not provide Resident 85 with a scoop plate (an adaptive, high-walled dish designed to help individuals with limited motor skills, tremors, or single-hand dexterity to eat independently) during the 5/18/26 lunch meal. This failure had the potential to result in Resident 85 being unable to independently eat properly which could have caused nutritional problems.Findings:A review of Resident 85's clinical record indicated Resident 85 was admitted December of 2022 and had diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions causing memory loss and confusion), dementia (memory loss that interferes with daily functions), moderate protein-calorie malnutrition (PCM- a severe nutritional deficiency where inadequate intake of protein and calories leads to dangerous changes in body composition, function, and weight loss), and muscle weakness.A review of Resident 85's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 1/8/26, indicated Resident 85 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 5 out of 15 which indicated Resident 85 had a severely impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 85's MDS Functional Abilities, dated 1/8/26, indicated Resident 85 needed supervision or touching assistance with eating.A review of Resident 85's care plan, revised 1/7/25, indicated, Malnutrition: [Resident 85] is at risk for malnutrition due to .dementia .malnutrition.A review of Resident 85's active physician's order, dated 1/7/26, indicated, Fortified diet [foods or drinks that have had extra vitamins, minerals, or proteins deliberately added to them] .Regular texture [of food] .Thinconsistency [of liquids].A review of Resident 85's NUTRITIONAL RISK REVIEW, dated 4/9/26, indicated, Adaptive Feeding Equipment SCOOP PLATE to be provided during all meals to facilitate independence with self-feeding .Continue plan of care Allow adequate time for meals, Assist with meals/fluids as needed, Encourage adequate nutrition and hydration.During a concurrent observation and interview on 5/18/26 at 12:44 p.m. with Resident 85 in Resident 85's Room, staff served Resident 85's lunch meal on a regular white dinner plate. Resident 85 displayed weak and unsteady hands while attempting to scoop food from the plate.Review of Resident 85's meal ticket showed the instruction: Adap. [adaptive] Equip Scoop Plate. Resident 85 confirmed the scoop plate was not provided and stated that having the scoop plate would have helped scoop food properly and prevented the meal tray from becoming cluttered.During a concurrent observation and interview on 5/18/26 at 12:46 p.m. with Certified Nurse Assistant (CNA) 3 in Resident 85's room, CNA 3 confirmed that staff did not provide a scoop plate. CNA 3 reviewed the meal ticket and stated that Resident 85 should have received a scoop plate with every meal.During an interview on 5/20/26 at 1:35 p.m. with the Food Services Director (FSD), the FSD stated that adaptive equipment listed on a resident's meal ticket should be provided with every meal to support the resident's independence with eating. The FSD further stated that residents could not eat properly if required adaptive equipment was not provided.During an interview on 5/20/26 at 2:58 p.m. with the Director of Nursing (DON), the DON stated that adaptive eating utensils should always be provided to residents requiring such equipment in order to promote their independence with eating.A review of the facility's policies and procedures titled, Assistance with Meals/Mealtime Policy, dated 10/2025, indicated, Residents Who May Benefit from Assistive Devices: 1. Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may include devices such as silverware with enlarged/padded handles, plate guards, and/or specialized cups. 2. Assistance will be provided to ensure that residents can use and benefit from special eating equipment and utensils .

Based on observation, interview and record review, staff failed to provide a clean environment for residents when one of three outside dumpsters did not keep waste properly contained with the lid closed.This failure created the potential for an unsafe environment due to garbage storage area not being maintained in a sanitary condition to prevent a fly, rodent, or pest infestation that could spread diseases in the facility.Findings:During a concurrent observation and interview on 05/18/2026 at 8:35 a.m., the Food Services Director confirmed the top of one of three outside dumpsters was not closed. The Food Services Director verified that a piece of a bike from the rehab department was sticking up and out of the dumpster, preventing it from being properly closed.During an interview on 05/20/2026 at 10:25 a.m., the Food Services Director confirmed that garbage dumpsters not being closed attracted flies, bugs, and rodents. The Food Services Director confirmed the lid had not been closed.During a review of the facility's policy and procedure (P&P) titled: Garbage and Refuse Disposal, dated September 2025, the P&P indicated: Garbage and refuse containing food wastes will be stored in a manner that prevents pests. Outside dumpsters provided by garbage pickup services will be kept closed.

Based on observation, interview, and record review, the facility did not follow and maintain an effective infection prevention and control program for one out of 19 sampled residents (Resident 5) when a visiting hospice staff did not wear the required personal protective equipment (PPE) during high-contact care for Resident 5, who was on enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] by targeted gown and glove use).This failure increased the risk of cross contamination and exposed Resident 5 to germs and infection.Findings:A review of Resident 5's clinical record indicated that Resident 5 was admitted in December 2025 and had diagnoses including hemiplegia (complete loss of the ability to move one side of the body) and hemiparesis (partial weakness of one side of the body) following cerebral infarction (damage to a part in the brain due to disrupted blood flow) affecting the left non-dominant side, congestive heart failure (a serious condition in which the heart does not pump blood as efficiently as it should), and dementia (memory loss that interferes with daily functions).A review of Resident 5's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 4/11/26, showed that Resident 5 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 4 out of 15, indicating severely impaired cognition (mental process of acquiring knowledge and understanding).A review of Resident 5's care plan, dated 2/9/26, showed that Resident 5 required enhanced barrier precautions during high-contact resident care activities due to the history of infection or colonization (the process where microorganisms grow/multiply in or on a host without invading host tissues or causing disease) with a MDRO. The care plan intervention, dated 4/10/26, instructed staff to utilize PPE (gown and gloves; face-shield as indicated) during high-contact resident care activities, including dressing, bathing/showering, transferring, hygiene, brief changes, and toileting assistance.A review of Resident 5's active physician's order, dated 2/17/26, directed staff to use Enhanced Barrier Precautions for ADLs (activities of daily living), hygiene, toileting, and transferring/repositioning every shift for EBP.A review of Resident 5's active physician's order, dated 4/1/26, directed staff to cleanse excoriation (an injury where the outer layers of the skin are removed) on the left buttocks with soap and water, pat dry, apply triad (a type of wound dressing), and cover with foam dressing every day shift for excoriation on the left buttocks.During an observation on 5/18/26 at 9:40 a.m. in Resident 5's room, a staff member provided ADL and hygiene care to Resident 5 while wearing only gloves and not a gown. EBP signage was posted in front of Resident 5's room, indicating that for six groups of care activities, staff should use hand hygiene, gloves, and gowns for residents on Enhanced Standard Precautions, including morning and evening care, toileting and changing incontinence briefs, and mobility assistance.During a subsequent interview on 5/18/26 at 9:52 p.m. with Visiting Hospice Aide (VHA), the VHA confirmed that she wore only gloves while providing ADL and hygiene care to Resident 5. The VHA stated that she provided a partial bed bath, washed Resident 5's face, provided incontinence care, applied cream to Resident 5's bottom, and changed Resident 5's gown. The VHA stated she was not aware that Resident 5 was on EBP or that signage regarding EBP was posted in front of Resident 5's room. The VHA further stated that no facility staff informed her that Resident 5 was on EBP.A review of the list of residents on EBP, provided by the Infection Preventionist (IP) on 5/19/26 at 9:57 a.m., showed that Resident 5 was on EBP due to a chronic wound.During an interview on 5/20/26 at 1:44 p.m. with the IP, the IP stated that she expected staff and visiting hospice staff caring for residents to be aware of EBP and to always wear the required PPE when performing high-contact care for residents on EBP. The IP stated that failure to wear the required PPE could expose the resident to germs and potential infection.During an interview on 5/20/26 at 2:58 p.m. with the Director of Nursing (DON), the DON stated that staff should follow EBP and wear both gloves and gown when providing high-contact care to a resident on EBP to prevent cross contamination and possible infection of the resident.A review of the facility's policies and procedures titled, Multidrug-Resistant Organisms; Infection Precaution & Enhanced Standard Precautions, dated 10/2025, indicated, Appropriate precautions are taken when caring for individuals known to or suspected to have infection with a multidrug-resistant organism .Infection Precautions .b. EBP is used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .c. EBP are indicated for residents with any of the following: 1. Infection or colonization with MDRO when Contact Precautions do not otherwise apply; or 2. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .

Based on observation, interview and record review, the facility failed to ensure the call light system was functioning properly for 2 residents (Resident 1 and Resident 2) residing in room [ROOM NUMBER]. This failure had the potential to result in residents' needs not being met and prevent residents' communication for assistance when needed. Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated Resident 1 was admitted on [DATE] with diagnoses which included displaced comminuted fracture of left patella (kneecap was broken into multiple pieces and pieces were not properly aligned). During a review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), the MDS indicated Resident 1 had moderate cognitive impairment. During a review of Resident 2 ' s AR, the AR indicated Resident 2 was admitted on [DATE] with diagnoses which included surgical aftercare following surgery on the digestive system. During a review of Resident 2 ' s MDS, the MDS indicated Resident 2 had moderate cognitive impairment. During a concurrent observation and interview on 5/9/25 at 10:57 a.m. with Resident 1 in room [ROOM NUMBER], Resident 1 ' s call light was activated but the light above the door did not turn on, and the call light panel at the nurse ' s station did not show the call. Resident 1 stated the call light had not worked since she was admitted and that she was not given a call bell. Resident 1 said she waited for someone to walk by her room and called out when she needed help. During an interview on 5/9/25 at 11:06 a.m. with Resident 2, Resident 2 stated she had experienced problems with her call light not working. Resident 2 stated that when she pushed the button, most of the time no one came, and sometimes she waited up to two hours for assistance. During a concurrent observation and interview on 5/9/25 at 11:11 a.m. with the Director of Nursing (DON), Resident 1 ' s call light was activated, but the light above the door did not turn on. DON confirmed that the call light was not working. During a concurrent observation and interview on 5/8/25 at 11:16 a.m. with Director of Staff Development (DSD) in room [ROOM NUMBER], DSD stated the button on the call light cord was not working. The DSD was observed replacing it with a new cord. The DSD then activated the call light using the new cord and confirmed that it was still not working. During a concurrent observation and interview on 5/9/25 at 11:39 a.m. with Registered Nurse (RN) 1 in room [ROOM NUMBER] ' s bathroom, RN 1 pulled the string for the emergency call light in the restroom, but it did not turn on. RN 1 attempted to activate it three more times, but it still did not work. RN 1 stated the call light was not working, and explained that if it was working, there would be a beeping sound, the light on the panel in the bathroom would turn on, and the light above the room door would illuminate. At 11:43 a.m. RN 1 attempted to activate the call light again. The first two attempts did not work. On the third attempt, RN 1 pulled the string down hard, and the call light activated. RN 1 stated that the string had to be pulled very hard for it to work and that it needed to be fixed. RN 1 stated that the call light should be activated easily. RN 1 stated that bathroom call lights are important for resident safety so that residents can call for help when they need assistance. During an interview on 5/9/25 at 12:09 p.m. with DON, DON stated the expectation is for call lights to always be functioning. The DON stated call lights are in place for resident safety and to allow staff to respond to residents ' needs. The DON stated that if a call light is not working, or if it is difficult to activate, it could lead to potential harm. During a review of the facility ' s policy and procedure (P&P) titled, Call Systems, Residents dated 9/22, the P&P indicated, .the resident call system remains functional at all times .

Based on observation, interviews, and record review, the facility failed to ensure the planned menu was followed for the therapeutic diets (modified diets from regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) during lunch on 3/12/25 when: 1. 19 Residents (Resident (3, 4, 5, 7, 22, 29, 33, 35, 47, 52, 56, 63, 66, 68, 75, 79, 82, 291, and 341) with regular portion with regular texture diets got 6 ounces (oz.) (3/4 cup) of pasta instead of 4 oz. (1/2 cup) 2. 11 residents (Resident 19, 23, 24, 30, 32, 36, 44, 57, 60, 72, and 85) with CCHO (Consistent Carbohydrate) diet (a therapeutic diet to manage diabetic disease and/or to stabilize blood sugar level) and CCHO Renal (kidney) diet (a diet to manage chronic kidney disease and diabetic disease) got one serving of dessert (lemon snow bar) and 6 oz. of pasta instead of half (1/2) serving of dessert and 4 oz. of pasta 3. Four residents (Resident 9, 34, 76, and 340) with small portion with diets received one serving of dessert, 6 oz. of pasta and 6 oz. chicken instead of 1/2 serving of dessert, 4 oz. of chicken and 2 oz. (1/4 cup) of pasta 4. Two residents (Resident 17 and 58) with fortified (add extra calories and nutrients) diet (diet designs for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status) did not receive 1/2 oz. of melted margarine on the vegetables 5. Three residents (Resident 14, 65 and 73) with finger food diet did not receive the dessert cut in half 6. 88 out of 88 residents who received meals form the facility kitchen did not receive garnish (food decor to enhance the presentation of meals to help increase appetite) with their lunch meals. These deficient practices had the potential to result in residents having meals which did not meet their nutritional needs and compromising the medical and nutrition status of the 88 residents who consumed meals from the facility kitchen. Findings: During the lunch meal distribution on 3/12/25 beginning at 11:52 a.m., it was noted as followed: Observed there were one kind of serving utensils (6 oz.) for serving chicken and pasta, and a concurrent interview with [NAME] (CK) to confirm both serving sizes were 6 oz. For the dessert (lemon snow bar, one serving measurement: 2 inches long x 2 inches wide x 1/2 inch height), CK stated she prepared only one serving size for all the residents. 1. 19 residents (Resident 3, 4, 5, 7, 22, 29, 33, 35, 47, 52, 56, 63, 66, 68, 75, 79, 82, 291 and 341) with regular portion with regular texture received 6 oz. of pasta. A concurrent review of facility spreadsheet (a menu excel sheet that indicated what items and portions to be served for each prescribed diet) titled, Spring Cycle Menus, Week 2 Wednesday, indicated regular portion with regular texture should receive 1/2 cup (4 oz.) of pasta. 2. 11 residents (Resident 19, 23, 24, 30, 32, 36, 44, 57, 60, 72 and 85) with CCHO and CCHO Renal diet received one serving of dessert and 6 oz. of pasta. A concurrent review of facility spreadsheet titled, Spring Cycle Menus, Week 2 Wednesday, indicated CCHO and CCHO Renal diet should receive 1/2 serving of dessert and 4 oz. of pasta. 3. Four residents (Resident 9, 34, 76 and 340) with small portion with diets got one serving of dessert, 6 oz. of pasta and 6 oz. of chicken. A concurrent review of facility spreadsheet titled, Spring Cycle Menus, Week 2 Wednesday, indicated small portion with diets should receive 1/2 serving of dessert, 2 oz. of pasta and 4 oz. of chicken. 4. Two residents (Resident 17 and 58) with fortified diets did not receive extra 1/2 oz. of melted margarine on the vegetables as fortified food. A concurrent review of facility document titled, Spring 2025 - Week 2, Fortified Breakfast, Fortified Lunch, Fortified Dinner, indicated fortified diet should give extra 1/2 oz. of melted margarine on the vegetables for lunch 3/12/25. 5. Three residents (Resident 14, 65 and 73) with Finger Food diet receive one whole piece of dessert. A concurrent review of facility spreadsheet titled, Spring Cycle Menus, Week 2 Wednesday, indicated finger food diet should receive one serving of dessert cut in half. 6. 88 out of 88 residents who received lunch meals from facility kitchen did not get parsley garnish. A concurrent review of facility spreadsheet titled, Spring Cycle Menus, Week 2 Wednesday, indicated all diets should have received parsley garnish. An interview with Dietary Manager (DM) and a concurrent review of the spreadsheet on 3/12/25 at 1:19 p.m. was conducted. DM acknowledged and confirmed the issues found during the meal distribution. He stated his expectation for the staff should be accurate for the portion measurement of the food, and they should follow the menu or spreadsheet according to the therapeutic diets. During an interview with Registered Dietitian (RD) on 3/13/25 at 12:27 p.m., RD acknowledged issues that were found during the meal distribution on 3/12/25. RD stated the staff should follow the menu and spreadsheet because it would provide the correct portions for the according therapeutics diets. She further explained especially for CCHO diet, the portion sizes were to control blood sugar level. RD stated if the portion sizes are not being followed would lead to over- or under- nutrition. She explained the fortified foods provided extra calories for the residents had weight loss or to stabilize weight. RD further stated the finger foods were given for the residents with mobility issues and helped them to maintain independence during eating. A review of the facility's policy and procedure titled, Menu Planning dated 2023, it indicated, .menus are planned to meet nutritional needs of residents in accordance with established national guidelines .the facility's diet manual and diets are ordered by the physician should mirror the nutritional care provided by the facility .menus are written for regular and therapeutic diets in compliance with the diet manual . A review of facility document titled, Job description, Cook, dated 10/2016, indicated the cook was to follow prepared menus and portion control guides .prepare special diets accurately .make the presentation of the food appealing to the residents .

Based on observation, interview and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food serve in a safety manner when: 1. Various sizes of metal pans were found having issues stored in the clean and ready-to-use storage areas: - Stacked wet - Were not clean with food particles 2. The storage areas for storing the clean and ready-to-use metal pans were not clean 3. The blade of the can opener was not well maintained 4. Dietary Aide (DA) 1 was not able to verbalize the process of manual dishwashing by 2-compartment sink 5. DA 2 was not able to perform cleaning and sanitizing procedure correctly for the soiled food contact surface areas 6. DA 2 was not able to verbalize and demonstrate the correct procedure to prepare and test the sanitizer solution for the red bucket (red color-coded bucket is used as a standard of practice to contain sanitizer solution) 7. DA 3 did not have the hair restraint fully cover the hair 8. There were issues found for the resident's refrigerator: - Residents' food did not label and date properly - Outdated food did not discard in the freezer - The interior of the refrigerator was not clean These failures had potential to cause food-borne illness in a highly susceptible population of 88 out of 88 residents who received food from the facility kitchen. Findings: 1. During a concurrent observation and interview on [DATE] at 8:23 a.m. with Dietary Manager (DM), DM confirmed the following items were stack wet and had food particles stored in the clean and ready-to-use storage areas: - five of full sheet metal pans (stacked wet; 4 out of 5 had red and white particles) - one of ,d+[DATE] sheet metal pan (had red particles) - 10 of ,d+[DATE] sheet metal pans (stacked wet) - 11 of ,d+[DATE] sheet metal pans (stacked wet) DM stated the dishes, pans and pots should be completely dried and clean before stored away. He further stated the staff who put away the dishes should check if they were clean and dried before stored away. During an interview with Registered Dietitian (RD) on [DATE] at 12:27 p.m., RD stated the dishes, pans and pots should be clean and air-dried before stored away. A review of facility policy and procedure (P&P) titled, Dishwashing, dated 2023, indicated, .Dishes are to be air dried in racks before stacking and storing . A review of facility P&P titled, Sanitation, dated 2023, indicated, .all utensils .shall be kept clean, maintained in good repair . 2. During an inspection of the condition of the metal sheet pans stored at the storage areas at [DATE] at 8:46 a.m., it was noted the storage areas (the areas used for storing clean and ready-to-use metal sheet pans) were not clean with particles on them. A concurrent interview with DM, DM confirmed and stated the particles were food debris. He further stated the storage areas should be clean, and the staff usually clean them daily. During an interview with RD on [DATE] at 12:27 p.m., RD stated the storage areas for storing dishes, pans and pots should be clean. A review of facility P&P titled, Sanitation, dated 2023, indicated, .all .counters, shelves .shall be kept clean, maintained in good repair . 3. During a kitchen inspection and a concurrent interview of DM on [DATE] at 10:45 a.m., it was noted the blade of can opener with discoloration and the blade surface was chipped. DM confirmed and stated the blade was chipping away and needed replacement. He further stated it was one of the findings during the facility internal inspection. A review of facility P&P titled, Can Opener and Base, dated 2023, indicated, Proper sanitation and maintenance of the can opener .is important to sanitary food preparation. Metal shavings and shredding can result from a dull cutting blade or worn out cogwheel .Replace blade on can opener, as needed . 4. During an interview on [DATE] at 8:57 a.m. with Dietary Aide (DA) 1, DA 1 stated if the dishwashing machine was not functioning, he would switch to manual dishwashing with 2-compartment sink. DA 1 stated the steps were washing, rinsing and air-dried. He stated No when asked if he was missing a step. A concurrent interview with DM, DM verified and stated the correct process were washing, rinsing, sanitizing and air-dried. DM stated they had a big tub worked as third compartment filled with sanitizer solution for sanitizing step. Asked DA 1 how long the dishes should immerse in the sanitizer after the rinsing step, and he stated 5 to 10 minutes. DA 1 stated he did not know the effective concentration for the sanitizer was when asked. DM cued DA 1 to read the instruction posted on the wall and DM stated the concentration should be at the range of ,d+[DATE] ppm (parts per million - a measurement unit for the sanitizer solution). During an interview with RD on [DATE] at 12:27 p.m., RD stated the dietary staff should have a good knowledge about the manual dishwashing process especially there was an emergency like out of power. A review of facility P&P titled, 3-Compartment Procedure for Manual Dishwashing, dated 2023, indicated the process involved washing, rinsing, sanitizing, and air-dried, and .sanitizer solution .must read ,d+[DATE] ppm .immerse all washed items (in the sanitizer solution) for at least 1 minute (60 seconds) . 5. During a confirmation with DM regarding the storage areas for clean metal pans was not clean with food debris on [DATE] at 8:34 a.m., observed DA 2 used a towel to wipe the storage areas. DA 2 stated she used the towel from the red bucket (bucket contained sanitizer solution) to clean the storage areas. During an interview with DM on [DATE] at 8:45 a.m., DM confirmed DA 2 used the sanitizer to clean the dirty storage areas. He stated the procedure was to sanitize and clean when the food contact surfaces were soiled. Then he switched answer to the correct procedure should be first to clean with soap and water, and then using the sanitizer to sanitize. DM further stated DA 2 did not performed the procedure correctly. A review of department document titled, Inservice: Cleaning and Sanitizing Dishes, Utensils, Pots and Pans, dated ,d+[DATE], indicated, .cleaning and sanitizing of .food contact surfaces .food storage areas are vital in keeping food wholesome and safe to consume .Cleaning is the removal of soils, tarnishes, or stains .Sanitizing is the process of reducing the number of microorganisms on the surface to safe levels so that they cannot cause disease or food spoilage .to be effective, cleaning and sanitizing must be a two-step process. Surface must first be (1) cleaned and rinsed before (2) being sanitized .any surface that comes in contact with food much also be cleaned and sanitized . 6. During an interview with DA 2 on [DATE] at 8:34 a.m., DA 2 verbalized the process to prepare and test the sanitizer solution for the red bucket. DA 2 stated she got the pre-mixed sanitizer solution from the dispenser and then used the test strip to test the effective concentration and stated it should be at ,d+[DATE] ppm. DA 2 demonstrated to use the test strip by dipping the sanitizer solution for more than 15 seconds and took it out to compare the color chart (different colors from the chart corresponds to different concentration (ppm) range includes: 0, 150, 200, 400 and 500) on the test strip container. Then she used the same test strip to dip in the sanitizer solution again. A concurrent confirmation with DM and he stated DA 2 should not dip in the solution again and the test strip should dip in the solution for 10 seconds. DA 2 stated when preparing the sanitizer solution, she usually dipped the test strip for more than 10 seconds because the color would not change. She stated the solution should be cold. The solution was cold when touched and then took the temperature with thermometer and it read 59.7 degrees Fahrenheit (F). DM verified and stated the sanitizer solution should be cold and stated 59.7 degrees F was fine. A concurrent review of the instruction on the test strip container, and it stated, .dip paper (test strip) in quat (sanitizer) solution, not from surface, for 10 seconds .testing solution should be between ,d+[DATE] degrees F . DM stated he was not aware of the temperature range of the sanitizer solution, and he would contact the sanitizer vendor to adjust the temperature. A review of facility P&P titled, Quaternary Ammonium Log Policy, dated 2023, indicated, .Read instructions on quaternary container and the test strip for proper concentration length of time the strip needs to be in contact with the solution, and if temperature of the solution is to be considered when testing for concentration .Follow container and test strip instructions. A high concentration may potentially hazardous and may be a chemical contaminate of food. 7. During a kitchen inspection tour on [DATE] at 10:55 a.m., it was noted DA 3 had a cap on (without any hairnet under the cap) but did not completely cover all his hair. Observed the back of his hair and the side burns on both sides extending outside the cap. A concurrent confirmation with DM and he agreed DA 3's cap did not cover all his hair. DM stated DA 3 should put the hairnet on to completely cover his hair before putting his cap on. A review of facility P&P titled, Dress Code, dated 2023, indicated, .Hat for hair, if hair is short, which completely covers the hair .Hair net for hair, if hair is long (over the ears or longer) . 8. An observation and a concurrent interview with Licensed Vocation Nurse (LVN) 1 regarding the resident's food refrigerator located at nurse station on [DATE] at 2:41 p.m. was conducted. It was noted there were issues found as followed: - The interior of the refrigerator was not clean with dry liquid spills on the bottom of shelf (confirmed with LVN 1 and stated it was dirty) - An opened bag of individual wrapped ice cream cups in the freezer (confirmed with LVN 1 and stated it had no name and received date and should discard) - An opened box of individual wrapped ice cream sandwiches in the freezer (confirmed with LVN 1 and stated it had no resident's name and the manufacture's expired date of [DATE] and should discard) - A tub of chocolate ice cream in the freezer (confirmed with LVN 1 and stated it had resident's name but no received date, stated should discard) - A bag with a popsicle in the freezer (confirmed with LVN 1 and stated it had name but no received date, should discard) - A half-drank drink in paper cup in the freezer (confirmed with LVN 1 and stated it had name but no received date, and needed to be discarded) LVN 1 stated the nurses were responsible to monitor temperature and food of the refrigerator. She further stated the nurses who monitor the refrigerator also responsible to clean the refrigerator. She stated there was no set schedule for the refrigerator to be clean. LVN 1 explained the process of when they received food from the residents' families or visitors, the nurses should label the food with resident's name and received date, and the food would be discarded on the third day from the received date and it also applied to the frozen food. During an interview with LVN 2 on [DATE] at 2:29 p.m., LVN 2 stated the process of receiving food from the family or visitor. He stated the nurses usually put the label on the food with resident's name, room number and received date. LVN 2 stated the food could keep in the refrigerator for three days. He stated he was the PM (post meridiem-after midday) nurse and responsible to monitor the refrigerator at PM shift. He further stated the nurses who monitor the refrigerator also responsible to clean the refrigerator. He stated the housekeeping sometimes would clean the refrigerator too but not sure how often. During an interview with housekeeping (HK) on [DATE] at 3:05 p.m., HK stated housekeeping was not responsible to clean the resident's food refrigerator. During an interview with Director of Nursing (DON) on [DATE] at 3:15 p.m., DON acknowledged the issues found in the resident's food refrigerator. DON stated she was not sure how often the resident's food refrigerator getting clean by the nurses. She further stated may be once a week and deep clean every three months. A review of facility P&P titled, Foods Brought by Family/Visitors, revised ,d+[DATE], indicated, .Perishable foods are stored in re-sealed containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the room number and the use by date .Perishable foods .may be refrigerated for up to 3 days, then will be discarded by staff . A review of facility P&P titled, Refrigerators and Freezers, revised ,d+[DATE], indicated, .Supervisors are responsible for ensuring food items in .refrigerators, and freezers are not past use by or expiration dates .Refrigerators and freezers are kept clean, free of debris, and disinfected with sanitizing by designated staff .

Based on observation, interview, and record review, the facility failed to provide timely assistance with incontinence (a condition where a person experiences involuntary loss of urine or stool) care for four of 25 sampled residents (Resident 23, Resident 339, Resident 340, and Resident 60). This failure resulted in residents not attaining their highest practicable physical, psychosocial, and emotional well-being. Findings: During a review of Resident 23's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 23 was admitted [DATE] with diagnoses including fracture (a break or crack) of left femur (thigh bone). Resident 23's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 2/20/25, indicated Resident 23 had moderate cognitive impairment. Resident 23's self-care functional ability indicated, needed maximum assistance for toileting hygiene (helper does all the effort). The MDS indicated, he is always incontinent. During a review of Resident 23's March 2025 bladder continence task records indicated, 1 incontinence episode on night shift, 2 episodes on evening shift, 2 episodes on day shift. During a review of Resident 23's care plan dated, 3/11/25, indicated, resident at risk for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) decline. There was no documented evidence of a care plan for bladder incontinence. During a review of Resident 339's face sheet, indicated Resident 339 was admitted [DATE] with diagnoses including Spinal stenosis (narrowing of the spinal canal) lumbar (lower back) region, and difficulty walking. Resident 339's MDS, dated [DATE], indicated Resident 339 had moderate cognitive impairment. The MDS indicated, Resident 339's self-care functional ability requires maximum assistance for toileting hygiene. The MDS further indicated, Resident 339 was frequently incontinent. During a review of resident 339's March 2025 bladder continence task records indicated, incontinence throughout all shifts. During a review of Resident 339's care plan, dated 2/27/25, indicated Resident 339 had impaired skin integrity as evidenced by surgical wound at lumbar spine. There was no documented evidence of a care plan for bladder incontinence. . During a review of Resident 340's face sheet, indicated Resident 340 was admitted [DATE] with diagnoses including panniculitis (a condition where the fat layer under the skin becomes inflamed, causing painful bumps, sometimes accompanied by fever), and morbid obesity. Resident 340's MDS, dated [DATE], indicated he had intact cognition. Resident 340's self-care functional ability requires partial assistance for toileting hygiene (helper does less than half). The MDS further indicated, occasionally incontinent. During a review of Residents 340's March 2025 bladder continence task records indicated, 1 incontinence episode for night shift, 2 incontinence episodes for day shift. During a review of Resident 60's face sheet, indicated Resident 60 was admitted [DATE] with diagnoses including enterocolitis (inflammation of both the small intestine, and the colon [large intestine]) due to Clostridium Difficile (C. diff- a highly contagious bacteria that causes severe diarrhea). During a review of Resident 60's MDS dated , 2/17/25, indicated she had moderate cognitive impairment. Resident 60's self-care functional ability requires maximal assistance for toileting hygiene. The MDS further indicated, always incontinent with bowel movement. During a review of Resident 60's March 2025 bowel continence task records indicated, bowel incontinence throughout all shifts. During a review of Resident 60's care plan dated 2/14/25 indicated, Resident 60 had clostridium difficile. The care plan intervention indicated, keep skin clean and dry, provide incontinence care after each episode of loose stool. During a concurrent observation and interview on 3/11/25 at 9:15 a.m. in Resident 60's room, Resident 60 was observed distraught, restless, and was upset. Resident 60 stated, she was just cleaned up after another accident (diarrhea). Resident 60 stated, It took hours to get some help to be cleaned up. I called for help at 7 in the morning. When asked about her pain and discomfort, the resident stated, the pain was triggered when she had an episode of diarrhea. Resident 60 stated the skin at her buttocks and at her groin area felt raw from frequent stooling and said, It feels raw down there. During a concurrent observation and interview on 3/11/25 at 12 noon in Resident 23's room, Resident 23 was up on his wheelchair and supplied with oxygen through nasal cannula. Resident 23 stated, he had an episode of incontinence last night. Resident 23 stated, I did not have a clear path to go to the restroom .there was a walker, and table on my path and I felt restrained. Resident 23 stated, the nurse answered the call light and said, she will be back but never returned. Resident 23 stated, he felt like a child when he had an accident. Resident 23's complaint was corroborated and confirmed by his roommate Resident 340 who had the same complaint. During an interview on 3/11/25 at 1:00 p.m. with Resident 340, Resident 340 stated, he gets angry when he calls for assistance to the bathroom because the staff takes 45 minutes to help him. Resident 340 stated, there was an instance he ended up getting his shorts dirty because the wait was too long and ended up peeing on himself. Resident 340 stated, I was angry .It shouldn't be that way. During a concurrent observation and interview on 3/12/25, at 9:30 a.m. in Resident 339's room, Resident 339 stated, it takes a long time for the staff to come in and help me get up to use the bathroom . She stated, she was wearing a diaper but preferred to get up and use the bedside commode or the toilet. Resident 339 stated, I felt upset and angry because I know when I needed to use the toilet, and they take so long to help me. Resident stated, I feel unvalued. During an interview with LN 3 at 3/12/25, at 9:45 a.m., LN 3 stated, the expectation is that incontinence care was done as soon as possible to keep residents clean and dry. LN 3 stated This will prevent worsening of skin conditions and prevents any skin irritation and infection. During an interview with Physical Therapist 1 (PT 1) at 3/13/25 at 11:25 a.m., PT 1 stated, Resident 339 is improving and should be using bedside commode or toilet. During an interview with LN 4 at 3/13/25, at 11:39 a.m. stated, LN 4 expects that care is provided in a timely manner when residents are incontinent or, responds to their needs to assist them to use the bathroom to prevent any incontinence. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living . dated May 2024, the P&P indicated, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently including appropriate support and assistance with but not limited to . hygiene . mobility . elimination (toileting) .

Based on observation, interview and record review, the facility failed to ensure Dietary Aide (DA) 1 and DA 2 had the appropriate skill set to safely perform the daily operations of the food and nutrition services department when: 1. DA 1 was unable to verbalize the correct process of manual dishwashing with 2-compartment sink (cross refer to F812, #4); 2. DA 2 was unable to perform cleaning and sanitizing procedure correctly for the soiled food contact surface areas (cross refer to F812, #5), and 3. DA 2 was unable to verbalize and demonstrate the correct procedure for testing and proper temperature when preparing the sanitizer solution for the red bucket (red color-coded bucket is used as a standard of practice to contain sanitizer solution) (cross refer to F812, #6). These failures had the potential to place 88 out of 92 highly susceptible residents who consumed food from the facility at risk for food borne illness. Findings: 1. During an interview with DA 1 regarding the process of manual dishwashing by the 2-compartment sink on 3/11/25 at 8:57 a.m., DA 1 stated he would switch to manual dishwashing when the dishwashing machine was not working. He stated the steps were washing, rinsing and air-dried. A concurrent confirmation with Dietary Manager (DM) and stated the correct process were washing, rinsing, sanitizing and air-dried. For the sanitizing step, DA 1 stated the dishes would immerse into the sanitizer solution for 5 to 10 minutes. DA 1 could not state the effective concentration for the sanitizer solution when asked. DM cued DA 1 to read the instruction posted on the wall, and DM stated the concentration should be at the range of 200-400 ppm (parts per million - a measurement unit for the sanitizer solution). A review of facility policy and procedure (P&P) titled, 3-Compartment Procedure for Manual Dishwashing, dated 2023, indicated the process involved washing, rinsing, sanitizing, and air-dried, and .sanitizer solution .must read 200-400 ppm .immerse all washed items (in the sanitizer solution) for at least 1 minute (60 seconds) . 2. During a kitchen observation on 3/11/25 at 8:34 a.m., it was noted the storage areas for clean metal pans was not clean with food debris. Observed DA 2 used a towel to wipe the storage areas. DA 2 stated she used the towel from the red bucket (bucket contained sanitizer solution) to clean the storage areas. During an interview with DM on 3/11/25 at 8:45 a.m., DM confirmed and stated DA 2 used the sanitizer to clean the soiled storage areas. DM stated DA 2 did not performed the procedure correctly. He further stated DA 2 should first clean with soap and water, then using the sanitizer to sanitize. A review of department document titled, Inservice: Cleaning and Sanitizing Dishes, Utensils, Pots and Pans, dated 3/2022, indicated, .cleaning and sanitizing of .food contact surfaces .food storage areas are vital in keeping food wholesome and safe to consume .Cleaning is the removal of soils, tarnishes, or stains .Sanitizing is the process of reducing the number of microorganisms on the surface to safe levels so that they cannot cause disease or food spoilage .to be effective, cleaning and sanitizing must be a two-step process. Surface must first be (1) cleaned and rinsed before (2) being sanitized .any surface that comes in contact with food much also be cleaned and sanitized . 3. A concurrent observation and interview with DA 2 and DM regarding the preparation and testing of the sanitizer solution for the red bucket was conducted on 3/11/25 at 8:34 a.m. DA 2 stated the sanitizer solution was pre-mixed and she got the solution from the dispenser. She stated she would test the effective concentration of the solution by using the test strip and the concentration range should be 200-400 ppm. DA 2 demonstrated how to test the effectiveness of the sanitizer solution. She used the test strip by dipping the sanitizer solution for more than 15 seconds and took it out to compare the color chart (different colors from the chart corresponds to different concentration (ppm) range includes: 0, 150, 200, 400 and 500) on the test strip container. Then she used the same test strip to dip into the solution again. DM confirmed and stated DA 2 should not dip in the solution again and test strip should dip in the solution for 10 seconds. DA 2 stated when she prepared the solution, she usually dipped the test strip in the solution more than 10 seconds because the color would not change. She further stated the solution should be cold. The solution was cold when touch and took the temperature with thermometer with the result was 59.7 degrees Fahrenheit (F). DM verified and stated the solution was fine because it was cold. A concurrent review of the instruction of the test strip container, it stated, .dip paper (test strip) in quat (sanitizer) solution, not from surface, for 10 seconds .testing solution should be between 65-75 degrees F . DM stated he was not aware of the temperature range and would contact the sanitizer vendor to adjust the temperature. A review of facility P&P titled, Quaternary Ammonium Log Policy, dated 2023, indicated, .Read instructions on quaternary container and the test strip for proper concentration length of time the strip needs to be in contact with the solution, and if temperature of the solution is to be considered when testing for concentration .Follow container and test strip instructions. A high concentration may potentially hazardous and may be a chemical contaminate of food. A review of DA 1's employee file, it indicated his date of hire was on 2/28/23 for dietary aide position. Review the job description for dietary aide, it stated the position required food handler's certificate. DA 1's file did not have any certificate. An interview with DM on 3/13/25 at 10:38 a.m., DM confirmed and stated DA 1 did not have any food handler's certificate. A review of DA 2's employee file, it indicated her date of hire was on 2/14/23 for a position as a cook. A review of the job description for a cook, it stated the position required ServSafe (set of training courses for food safety) food handler certificate. DA 2's file did not have any certificate. An interview with DM on 3/13/25 at 10:38 a.m., DM stated D2 should be hired as dietary aide position and not sure why her position changed to be a cook. DM confirmed and stated DA 2 did not have any food handler's certificate. A review of facility documents titled, Verification of Job Competency Demonstration - Diet Aides, for DA 1 and DA 2, both completed for the year of 2024 by DM, indicated DA 1 was competent on Emergency dish washing procedure and when to use it, and DA 2 was competent on How to clean and sanitize equipment, counter top and Sanitizing solution; preparation, test concentration and record results; when to replace solution by demonstration and verbalization. A review of departmental document titled, Food & Nutrition Service In-Service, Topic: Competency Checks Update and Inspection List, completed on 10/28/24 and added on dates of 11/21/24, 12,20/24 and 1/22/25 and given by DM. The document showed DA 1 and DA 2 attended the in-services. There was no individual lesson plans referred to the different competency topics. A concurrent interview with DM on 3/13/25 at 9:22 a.m., DM stated the topic Competency Checks Update and Inspection List was to review everything for the competency subjects to prepare the staff for survey. A review of facility job description titled, Director of Food and Nutrition (DM), dated 2/2018, it stated, .Essential Job Functions .provide .training .oversee that proper levels of cleanliness and sanitation within the department .plan and conduct staff meetings and in-service education programs on dietary policies and procedures .Practice and ensure compliance of infection control policies and procedures of the department and facility .

Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were implemented when: 1. Oxygen tubing was on the floor for Resident 18, Resident 12 and Resident 36. 2. Resident 10's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) tubing was dragging on the floor while on the wheelchair. 3. Tube feeding formula was left uncapped and open to air while disconnected from Resident 45. These failures had the potential to compromise resident's health and safety, and potentially lead to the spread of communicable illnesses. Findings: 1. During a review of Resident 18's Admission Record (AR), the AR indicated, Resident 18 was admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease with acute exacerbation (COPD-a chronic lung disease causing difficulty in breathing), acute respiratory failure with hypoxia (when lungs suddenly can't get enough oxygen into the blood) and asthma (condition in which airways narrow and swell). During a review of Resident 18's Order Summary Report (OSR), printed on 3/12/25, the OSR indicated, Resident 18 had an order for oxygen at 2 liters (unit of measurement) via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) every 8 hours as needed for SOB (shortness of breath), chest pain, O2 sat (oxygen saturation-measurement of how much oxygen the blood is carrying as a percentage); Notify MD if O2 sat <90%. During a review of Resident 12's AR, the AR indicated, Resident 12 was admitted on [DATE] with diagnoses which included acute respiratory failure with hypercapnia (condition that occurs when the lungs can't get rid of enough carbon dioxide from the blood) and COPD. During a review of Resident 12's OSR, printed on 3/12/25, the OSR indicated, Resident 12 had an order for continuous O2 (oxygen) at 4 LPM (liters per minute) via nasal cannula to maintain O2 sat >90%. During a review of Resident 36's AR, the AR indicated, Resident 36 was admitted on [DATE] with diagnoses which included acute and chronic respiratory failure with hypoxia and pleural effusion (buildup of fluid between the tissues that line the lungs and the chest). During a review of Resident 36's OSR, printed on 3/14/25, the OSR indicated, Resident 36 had an order oxygen at 2 L/Min via nasal cannula routine/continuous. During a concurrent observation and interview on 3/11/25 at 8:41 a.m. with Licensed Nurse (LN) 1 in Resident 36's room, Resident 36 was lying on the bed with oxygen in use, and the oxygen tubing was touching the floor. LN 1 confirmed that the oxygen tubing was on the floor and stated it should not be touching the floor due to infection control and safety concerns. During a concurrent observation and interview on 3/11/25 at 9:08 a.m. with LN 6 in Resident 12's room, Resident 12 was lying on the bed with oxygen in use, LN 6 confirmed that the oxygen tubing was on the floor. During a concurrent observation and interview on 3/11/24 at 9:40 a.m. with Director of Nursing (DON) in Resident 18's room, Resident 18 was sitting up on bed with oxygen in use, DON confirmed the oxygen tubing was on the floor and should not be touching the floor due to infection control concerns. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items, Surfaces and Equipment, dated October 2021, the P&P indicated, Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (e.g. respiratory therapy equipment) . such devices should be free from all microorganisms . 2. During a review of Resident 10's AR, the AR indicated, Resident 10 was admitted on [DATE] with diagnoses which included acute pyelonephritis (bacterial infection causing inflammation of kidneys, a complication of an ascending urinary tract infection), uterovaginal prolapse (the womb or other pelvic organs dropping down and pressing into the vaginal area), neuromuscular dysfunction of the bladder (the nerves and muscles that control urination aren't working properly), acute cystitis without hematuria (sudden bladder infection that's not causing blood in urine). During a review of Resident 10's OSR, printed on 3/12/25, the OSR indicated Resident 10 had an order for Foley catheter (a type of urinary catheter) Fr 16 (French 16-size of catheter) vol (volume) 10. During a concurrent observation and interview on 3/11/25 at 12:26 p.m., with LN 3 in the dining room, Resident 10 was wheeling herself in the wheelchair. LN 3 confirmed the catheter tubing was dragging on the floor and stated that it should not be touching the floor due to infection control concerns. During a concurrent observation and interview on 3/11/25 at 12:28 p.m., with DON in the nursing station, Resident 10 was in front of the nursing station when the DON checked the catheter tubing and confirmed it was touching the floor. The DON stated that the expectation is for the catheter tubing not to drag on the floor. During an interview on 3/12/25 at 1:00 p.m., with DON, DON stated the expectation is for oxygen tubing and catheter tubing not to touch the floor and that they follow standard nursing practices for infection control. During an interview on 3/13/25 at 10:57 a.m., with Infection Preventionist (IP), IP stated that oxygen and catheter tubing should be kept off the floor because touching the floor increases the risk of contamination and the floor can be a source of bacteria. During a concurrent interview and record review on 3/14/25 at 8:49 a.m., with IP, the facility's P&P titled, Indwelling Catheters, dated September 2021 was reviewed. The P&P indicated, Be sure catheter tubing and drainage bag are kept off the floor. IP confirmed that this is the policy in her infection control binder and is the policy she uses to teach staff about infection control practices for urinary catheters. 50517 3. During a review of Resident 45's AR, the AR indicated, Resident 45 was admitted [DATE] with diagnoses including malignant neoplasm (cancerous/ abnormal growth tissue) lower third of esophagus (muscular tube through which food passes from the throat to the stomach), artificial opening of gastrointestinal tract (feeding tube placement). During a review of Resident 45's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated, 1/16/25 indicated Resident 45 had mild cognition impairment. Resident 45's Physician Orders indicated, NPO (nothing by mouth), and Enteral feeding (tube feeding), continuous. During a review of Resident 45's care plan, dated 1/9/25 indicated, resident will not have any complications with feeding tube. The care plan interventions indicated, observe signs and symptoms of infection. During a concurrent observation and interview on, 3/11/25 at 12:30 p.m., in Resident 45's room, Resident 45 arrived from physical therapy with tube feeding disconnected. Feeding formula (liquified food) was observed hanging on feeding tube pole, with tubing left hanging from pole uncapped and was open to air. LN 4 confirmed that the tubing was left uncapped and stated, leaving a tube feeding formula open to air can lead to a potential infection and contamination especially for residents who are vulnerable. During a review of the facility's P&P titled, Enteral Feedings, reviewed August 2024, indicated, .preventing contamination maintain aseptic technique use closed enteral nutrition systems when possible. During a review of the facility's P&P titled, Cleaning and Disinfection of Resident-Care items, Surfaces and Equipment, revised October 2021 indicated, Critical items consist of items that carry a high risk of infection if contaminated with any microorganism . Objects that enter sterile tissue or vascular system are considered critical items .

Based on observation, interview, and record review, the facility failed to ensure resident needs were accommodated for one of 25 sampled residents (Resident 63), when the call light was not within reach. This failure had the potential to result in Resident 63 not attaining their highest practicable physical, psychosocial, and emotional well-being. Findings: During a review of Resident 63's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated, Resident 63 was admitted to the facility in September 2023 with multiple diagnosis of muscle weakness, difficulty walking, and history of falling. During a review of Resident 63's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/12/24, the MDS indicated Resident 25 required partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent observation and interview on 3/11/25 at 3:17 p.m. in Resident 63's room, Resident 63 was in bed laying, the call light was observed on the floor behind Resident 63's bed. Resident 63 stated he usually does not have his call light within reach. Resident 63 verbalized in frustration he needed the call light to ask staff to lower the volume of his television (TV). Resident 63 stated his privacy curtain was usually drawn so he cannot see who was walking by. Resident 63 further stated that his roommate had the volume on high so he did not know if anyone could hear him if he yelled out. Licensed Nurse 5 (LN 5) came into the room after being prompted to assist Resident 63. LN 5 confirmed and acknowledged that the call light was on the floor and not within reach. During a concurrent observation and interview on 3/13/25 at 3:27 p.m. in Resident 63's room, Resident 63 was in bed and watching TV. Resident 63's call light was dangling off the side of the bed not within reach. Resident 63 stated he was unable to reach his call light. Certified Nurse Assistant 3 (CNA 3) confirmed that the call light was not within reach. During an interview on 3/14/25 at 9:31 a.m., with Director of Nursing (DON), the DON stated her expectation was to have all call lights within reach of the residents. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light revised October 2024, the P&P indicated .when the resident is in bed or confined to a chair be sure the light is within easy reach of the resident .

Based on observation, interview and record review, the facility failed to ensure one out of 25 sampled residents (Resident 58) received appropriate pain management services consistent with professional standards of practice and facility's policy and procedure (P&P) when Resident 58's pain was not managed during wound care treatment. This failure had the potential for Resident 58 not achieve relief from pain and not attain her highest practicable well-being. Findings: During a review of Resident 58's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 58 was admitted to the facility March 2024 with multiple diagnoses which included sacral pressure ulcer stage 3 (full-thickness loss of skin, dead and black tissue may be visible) and chronic pain. During a review of Resident 58's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 3/5/25, the MDS indicated Resident 58's wound was documented as pressure ulcer Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). During a review of Resident 58's Order Summary Report, (OSR) dated 3/13/25, OSR indicated, Pain-Monitor for Presence of Pain Every Shift Using Scale 0-10 .0=No pain 1-2=Least pain 3-4=Mild Pain 5-6=Moderate Pain 7-8=Severe Pain 9-10 Very Severe/Horrible/Worst pain . Resident 58's OSR also indicated, Morphine (pain medication) .Give 0.5 ml (milliliter, unit of measurement) orally every 1 hour as needed for moderate (4-6) to severe (7-10) pain . Resident 58's OSR dated 3/13/25 further indicated, oxycodone (pain medication) .give 1 tablet by mouth every 4 hours as needed for severe pain . During an interview on 10/11/25 at 11:57 a.m., Resident 58 stated she was on hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) care. Resident 58 stated she had not gotten up that day because she was in pain. During an interview on 10/11/25 at 11:57 a.m., Resident 58 stated she was on hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) care. Resident 58 stated she had not gotten up that day because she was in pain. During a review of Resident 58's care plan intervention for pain, initiated 9/30/24, indicated, pain will be managed to a tolerable level .will express/exhibit pain relief after alternative comfort measures and/or administration of medication as needed . During a concurrent observation and interview on 3/13/25 at 11:12 a.m., in Resident 58's room, Licensed Nurse 3 (LN 3) was in the room to provide Resident 58 with wound care. Resident 58 stated to LN 3 that her pain was a lot. LN 3 was observed taking multiple trips back to the treatment cart due to not having enough supplies for the wound treatment. Resident 58 was laying on her right side while LN 3 was providing wound care. Resident 58 stated her legs were hurting during wound treatment. Resident 58 continued to moan in pain and stated it hurts while LN 3 cleaned the wound. LN 3 completed wound treatment and exited Resident 58's room at 11:44 a.m. Resident 58 was heard crying inside the room from outside of the hallway. During a concurrent interview and record review on 3/13/25 at 11:45 a.m. with LN 3, LN 3 confirmed that no pain scale assessment was used for Resident 58's pain, and no documented evidence of pain medication administered prior to wound treatment when Resident 58 stated she was in a lot of pain. LN 3 confirmed and acknowledged that having supplies not within reach prolonged the treatment time, which prolonged Resident 58's pain episode, and stated that Resident 58 could not tolerate laying on her side for very long. During an interview on 3/14/25 at 9:31 a.m. with the Director of Nursing (DON), the DON stated it was the expectation for LNs to pre medicate resident with pain medications to manage pain and if resident is in pain during wound treatment, to administer prn (given as needed or requested) pain medication and come back when the pain has subsided. The DON further stated that a pain scale should be used to assess pain level. During a review of the facility's policy and procedure (P&P), titled, Pain Assessment and Management , revised March 2023, indicated, .Assess pain using a consistent approach and a standardized pain assessment .if pain has not been adequately controlled the multidisciplinary team, including the physician, shall reconsider approaches as indicated . During a review of the facility's P&P, titled Wound Care, revised October 2010, indicated, Review the resident's care plan to assess for any special needs of the resident .a. For example, the resident may have a PRN order for pain medication to be administered .Assemble the equipment and supplies .arrange the supplies so they can be easily reached .

Based on interview and record review, the facility failed to ensure care and services were provided to prevent the development of pressure ulcers (PUs, injury to the skin and underlying tissue resulting from prolonged pressure on the skin) for one of three sampled residents (Resident 1) when documentation of resident repositioning was not maintained per facility policy. This failure resulted in the resident developing several avoidable pressure ulcers. Findings: According to the Resident Face Sheet, Resident 1 was admitted in the Spring of 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's clinical record included the following documents: An admission nursing note, dated 3/25/20 written by Licensed Nurse 4 (LN 4), indicated the resident had blanchable redness to the buttocks. A care plan for risk of impaired skin integrity, initiated 3/25/20, indicated preventative approaches such as monitoring for skin breakdown, weekly skin checks, and turning and repositioning frequently. An Activities of Daily Living care plan, initiated 3/25/20, indicated the resident required extensive assistance of two staff for bed mobility, and staff would provide assistance with ADLs as indicated. A Minimum Data Set (MDS, an assessment tool), dated 4/1/20, described the resident as having severe memory impairment, scoring 3 out of 15 possible points on the Brief Interview for Mental Status (BIMS). The MDS indicated the resident required extensive assistance for bed mobility and was at risk for developing pressure ulcers, but did not have any at the time. An MDS, dated [DATE], indicated the resident was at risk for developing pressure ulcers, but did not have any at the time. A Treatment Administration History (TAH), dated 1/1/21- 1/22/21, indicated a 7/15/20 order staff were to reposition the resident every 2 hours for skin integrity maintenance. Skin Observation sheets, dated 11/7/20- 12/19/20 and completed weekly by nursing staff, indicated the resident had redness at the coccyx (tailbone) area and a treatment was in place. No other skin issues were noted. An Event Report, dated 12/20/20 and written by LN 1, indicated pressure ulcers were found on the resident's coccyx and left foot. The coccyx wound was described as measuring 1.5 by 2.5 cm (centimeter, a unit of measurement) in the middle aspect with black eschar (dry, dark skin) in the middle and open areas above and below it. The open area above the eschar measured 3 by 1.5 cm, and the open area below the eschar measured 2 by 1 cm. The left lateral foot had an area of black eschar measuring 1.5 by 1 cm, and the lateral left great toe had a reddened (non-blanchable) area measuring 2 by 1 cm. A nurse's note, dated 12/27/20 and written by LN 2, indicated a deep tissue injury (DTI, an injury to the soft tissue under the skin due to pressure and is usually over a boney prominence) to the right bunion measuring 1 by 2 cm, a DTI to the left hip measuring 6.5 by 7 cm with an open PU proximal to the DTI of the left hip measuring 2 by 1.5 cm, and an open PU to the left buttock measuring .5 by .5 cm. In an interview, on 1/10/22 at 12:53 p.m., the Director of Nursing (DON) confirmed the resident had been admitted without pressure ulcers. The DON stated she could not explain why the skin check dated 12/19/20, noted only redness on the resident's coccyx and the following day open wounds with eschar had been discovered. The DON reviewed the resident's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview, on 2/10/22 at 1:15 p.m., the Treatment Nurse (TN) stated she expected nurses to note whether an area of redness was blanchable or non-blanchable when conducting skin assessments. The TN reviewed the wounds discovered on 12/20/20, and described the area of eschar on the coccyx as unstageable, the open areas above and below it as Stage 2, the left lateral foot area with eschar as unstageable, and the non-blanchable area on the left great toe as Stage 1. The TN stated she believed the cause of the wounds was a lack of repositioning the resident, and the wounds would have taken at least a few days to progress to that point. In reviewing the additional wounds discovered on 12/27/20, the TN stated staff could not have been repositioning the resident as ordered. In an interview, on 2/10/22 at 3:16 p.m., the DON stated the nurses should have been documenting whether or not the area of redness on the coccyx was blanchable or non-blanchable. The DON stated the resident was on a repositioning program, but confirmed the repositioning documentation prior to the development of the PUs did not include information about what position the resident was placed in each time she was repositioned per policy, and was incomplete. A review of the facility's policy titled, Repositioning, last revised October 2010, stipulated, The following information should be recorded in the resident's medical record .The position in which the resident was placed .If the resident refused the care and the reason(s) why.

Based on interview and record review, the facility failed to implement measures for the prevention of pressure ulcers for one resident (Resident 1) of seven sampled residents when, Resident 1 developed an unstageable pressure ulcer (an ulcer that has full thickness tissue loss but is covered by extensive dead tissue black, tan or brown in color) at her coccyx. This failure resulted in Resident 1 aquiring a preventable pressure ulcer and suffering pain. Findings: According to the Resident Face Sheet, Resident 1 was admitted in early 2022 with diagnoses including wedge compression fracture of T11-T12 vertebra (collapse of the front of the vertebral body or bone structure at the bottom of the thoracic spine), urinary tract infection and difficulty in walking. A review of Resident 1's clinical record included the following documents: An MDS (Minimum Data Set, an assessment tool), dated 2/4/22, indicated Resident 1 had no memory impairment. It also indicated Resident 1 was extensive assistance of 2 persons for bed mobility, and had no pressure ulcers at the time. A Nursing Admission Note, dated 1/28/22 and written by Licensed Nurse 1 (LN 1), indicated Resident 1 had blanchable redness (turns white when pressed with a fingertip, and then immediately turns red again when pressure is removed) to the coccyx (tailbone). A Physician's Order Report, dated 1/28/22, indicated a treatment order to cleanse the area of redness each shift and as needed with soap and water, pat dry and apply barrier cream. An At Risk for Altered Skin Integrity Care Plan, dated 1/29/22, included interventions to monitor the resident's skin for any signs of breakdown (sore, tender, red, or broken areas) and turn and reposition frequently. A nursing note, dated 2/1/22 and written by LN 5, indicated she had assessed Resident 1's skin and found no open areas. A Skin Observation Sheet, dated 2/4/22 and completed by LN 2, indicated Resident 1 had blanchable redness at the coccyx area. A nursing note, dated 2/6/22 and written by LN 3, indicated Resident 1 was tested on [DATE] for COVID-19 (a highly transmissible respiratory virus) and a positive result was received on 2/6/22. The note also indicated Resident 1 was moved to the COVID unit. A nursing note, dated 2/14/22 and written by LN 1, indicated staff noted macerated skin to Resident 1's bilateral buttocks, applied cream and referred her to the Treatment Nurse (TN). A nursing note, dated 2/14/22 and written by LN 4, indicated Resident 1 was moved from the COVID-19 unit because she had completed her isolation period. A nursing note, dated 2/15/22 and written by LN 5, indicated she assessed Resident 1's skin and found an unstageable wound (full thickness tissue loss) at the coccyx extending to the bilateral buttocks measuring 9 x 8 cm (centimeter, a unit of measurement) and the depth of the wound could not be determined. The note also indicated the resident had some tenderness and sensitivity to the area, especially during movement. In an interview, on 3/16/22 at 1:45 p.m., the Director of Nursing (DON) stated it was her expectation residents assessed to require extensive assistance for bed mobility be on a turning and repositioning program, and every 2 hours or so the resident was repositioned. The DON agreed the resident could not have been repositioned regularly and the wound was avoidable. In an interview, on 3/16/22 at 1:52 p.m., LN 5 stated she had seen Resident 1 prior to her being moved to the COVID-19 unit and she had no open wounds at that time. LN 5 stated she did not see Resident 1 again until after she was out of the COVID-19 unit. LN 5 stated the nurses on the COVID unit were supposed to be completing treatments. LN 5 stated Resident 1 was dependent on staff for repositioning. When asked regarding how the area could have progressed from blanchable redness on 2/4/22 to an unstageable pressure ulcer on 2/14/22, LN 5 stated she could not have been repositioned appropriately every 2 hours. A review of the facility's policy titled, Prevention of Pressure Ulcers/Injuries, last revised 7/17, stipulated, Inspect the skin on a daily basis when performing or assisting with personal care .Identify any signs of developing pressure injuries .Reposition resident as indicated on the care plan.

Based on interview and record review, the facility failed to ensure one of 8 sampled residents (Resident 1) received adequate assistance with transfers when, the resident was transferred to her wheelchair by 1 CNA (Certified Nursing Assistant). This failure resulted in the resident sustaining a rib injury with pain. Findings: According to the Resident Face Sheet, Resident 1 was admitted in the summer of 2021 with diagnoses including generalized muscle weakness. A review of Resident 1's clinical record included the following documents: A MDS (Minimum Data Set, an assessment tool), dated 12/12/21, indicated the resident had no memory impairment. The MDS indicated the resident required the extensive physical assistance of 2+ persons for transfers between surfaces including to or from bed to wheelchair. The MDS also indicated the resident had a functional limitation in range of motion on both sides of her lower extremities (hip, knee, ankle, foot). A nursing note, dated 1/26/22 and written by Licensed Nurse 1 (LN 1), indicated Resident 1 complained of pain on her right rib cage area and requested PRN (as needed) pain medication. The note indicated the resident informed LN 1 that a CNA had transferred her the previous day without using a mechanical lift or other person, and she heard a Pop, pop. The note indicated the resident was requesting an x-ray because she was in excruciating pain. LN 1 informed the DON (Director of Nursing) and PA (Physician's Assistant). A progress note, dated 1/26/22 and written by the PA, indicated she had seen the resident for her complaint of right-side chest wall pain. The note indicated Resident 1 had pain with palpation on the right side of her chest wall, and a STAT (immediately, without delay) chest wall x-ray was ordered. A MAR (Medication Administration History) report, dated 1/1/22- 1/31/22, indicated Resident 1 received PRN Tramadol (a narcotic pain reliever used to treat moderate to severe pain) twice on 1/26/22 and once on 1/27/22. A nurse's note, dated 1/27/22 and written by LN 2, indicated Resident 1 was sent out to the hospital that day due to a critical lab value. A GACH (General Acute Care Hospital) Inter-Facility Transfer Report, dated 1/30/22, indicated Resident 1 had been treated for a sprain of the ribs and an x-ray had not revealed any acute fracture. In an interview, on 3/10/22 at 3:06 p.m., the Registered Nurse Consultant (RNC) stated 2 staff should have been present when transferring the resident, with or without a lift. The RNC confirmed transferring the resident with only 1 CNA was unsafe. A review of the facility's policy titled, Resident Mobility and Range of Motion, last revised 7/17, indicated, Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility .

Based on observation, interview, and facility document review, the facility failed to ensure 1 of 9 sampled residents (Resident 1), a known elopement risk, was provided direct supervision to prevent Resident 1 from leaving the facility unaccompanied through an unsecured door and without staff knowledge for a census of 91. This failure resulted in Resident 1 leaving the facility unsupervised, falling down an incline and acquiring abrasions, bruises, and lacerations to Resident 1's face when he hit his face and head on the cement sidewalk. Based on the above failure, an Immediate Jeopardy (IJ) was called on 2/7/2020 at 10:18 a.m. On 2/7/2020 at 10:18 a.m., the Administrator was informed of the IJ situation which had the potential to result in injury or death when Resident 1 eloped on 1/22/2020 at approximately 2:15 a.m. The Administrator presented a Plan of Correction (P[NAME]) on 2/7/2020 at 1:53 p.m. which was accepted by the Department. In a concurrent interview with a demonstration by the Administrator on 2/7/2020 at 1:53 p.m., the alarm system installed on the back door was in good working order, and each shift would be in-service trained on the secure alarmed door for residents' safety. The Administrator was informed the immediacy of the IJ had been removed since all necessary changes were made and the interim P[NAME] had been accepted. Findings: Resident 1 was admitted to the facility toward the end of (MONTH) 2020 with [DIAGNOSES REDACTED]. Review of a facility document dated 1/21/2020, (Resident 1's admission) and titled Observation Detail List Report indicated, Decreased Mobility/Immobility, Chairfast- Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair, Physical Performance Limitation (e.g. Unsteady Gait, Impaired Balance, etc.), Fall Risk High, and Assistive Devices ( .Walker .). Resident 1 was assessed on admission as requiring assistance with activities of daily living including, bathing, dressing, grooming, toileting, and transfers. Resident 1's spouse was assisting with decision-making. There was no documented evidence of a baseline care plan in place for Resident 1 on admission. Review of a Nurse's Progress Note dated 1/22/2020 at 1:54 a.m. indicated, .Resident alert and oriented x 2-3 (the orientation was to 1-person, 2-place, and 3-time), some confusion . Review of a Nurse's Progress Notes dated 1/22/2020 at 3:02 a.m. indicated, .At 0155 (1:55 a.m.) LN (Licensed Nurse) check (sic) on Resident but Resident was not in bed, bathroom and empty room .Per CNA (Certified Nursing Assistant), I was sitting in my car on my lunch break, I happened to look up and I seen (sic) a man walking out the back parking lot approaching the decline (sic) in the driveway and he was gaining speed. I jumped out of my car as fast as I could to get him and he was all ready (sic) in a falling motion, he landed directly on his face .Noted skin tear to right side of the forehead and abrasion to the chin . An interview was conducted on 2/7/2020 at 5:48 a.m. with the Minimum Data Set (MDS-an assessment tool) Coordinator (MDSC). The MDSC stated the alarm on the back door near the Physical Therapy Room was removed a few months ago because the alarm was annoying the staff. The MDSC further stated the alarm was never replaced. An interview with the Licensed Nurse 2 (LN 2) was conducted on Station II. The LN 2 stated the exit door at the end of the hall on Station II was alarmed. A demonstration confirmed the active alarm system on the door. The exit door on Station II was visible from the Nurse's Station. The unsecured door was located to the right of the Nurse's Station, if looking at the desk. The unsecured door was not visible from Station II and was located at the end of the hall leading to the Dining Room and next to the right of the Physical Therapy Room . On 2/7/2020 at 6:11 a.m., an observation was made while accompanied by the MDSC. The MDSC stated, Station II was the Station Resident 1 was admitted to and where the Short Stay residents are residing for Rehabilitation Services only. The end of the hall to Station II leads to the Dining Room and to the right was the Physical Therapy (PT) Room, and to the right of the PT room was an unsecured door. The door was opened easily with no alarm connected to the door. The door led to the back of the facility where there were cement stairs and a ramp for the Occupational and Physical Therapy Services to be provided. There were multiple wheelchairs lined up, shower chairs, and commodes on the backyard patio. The MDSC stated they were all lined up to be cleaned. Further observations on 2/7/2020 at 6:20 a.m. of Resident 1's elopement from the facility, led to a latched gate located at the back of the patio in the back of the facility. The latch was unlocked and easily lifted. The latch was at a height of approximately 6 feet. The latched gate led to the employee parking lot. Turning left in the parking lot led toward the street and sidewalk with a steep incline before reaching the sidewalk. The MDSC stated Resident 1 fell face first, down the steep incline from the parking lot and landed on the sidewalk. There were no street lights in the area and it was very dark with cars parked on each side of the street. Turning left onto the sidewalk and walking approximately 1 block, led to the front parking lot of the facility. An interview was conducted with the Director of Nursing (DON) on 2/7/2020 at 9:24 a.m. The DON stated Station II was for the Short-Stay residents, usually for Rehabilitation Services. The DON stated Resident 1 was estimated to be in the facility for about 2 weeks. The DON stated there were a total of 9 residents on Station II, 4 residents were ambulatory and 5 were able to self-propel in their wheelchairs. A baseline, admission care plan for Resident 1 was requested from the DON. The DON stated there was no admission care plan available for Resident 1. In an interview with the Administrator on 2/7/2020 at 10:18 a.m., the Administrator said, Well, you know the Resident eloped when he was at home too. A Certified Nursing Assistant 1 (CNA 1) was interviewed on 2/10/2020 at 9:44 a.m. The CNA 1 stated on 1/22/2020 around 2 a.m., she was in her vehicle on her meal break. The CNA 1 stated her vehicle was parked across the street from the sidewalk where Resident 1 fell . The CNA 1 stated she looked up and saw Resident 1 with his walker gaining speed and headed toward the steep incline on the edge of the employee parking lot, leading to the sidewalk. The CNA 1 left her vehicle to run to help, but Resident 1 had fallen down the steep incline of the driveway and landed on the sidewalk closest to the road. The CNA 1 further stated, Resident 1 had fallen face first and was bleeding from his face, slow to respond, and limp when she tried to assist him. The CNA 1 was unable to reach a licensed nurse for assistance. The CNA 1 stated she assisted Resident 1 to his feet and walked him back into the facility. On 2/10/2020 at 10:02 a.m. an interview was conducted with the CNA 2 who was assigned to provide care to Resident 1 on 1/22/2020 during the night shift. The CNA 2 confirmed her assignment for the night of 1/22/2020. The CNA 2 stated she received report from evening shift of Resident 1's confusion, restlessness, and episodes of walking around with his walker. The CNA 2 stated she was called to assist in another room and within 10 minutes the licensed nurse came in to report Resident 1 was gone from his room. The CNA 2 stated the staffing for Station II on 1/22/2020 included, one licensed nurse, and one CNA (CNA 2). Review of a facility policy revised (MONTH) 2008 and titled Elopements indicated, Staff shall investigate and report all cases of missing residents .When the resident returns to the facility, the Director of Nursing Services of Charge Nurse shall: Complete and file an incident report; and Document relevant information in the resident's medical record. There was no documented evidence of a report completed and no documented evidence a report had been filed with the Department.

An unannounced visit was made on [DATE] to initiate an investigation of Complaint #CA 673 concerning quality of care and treatment. The reports identified allegations Resident 1 had fallen, sustained a head injury and died . As a result of the investigation, it was determined that the facility failed to: 1. Ensure the resident was free from unnecessary drugs when [MEDICATION NAME]/[MEDICATION NAME] was ordered and administered for 17 days without monitoring which contributed to his death from bleeding in the brain and coagulopathy (bleeding disorder). 2. Revise a care plan for anticoagulant treatment when [MEDICATION NAME] was ordered. Resident 1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 ' s most recent readmission was [DATE], following treatment of [REDACTED]. The last full MDS (minimum data set, an assessment tool) dated [DATE], described Resident 1 as being non-English speaking, but he used signs and gestures to enable staff to understand his needs. Resident 1 was described as having short term memory problems and modified cognitive skills. The resident was not able to walk, but used a wheelchair to move himself around the facility. Review of the clinical record initiated on [DATE] for Resident 1 revealed the following: Readmission physician's order [REDACTED]. PT stands for [MEDICATION NAME] Time. INR stands for International Normalized Ratio, a test which measures blood clotting time) monitor for [MEDICATION NAME]. " ([MEDICATION NAME] is a medication to prevent clot formation), " [MEDICATION NAME], start when bleeding stops - review by PCP " (primary care physician). A laboratory report dated [DATE] at 1:30 p.m. documented INR level of 1.2 and indicated the level was normal for someone not receiving anti-coagulation therapy. The INR lab report dated [DATE] contained a hand written note " Resident currently not on any dosage of [MEDICATION NAME], please decide dosage. " To the right of this note, in different handwriting was " D/C (discontinue) I&R (INR) if not on [MEDICATION NAME] [DATE] per (MD name) at 1345 (1:45 p.m.). " A third written note was below the first and it documented: " Resident new admit from hospital. Came with order for [MEDICATION NAME] but no dosage. PT/INR done to set parameter. Please advice (sic)!! " A physician's order [REDACTED]. (milligrams, a unit of measure for medications) orally every evening for [MEDICATION NAME] (prevention measure). " The order was written at 4 p.m. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The medication was documented as given daily starting [DATE]. The MAR indicated [REDACTED]. There were no signatures on any dates indicating a lab test result was available or checked. The clinical record contained no other laboratory reports documenting PT/INR values after [DATE]. Review of LexiComp.com, an on-line drug information source revealed the following information (in part) about [MEDICATION NAME], the generic name for [MEDICATION NAME]: " [MEDICATION NAME] is used for chronic oral anticoagulation in a variety of clinical settings. Monitoring [MEDICATION NAME] therapy by adjusting the INR to lie within the recommended range for the disorder treated (e.g., 2XXX,[DATE].0) is recommended. Dosing [MEDICATION NAME] is more complex than with many drugs. High alert medication: The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant resident harm when used in error. Geriatric Considerations: Before committing an elderly resident to long-term anticoagulation therapy, the risk for bleeding complications secondary to falls, drug interactions, living situation, and cognitive status should be considered. A risk of bleeding complications has been associated with increased age. Adverse Reactions - Bleeding is the major adverse effect of [MEDICATION NAME]. Hemorrhage may occur at virtually any site. Risk is dependent on multiple variables, including the intensity of anticoagulation and resident susceptibility. Warnings/Precautions Hemorrhage: Possible massive hemorrhage involving the GI (gastrointestinal) tract, spinal cord, GU ([MEDICAL CONDITION] tract), cerebral, pericardial, [MEDICAL CONDITION], adrenal, or hepatic (liver) sites. Hemorrhagic (bleeding) complications may be manifested by signs or symptoms that do not indicate obvious bleeding, such as paralysis; headache; pain in the chest, abdomen, joints, muscles, or other areas; dizziness; shortness of breath; difficulty breathing or swallowing; unexplained swelling; weakness; [MEDICAL CONDITION] (low blood pressure); or unexplained shock. Results principally from overdosage. Careful clinical management, including frequent PT or INR determinations, is required. " The [MEDICATION NAME] product information provided by the manufacturer with the medication validated the above reference. In the section titled, Highlights of Prescribing Information, (in part) stated: " WARNING: BLEEDING RISK. [MEDICATION NAME] can cause major or fatal bleeding. Perform regular monitoring of INR in all treated patients ...Monitoring: Obtain daily INR determinations until stable in the therapeutic range ...Most common adverse reactions to [MEDICATION NAME] are fatal and nonfatal hemorrhage from any tissue or organ ...An INR of greater than 4 appears to provide no additional therapeutic benefit in most patients and is associated with a higher risk of bleeding ...Patients [AGE] years or older appear to exhibit greater than expected INR response to the anticoagulant effects of [MEDICATION NAME] ...Therefore, as patient age increases, a lower dose is usually required to produce a therapeutic level of anticoagulation ... " The product insert also included specific guidelines for monitoring. On [DATE](Day #7 of his anticoagulation therapy), Resident 1 fell from his wheelchair without apparent injury. Neurological assessments were done but there was no documented evidence that a bleeding risk was considered or anticoagulation monitoring ordered. A Fax Notification Form dated [DATE] at 3:30 p.m. (Day #14 of his anticoagulation therapy) documented, " Resident had an unwitnessed and unassisted fall at 1530 (military time for 3:30 p.m.). Resident was sitting in w/c (wheelchair) and fell to floor. Bleeding to upper right forehead and to right cheek bone due to rug burn, no S/T (skin tear) observed. Right eye swollen and purple discoloration. Observed VS (vital signs) ,[DATE], 82 (pulse), 18 (respirations), 102.0 (temperature in Fahrenheit). (Complains) to right leg. No swelling or discoloration noted to legs/knees. Will continue to observe. " The physician documented " noted " and signed the form and returned it to the facility on [DATE]. There was no acknowledgement of an elevated temperature, and no orders were given. This note was signed by a Licensed Vocational Nurse (LVN). There was no documented evidence that anticoagulation monitoring was considered or ordered. A Nurse ' s Note dated [DATE] at 9:30 p.m. included, " DON (Director of Nursing) notified and will do an assessment tomorrow. " A Nurse ' s Note dated [DATE] at 2:53 a.m. documented the resident had a temperature of 100.9 Fahrenheit. " Skin excoriations to right side of face, right eye blackened. " The note was not signed. A Nurse ' s Note dated [DATE] at 1:58 a.m. included " Right is purple and swollen. Right side of face has two abrasions upper and lower. " The note was not signed. On that same day at 6 p.m. the notes indicated " forehead bleeding, refused to get out of bed, swollen bruised eye, generalized pain. " There was no documentation in the record that Resident 1 was assessed by a Registered Nurse (RN) following his fall. During an interview with the DON on [DATE] at 3:30 p.m. she stated " I came in on the night shift and assessed (Resident 1) ...I have no note ...I was concerned his cheek bone was fractured. " The DON stated there was not an x-ray done of the resident ' s facial bones. The DON was not able to locate an RN assessment of Resident 1 following the fall. On [DATE] at 1:35 p.m., there was an indication that the family member " wanted to speak to Hospice to decide if that is the next step ... " An untimed and unsigned order for a Hospice Consult was in the clinical record. On [DATE] Resident 1 was transferred to the emergency room of a General Acute Care Hospital (GACH) following a change in condition. The resident ' s condition was described in a [DATE] Nurse ' s Note at 5:56 p.m. as " Alert and responsive ...rapid respirations and low BP (blood pressure). " The resident ' s blood pressure was " ,[DATE] " (normal range was ,[DATE] to ,[DATE]) and his respiratory rate was " 36 " per minute (normal range was ,[DATE] per minute). Review of the GACH clinical record for Resident 1 ' s admission on [DATE] revealed: A History and Physical report dated [DATE] which included: " Assessment (1) septic (infection) shock with multiorgan failure ... (2) Intracranial (inside the skull) hemorrhage with subarachnoid bleed. This is probably secondary to his fall and his coagulopathy. (3) " Iatrogenic coagulopathy (clotting disorder due to medical treatment). The resident probably is on [MEDICATION NAME], and his INR is more than 18...I do not think the resident is going to survive this episode. " A laboratory report dated [DATE] included an INR result of " 18.2 " (18 times normal). On [DATE], Resident 1 was transferred from the GACH to another skilled nursing facility for comfort care. He died there on [DATE] at 5:10 a.m. The Death Certificate for Resident 1 listed the following Diagnoses: [REDACTED]. Subdural hematoma (blood accumulation between the brain and the dura covering); 3. Probably secondary to [MEDICATION NAME]. " Review of undated facility policy titled " INR [MEDICATION NAME] Protocol " included (in part) " Notify the attending physician of PT/INR results of 3.0 or greater ... 3. If INR is greater than 3.0 a. hold [MEDICATION NAME] ... " During an interview with LN 4 on [DATE] at 3:25 p.m. LN 4 stated " Before giving [MEDICATION NAME] I want to know the INR results. Monday and Thursday INRs are routine for our residents. All [MEDICATION NAME] is given on PM shift; PM nurses know to get the INR every Monday and Thursday. " During an interview with the Director of Nursing (DON) on [DATE] at 3:30 p.m. she stated they had reviewed the record and were unable to locate the lab tests following the [DATE] test. The DON stated " We ' re following up with the lab, they didn ' t come and draw blood, they received the order but never came out. " The DON stated " The evening shift nurse is responsible for ensuring the INR is done when they give the medication. " The DON verified the PT/INR tests ordered twice weekly on Mondays and Thursdays after [MEDICATION NAME] was started were not done for Resident 1 on the following scheduled days: [DATE], [DATE], [DATE], [DATE] and [DATE]. Resident 1 had received [MEDICATION NAME] 3 mg. daily for 17 days without any laboratory monitoring. An INR of 18.2 was six times the therapeutic range for prevention of blood clots. Further review of the clinical record revealed for Resident 1 revealed: A [DATE] Care Plan for Risk for bruising and/or abnormal bleeding referenced the use of [MEDICATION NAME], a blood thinner which was no longer administered to the resident after his discharge on [DATE]. The care plan included a goal of " will have therapeutic levels of medications (without signs and symptoms) of abnormal bleeding and excessive bruising daily (through) [DATE]. " No other blood thinner care plan was in the record and no revision was documented when the [MEDICATION NAME] was ordered. In an interview with the DON on [DATE] starting at 1:15 p.m. she stated the anticoagulant care plan " should have been changed when he went on [MEDICATION NAME]. " As a result of the investigation, it was determined that the facility failed to: 1. Ensure the resident was free from unnecessary drugs when [MEDICATION NAME]/[MEDICATION NAME] was ordered and administered for 17 days without monitoring which contributed to his death from bleeding in the brain. 2. Revise a care plan for anticoagulant treatment when [MEDICATION NAME] was ordered. These violations presented either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom and were a direct proximate cause of death of the patient or resident.