Every finding on record at Linden Woods Village

Based on observation, interview and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to ensure the kitchen was clean and in good repair. The facility census was 32. Review of the facility policy titled, Food Storage Policy, dated October 2018, showed:-Foods shall be stored in a manner that complies with safe food handling practices;-Staff will maintain clean food storage areas at all times;-Food in dry storage will be kept off the floor;-All foods stored in the refrigerator or the freezer will covered, labeled and dated with a use by date;-Open container must be dated and sealed.The facility did not provide a policy for cleaning and repair of the kitchen.Observation on 05/04/2026 at 08:20 A.M., showed:-Microwave with dirt and food debris inside on the roof and vents;-Floor by the dishwasher area was dirty and the grout looks black, gravel like and is pealing off;-The oven on the right side of the stove broken.-One opened 1/2 gallon of 2% milk, 2/3 full, will no open date;-One open 1/2 gallon of whipping cream, 1/2 full with no open date;-One open 1/2 gallon of ice cream mile 1/2 full, with no open date;Freezer: -Clear plastic bag of 5 frozen hamburger patties, a clear plastic bag, tied in a knot at the top with no open date;-Clear plastic bag of multiple pin wheel sandwiches, tied shut with a knot in the top of the bag with no open date;-A non transparent blue plastic bag tied shut at the top with unknown contents setting to the frozen broccoli with no open date.Dry Storage:-Open box of red potatoes on the floor.During an interview on 05/04/2026 at 08:46 A.M. Dietary Aide B said:-The floor by the dishwasher was in poor repair;-He/She had tried to clean the floor by the dishwasher and pieces the grout between the tiles are like gravel come off during cleaning;-The oven had been broken for two weeks;-They had used the oven to prepare meals;-They had another oven but it would help if the broken oven was fixed;-The Dietary Manager (DM) was aware of the floor and the broken oven.Observation on 05/06/2026 at 11:20 A.M., showed:-Microwave with dirt and food debris inside on the roof and vents;-Floor by the dishwasher area was dirty and the grout looks black, gravel like and is pealing off;Freezer: -Clear plastic bag of 5 frozen hamburger patties in a clear plastic bag, tied in a knot at the top with no open date;-Clear plastic bag of multiple pin wheel sandwiches, tied shut with a knot in the top of the bag with no open date;-A non transparent blue plastic bag tied shut at the top, with unknown contents sat next to the frozen broccoli with no open date;-The oven on the right side of the stove broken;-Three golf ball sized stains on the kitchen ceiling outside of the walk in cooler;-Floor by the dishwasher area was dirty and the grout looked black, gravel like and was pealing off;-One box of lemon dessert and one box of pecan dessert on the floor in the walk in cooler.-Unsealed bag of ground meat in the refrigerator with a date of 04/20;-Open package of frozen chicken patties with no date.During an interview on 05/07/26 at 09:49 A.M. the DM said:-The kitchen should be clean and in good repair:-There should not be food sitting on the floor in the walk in cooler, the freezer or the dry storage;-The ceiling should be free of stains and dirt;-The floor should be clean and in good repair;-The right side oven should be operational;-He said he was aware the right side oven was broken, the knobs fell off and it did not light;-He thought he had told the Maintenance Supervisor about it but nothing had been done yet;-The grout between the tiles if the floor needed profession cleaning because it was hard to get all the grease and dirt off of it without it falling apart;-Food should be labeled and have a date.During an interview on 05/07/2026 at 10:53 A.M. the Registered Dietitian (RD) said:-She expected the kitchen to be clean and in good repair;-Food should be labeled and dated as soon as it is opened;-No food setting on the floor in the walk in cooler, freezer or dry storage room;-The floors should be clean and in good repair;-She said the floor in the kitchen needed to be regrouted because the grout looked black and greasy;-The ceiling in the kitchen should be free of stains;-She expected the ovens in the kitchen to be working;-Surfaces in the kitchen should be cleanable to ensure that they are sanitary;-She expected the kitchen staff to be in charge of cleaning of the kitchen.During an interview on 05/07/2026 at 11:34 A.M. the Maintenance Supervisor said:-He was responsible for repairs to the kitchen;-The kitchen should be in good repair;-He is responsible for repairs to the oven and/or calling the company to get it repaired;-He was not aware the oven was not working;-The staff tell him by word of mouth of repairs or they fill out a work order. During an interview on 05/07/2026 at 11:52 A.M. the Administrator said:-She expected the kitchen to be clean, sanitary and all equipment should be working, including the oven;-She expected food to be labeled and dated per regulations;-The kitchen staff is responsible for the cleaning and making sure maintenance knows if there is anything that needed repaired.

Based on observation and interview, the facility failed to provide a clean and home like environment when the facility did not ensure vents in the hallways and the vents outside resident rooms were clean and free of debris, the ceiling in the dining room was clean and in good repair and when the facility failed to ensure the handrail by the dining room was clean. This had the potential to affect all residents who had the right live in a clean environment that was free from dirt, dust and in good repair. The facility census was 32. The facility did not provide the requested policy on clean and home like environment.Observation on 05/04/2026 at 08:35 A.M., showed: -The vent on the ceiling outside the public bathroom near the dining area covered in dust, dirt and debris;-The vent on the other side of the dining room next to the therapy room covered in dirt, dust and debris;-The handrail across the hall from the public bathroom near the serving station with a black scuff mark approximately 1 inch wide, that ran the length of hand rail;-The vent outside of room [ROOM NUMBER] covered in dirt, dust and debris;-The vent outside room [ROOM NUMBER] caked in dust and dirt;-The vent in the hallway between room [ROOM NUMBER] and 184 caked in dirt, debris and dust;-Three brown spots the size of grapefruits on the ceiling in the dining room;-A 3 foot piece of the ceiling falling down in the dining room by the door that has a high voltage sign on it.Observation on 05/05/2026 at 11:42 A.M., showed: -The vent on the ceiling outside the public bathroom near the dining area covered in dust, dirt and debris;-The vent on the other side of the dining room next to the therapy room covered in dirt, dust and debris;-The handrail across the hall from the public bathroom near the serving station with a black scuff mark approximately 1 inch wide, that ran the length of hand rail;-The vent outside of room [ROOM NUMBER] covered in dirt, dust and debris;-The vent outside room [ROOM NUMBER] caked in dust and dirt;-The vent in the hallway between room [ROOM NUMBER] and 184 caked in dirt, debris and dust;-Three brown spots the size of grapefruits on the ceiling in the dining room;-A 3 foot piece of the ceiling falling down in the dining room by the door that has a high voltage sign on it.Observation on 05/06/2026 at 01:05 P.M., showed: -The vent on the ceiling outside the public bathroom near the dining area covered in dust, dirt and debris;-The vent on the other side of the dining room next to the therapy room covered in dirt, dust and debris;-The handrail across the hall from the public bathroom near the serving station with a black scuff mark approximately 1 inch wide, that ran the length of hand rail;-The vent outside of room [ROOM NUMBER] covered in dirt, dust and debris;-The vent outside room [ROOM NUMBER] caked in dust and dirt;-The vent in the hallway between room [ROOM NUMBER] and 184 caked in dirt, debris and dust;-Three brown spots the size of grapefruits on the ceiling in the dining room;-A 3 foot piece of the ceiling falling down in the dining room by the door that has a high voltage sign on it.During an interview on 05/06/26 at 03:12 P.M., Resident #22's family member said:-The vents in the facility should be clean and free of dust;-He/She expected the facility to be clean and in good repair;-He/She expected the facility to be feel like home for the resident.During an interview on 05/07/26 at 09:12 A.M., the Maintenance Supervisor said:-He was responsible for cleaning the vents in the facility;-He tried to check the vents for cleanliness and disrepair at least every quarter;-He could not remember the last time the vents were cleaned at the facility;-He was responsible for ensuring the ceiling was clean and in good repair in the dining room;-The hand rail by the dining room should be clean and in good repair;-He was responsible for ensuring the facility is in good repair.During an interview on 05/07/2026 at 10:16 A.M., the Administrator said:- She expected the facility to be clean and in good repair;- She expected the vents to be clean and should be monitored for dust and dirt at least every week or so;- She expected maintenance to be in charge of cleaning of the vents and ensuring the facility is in good repair.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program when the facility staff did not wear proper Personal Protective Equipment (PPE) when providing high contact cares for one resident (Resident #3), when the facility staff did not change gloves and perform hand hygiene between dirty and clean tasks (Resident #11) and additionally when the staff failed to sanitize vital sign equipment (blood pressure cuff, thermometer, etc.) between uses on residents (Resident #3 and #11). This affected two of 12 sampled residents. The facility census was 32.Review of the facility policy titled, Enhanced Barrier Precaution (EBP), dated 3/2024, showed:-EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities;-EBP was indicated for a resident with an indwelling device (instrument inserted into the body to remain for an extended period), even if the resident is not known to be infected or colonized with MDRO;-EBP was utilized when staff perform resident dressing, bathing, transferring from one chair or bed to another and providing hygiene. Review of the facility undated policy titled, Hand Hygiene Competency, showed:-Gloves are disposable and for single use only;-Hands should be sanitized before applying gloves;-Gloves must be changed between dirty and clean tasks/cares. 1. Review of Resident #3's Comprehensive Minimum Data Set (MDS- a federally mandated assessment completed by facility staff), dated 03/05/26, showed:-No cognitive impairment;-Dependent on staff for care of Supra Pubic Catheter (a tube surgically inserted through the stomach and into the bladder, connected to an external collection device to drain and collect urine);-Dependent on staff and use of mechanical lift for transfers from bed to chair, etc;-Diagnoses included: High blood pressure, kidney disease and obstructive uropathy. Review of the resident's care plan dated 02/25/26, showed:-He/She was unable to perform his/her own Activities of Daily Living (ADL) independently due to limited mobility;-Direct care staff were supposed to wear gowns and gloves for all personal cares as resident had a suprapubic catheter;- The resident will remain free from infection. Observation on 05/06/26 at 5:15 A.M. showed:- Registered Nurse (RN) B entering residents room without applying gown or gloves and taking in vital sign equipment;-RN B assessed residents vitals with facility equipment using a blood pressure cuff and thermometer;-RN B administered medications to the resident;-RN B left resident's room with vital sign equipment, wheeled it up the hall and plugged it in without cleaning equipment after use. During an interview on 05/06/26 at 5:20A.M., RN B said that he/she should have worn a gown and gloves to assess vital signs to protect resident from infection and that he/she should have cleaned vital sign equipment after use. Observation on 05/06/26 at 6:40A.M., showed Certified Nurses Aide (CNA) A and CNA B entered the EBP room without appropriate PPE to provide morning care. Transferred the resident from the bed to wheelchair, provided peri care, personal grooming and dressing to resident without wearing isolation gowns. During an interview on 05/06/26 at 6:40A.M., CNA A said that staff were supposed to wear gowns and gloves with the resident as he/she had a urinary catheter. Wearing a gown helps prevent them from infection. 2. Review of Resident #11's Quarterly MDS, dated [DATE], showed:-No cognitive impairment;-Required maximum assist required from staff with toileting hygiene;-Diagnoses included: High blood pressure, malnutrition and high cholesterol. Review of the resident's care plan dated 02/09/26, showed:-Resident was unable to perform ADL's independently related to unsteady balance and gait disturbance;-At risk for developing a pressure ulcer (also called a bedsore);-Required assistance from nursing staff with personal hygiene;-Resident had foot wounds. Observation on 05/05/26 at 7:00A.M., showed:-CNA B applied gloves, did not apply isolation gown and assisted the resident to transfer to the toilet from the bed; -CNA B removed the resident's saturated incontinent brief and put in the trash can;-CNA B applied a new brief and pants for the resident and provided a clean shirt;-CNA B assisted the resident to stand, pulled up the brief and pants and transferred resident to the wheelchair;-CNA B then touched the resident's face with his/her same gloved hand and told the resident he/she would shave the resident after breakfast;-CNA B set up toothbrush and toothpaste for the resident at the sink with the same used gloves on;-CNA B then removed gloves and washed hands his/her before leaving the room;-CNA B did not change his/her gloves after they were soiled and did not wash his/her hands after becoming soiled. During an interview on 05/07/26 at 8:06 A.M., CNA B said he/she should have changed his/her gloves and washed his/her hands between dirty and clean tasks. 3. During an interview on 05/07/26 at 8:40A.M., the Infection Preventionist said:-Vital sign equipment should be sanitized after each use;-Staff are educated on EBP and have skills checkoffs and competencies when hired and several times throughout the year;-All staff are expected to follow EBP guidelines for patient safety and infection control. During an interview on 05/07/26 at 11:00A.M., the Director of Nursing said that all nursing staff were expected to remove gloves, perform hand hygiene and then apply new gloves when transitioning from a dirty task to a clean task. Blood pressure cuffs and thermometers should be cleaned between residents.

Based on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent with an error rate of 24% out of 29 opportunities, when the staff crushed medications for administration that were not supposed to be crushed, additionally when the facility staff failed to administer medication with sufficient water and with, or after food as ordered by the physician. This affected one of 12 sampled residents (Resident #16). The facility census was 32. Review of the facility undated policy titled, Medication Administration Competency: General Guideline, showed staff were supposed to compare the order in the Medication Administration Record (MAR) three times prior to medication administration. Review of the facility undated policy titled, Medication Administration Competency: Oral Medications, showed: -Refer to and follow instructions if medication has additional recommended administration directions (e.g. give with food, with 120 milliliters (mLs) of water); -Crush medications only after ensuring the medication is NOT on the Do Not Crush list; -Do not crush sustained or extended-release medications. Review of the manufacture guidelines 2024., showed that Donepezil (a medication used to treat dementia): -Should be swallowed whole; -Do not crush, break or chew the medication; -Donepezil should be taken at bedtime as it can cause people to become dizzy or drowsy. Review of the manufacture guidelines 2020 showed that Meloxicam (a medication used for arthritis or inflammation) should be swallowed whole; do not crush, break or chew the medication. 1.Review of Quarterly MDS (Minimum Data Set), a mandatory assessment completed by facility staff., dated 4/24/26., showed:-Cognition intact;-Diagnoses: Dementia, diabetes, respiratory failure;-Required assistance with Activities of daily living. Review of Resident #16's Physician Order Sheet, dated 05/05/26, showed:-An order that staff can crush medications if appropriate; -An order for Meloxicam 7.5mg with instructions to take with food and plenty of water; -An order for Metoprolol Succinate Extended Release tablet 25mg (a medication used to treat high blood pressure) with instructions that include not to crush; -An order for Potassium Chloride 20 milliequivalent (MEQ) (a supplement) with instructions not to crush medication, to give with or after food and at least 120 mL of water to avoid GI irritation. Observation on 05/05/26 at 6:23A.M., showed: -CMT B obtained medications, did not verify orders, then placed all medication into a single medicine cup; -CMT B used a crusher to crush all medications, mixed crushed tablets with two spoonful's of applesauce in a medication cup; -Medications administered included Meloxicam, Metoprolol Succinate, Donepezil and Potassium Chloride; -CMT B hand fed medications to the Resident while he/she was still in bed and provided approximately 60mLs of water to the resident during medication administration. During an interview on 05/05/26 at 6:23A.M., CMT B said the Medication Administration Record (MAR) indicated which medications cannot be crushed or have special instructions and that he/she received a report each day with resident's medication administration preferences. During an interview on 05/07/26 at 11:00A.M., the Director of Nursing said that he/she expected physician orders to be followed, and that medications should not be crushed unless ordered to do so, and CMT B should not have crushed the medications.

Based on observation, interview, and record review, the facility failed to ensure a residents received the appropriate care and services to prevent urinary tract infections to the extent possible and when the facility staff failed to ensure proper urinary catheter care was performed for one resident (Resident #6), and additionally when the facility failed to collect a physician ordered urine sample for eight days causing delay in start of treatment for one resident (Resident #30) of the 12 sampled. The facility census was 32. Review of the facility training and competency titled, Combined Catheter Care, undated, showed:- Once care is completed, ensure tubing is strapped to inner thigh;- One wipe, one swipe: no scrubbing or re-using wipes or cloths;- Spread the personal folds with non-dominant hand, with clean cloth/wipe clean the catheter at point of insertion into urethra using a pen roll to cleanse the entire circumference of the catheter;- Hold catheter in place as dominant hand cleanses the extension of catheter tubing down four inches. 2. Review of the facility training and competency titled, Combined Perineal Care Female and Male, undated, showed:- Once a gloved hand has touched something soiled (old depends, garbage can, used trash bags, etc), it cannot be used to touch something clean without removing gloves and performing hand hygiene;- Having a second clean person can assist with this procedure;- Do not place soiled items on the clean surface or bed;- One wipe, one swipe: no scrubbing or re-using wipes or cloths;- Always wipe away from the peri-area. Do not wipe towards as this can bring bacteria/soilage into the peri-area. Review of the facility policy titled, Supporting Activities of Daily Living (ADL's), revised March 2018, showed:- Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADL's;- Residents who are unable to carry out ADL's independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene;- Residents will be provided with care, treatment and services to ensure that their ADL's do not diminish unless the circumstances of their clinical conditions demonstrate that diminishing ADL's are unavoidable;- Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care) and Elimination (toileting);- The resident's response to interventions will be monitored, evaluated, and revised as appropriate. 1. Review of Resident #6's Significant Change Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 03/27/26, showed:- Cognition was not intact;- Was dependent on staff for completing activities of daily living;- Had an indwelling catheter and was always incontinent of bowel;- Diagnoses of Quadriplegia (paralysis affecting all four limbs), encephalopathy (brain disease that leads to altered mental status), schizophrenia, and psychotic disorder. Review of the resident's care plan, revised 03/31/26, showed:- He/She had a history of Urinary Tract Infections (UTI's) and staff were to monitor, document, and report signs and symptoms of UTI to the provider as needed;- He/She was totally dependent on staff for cares;- He/She required mechanical lift with two staff assistance for transfers. Review of the facility's infection surveillance sheets showed the resident was prescribed the antibiotic Levaquin 500 milligrams by mouth, twice daily for five days for Escherichia coli (E.coli) organism UTI with altered mental status (AMS), pelvic pain, malodorous urine and symptom onset of 01/18/26, start date of 01/27/26 and stop date 02/01/26. Review of the resident's electronic medical record showed he/she was transferred by ambulance and admitted to a local hospital on [DATE] with diagnoses of AMS and UTI and discharged back to the facility returning by ambulance on 03/23/26. Observation on 05/05/2026 at 7:07 A.M., showed:- Licensed Practical Nurse (LPN) B knocked and entered the resident's room to perform wound care;- LPN B applied enhanced barrier gown, gloves, raised up the bed, and opened the resident's brief and found feces in the brief;- LPN B grabbed a wipe and wiped the feces down the lower abdominal area toward and into the peri-area and catheter insertion point using multiple swipes per wipe. There were six swipes noted with a single wipe;- LPN B pressed the soiled wipes down between the resident's legs and left them stored on the chuck beneath him/her;- LPN B had the resident roll and the catheter was stretched tightly and not anchored to the resident's thigh;- LPN B provided some slack for the catheter tube and wiped the backside with multiple swipes with each wipe, from three to six wipes per wipe and then wiped down the buttocks crease and anus toward the peri-area which caused the resident to exclaim, boy, all of that hurts;- LPN B began to perform the wound care, struggling to position the resident and continuing to stretch the catheter tubing tightly during the process;- The resident's catheter tube was stretched tightly to the resident's right side;- LPN B completed the procedures and did not spread the resident's skin folds or cleaned the catheter tube directly, and did not ensure there was a catheter lock on leg-anchoring device in place for the resident's catheter tubing. During an interview on 05/05/2026 at 7:58 A.M., LPN B said:- He/She shouldn't wipe feces from the lower abdominal area down to the peri-area or catheter tube. Staff should wipe away from the catheter tube/peri-area;- Staff should perform catheter care throughout the day and he/she would have done it then if he/she had more time;- There should be an anchoring device in place for the catheter. During an interview on 05/05/2026 8:25 A.M., the Infection Control (IC) nurse said: - Nursing staff should try as much as possible to wipe feces away from the catheter tubing and peri-area, not into it;- There should be a catheter anchoring device in place if ordered, but it depends on the care plan too as some residents will pull them off. If that's the case it should be well documented. During an interview on 05/07/2026 at 8:08 A.M., Resident #6 said:- LPN B wasn't able to do catheter care right and kept saying he/she was too hot;- The poor care made him/her feel very insecure, as if he/she didn't have the right help, as if it was his/her fault and it wasn't his/her fault;- LPN B should definitely get more training. During an interview on 05/07/2026 at 10:55 A.M., the Director of Nursing (DON) said:- Feces should be wiped away from the catheter tube or peri-area;- There should only be one swipe per wipe;- The dirty wipe shouldn't be left on the bed, between the resident's legs. They should be thrown in the trash;- There should be an anchor for the catheter tube in place or documented clearly why not;- The catheter tube should not be stretched tightly, pulling at the resident;- Catheter care should be performed after or in conjunction with peri-care;- All areas where feces touched should be cleaned, including peri-area folds. Review of Resident #30's Quarterly MDS dated [DATE], showed: -No cognitive impairment; -Incontinent of urine; -Dependent on nursing staff for all hygiene cares, toileting and transfers; -Diagnoses included: Heart failure, high blood pressure and chronic pain. Review of resident's care plan dated 03/25/26, showed: -Assist of two staff and a mechanical lift required for all transfers; -Resident at risk for skin breakdown related to urinary incontinence; -Required perineal care and application of barrier cream (a specialized skincare product that protects skin from external irritants) after incontinence. Review of the resident's Electronic Medical Record (EMR) showed: -Nurse's progress note, dated 02/12/26 indicated resident had complaints of burning and irritation when urinating, the nurse practitioner was notified and an order received for a UA (Urinary Analysis); -Nurse's progress note dated 02/16/26, that a device had been placed in resident's toilet for urine collection; -Results dated 02/21/26 from a UA collected 02/20/26 indicated urine tested positive for the bacteria Klebsiella pneumoniae; -No new medication or additional lab work ordered after facility notification of positive result; -Nurse's progress note dated 02/26/26 indicated resident had continued complaints of urinary discomfort and had new reports of bladder pain and fullness, provider to be notified of resident condition; -Physician order dated 02/26/25 for Bactrim DS (an antibiotic) for seven days for treatment of UTI; Observation on 05/06/26 at 8:45A.M., showed CNA A and CNA F: -Assisted the resident to the toilet using a mechanical lift; -CNA A removed saturated incontinence brief and put in trash can; -CNA A assisted the resident to a standing position; -CNA A wiped resident 3 times in his/her front perineal area; -CNA A removed gloves, performed hand hygiene and applied new gloves while CNA F pulled up clean brief and pants; -Neither CNA A nor CNA F wiped the resident's buttocks or inner thighs; -Staff removed gloves, gathered trash and left room. During an interview on 05/07/26 at 10:40A.M., Resident #30 said: -When there was a delay in collecting ordered UA, he/she felt bad and had to have a shot of antibiotics; -He/She does not know why there was a delay in urine collection as he/she uses the toilet several times daily, but it seems that there is often a delay in care on the weekends; -He/She expected the staff to provide proper perineal care as he/she is no longer and to do it and that is why he/she is at facility. During an interview on 05/06/26 at 9:00A.M., CNA F said that all areas where urine has touched, including inner thigh and buttocks, need to be wiped because urine on left on skin can cause problems like redness, rashes and sores. During an interview on 05/07/26 at 8:26A.M., LPN A said: -Any area that urine has touched needs to wiped whether the resident was continent or incontinent; -If perineal care is not done properly, it can lead to skin breakdown and cause the resident to have an odor of urine; -Poor perineal care can lead to a urinary tract infection; -After an order is received, collection should be done as soon as possible, so that treatment can initiated if indicated; -Delay in collection or testing of urine sample can lead to worsening symptoms for the resident. During an interview on 05/07/26 at 11:00A.M., the Director of Nursing said: -All perineal areas need to be cleaned after urinary incontinence; -Urine should be collected the day an order is received for a UA; -A delay in analysis of urine and the start of antibiotic treatment can cause increased pain to the resident, and could lead to Urosepsis (a life-threatening condition where a UTI spread to the kidneys and enters the bloodstream); -It is not reasonable that a urine sample was not collected until eight days after initial urinary complaints and physician order received; -The laboratory comes to the facility each Monday, Wednesday and Friday to pick up collected blood and urine samples.

Based on observation, interview, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide proper peri-care for three of 12 sampled residents (Resident #6, #11, and #30). The facility census was 32.Review of the facility training and competency, titled, Combined Perineal Care Female and Male, undated, showed:- Once a gloved hand has touched something soiled (old depends, garbage can, used trash bags, etc), it cannot be used to touch something clean without removing gloves and performing hand hygiene;- Having a second clean person can assist with this procedure;- Do not place soiled items on the clean surface or bed;- One wipe, one swipe: no scrubbing or re-using wipes or cloths;- Always wipe away from the peri-area. Do not wipe towards as this can bring bacteria/soilage into the peri-area. Review of the facility training and competency, titled, Combined Catheter Care, undated, showed:- Once care is completed, ensure tubing is strapped to inner thigh;- One wipe, one swipe: no scrubbing or re-using wipes or cloths;- Spread the labia with non-dominant hand, with clean cloth/wipe clean the catheter at point of insertion into urethra using a pen roll to cleanse the entire circumference of the catheter;- Hold catheter in place as dominant hand cleanses the extension of catheter tubing down four inches; Review of the facility policy titled, Supporting Activities of Daily Living (ADL's), revised March 2018, showed:- Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADL's;- Residents who are unable to carry out ADL's independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene;- Residents will be provided with care, treatment and services to ensure that their ADL's do not diminish unless the circumstances of their clinical conditions demonstrate that diminishing ADL's are unavoidable;- Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care) and Elimination (toileting);- The resident's response to interventions will be monitored, evaluated, and revised as appropriate. 1. Review of Resident #6's Significant Change Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 03/27/26, showed:- Cognition was not intact;- Was dependent on staff for completing activities of daily living;- Had an indwelling catheter and was always incontinent of bowel;- Diagnoses of Quadriplegia (paralysis affecting all four limbs), encephalopathy (brain disease that leads to altered mental status), schizophrenia, and psychotic disorder. Review of the resident's care plan, revised 03/31/26, showed:- He/She had a history of Urinary Tract Infections (UTI's) and staff were to monitor, document, and report signs and symptoms of UTI to the provider as needed;- He/She was totally dependent on staff for cares;- He/She required mechanical lift with two staff assistance for transfers. Observation on 05/05/2026 at 7:07 A.M., showed:- Licensed Practical Nurse (LPN) B knocked and entered the resident's room to perform wound care;- LPN B applied enhanced barrier gown, gloves, raised up the bed, and opened the resident's brief and found feces in the brief;- LPN B grabbed a wipe and wiped the feces down the lower abdominal area toward and into the peri-area. There were six swipes noted with a single wipe;- LPN B pressed the soiled wipes down between the resident's legs and left them stored on the chuck beneath him/her;- LPN B continued to perform multiple swipes with one wipe and would pull the resident's red and aggravated looking thigh skin tight to scrub and reach through the leg to the resident's backside;- LPN B began to wipe the resident's backside with multiple swipes with each wipe, from three to six wipes per wipe and then wiped down the buttocks crease toward the peri-area which caused the resident to exclaim, boy, all of that hurts;- LPN B appeared to struggle rolling the resident from side to side, was sweating profusely, and the protective gown slipped down to the LPN's elbows;- LPN B told the resident his/her skin was broken down everywhere. Both of the resident's inner thighs had been bright red and he/she grimaced when touched.- LPN B proceeded to retrieve the soiled wipes from beneath the resident and attempted to roll the resident onto two pillows, the resident said, oww wait, there's a pillow there and the LPN stopped to removed the pillows;- LPN B held the soiled wipes and said, normally I'm supposed to have a trash bag right there (his/her trash bag was on the other side of the bed) and he/she pulled a second trash bag out of a nearby trash can and laid it on the floor;- LPN B said he/she should have raised the bed up a little more; - LPN B completed the procedures and never spread the resident's skin folds;- LPN B changed the resident's clothing and continued to have difficulty positioning the resident which caused the resident to say, oh, my shoulder, my bottom burns, and there is burning in the middle there, under my leg;- There were two trash bags laying on the floor with one by the foot of the resident's bed open with a soiled chuck halfway out on floor and a soiled glove next to bag on the floor. During an interview on 05/05/2026 at 7:58 A.M., LPN B said:- He/She shouldn't wipe feces from the lower abdominal area down to the peri-area;- He/she was supposed to clean the resident with one swipe per wipe;- He/She should have gotten help for the cares; During an interview on 05/05/2026 8:25 A.M., the Infection Control (IC) nurse said: - Nursing staff should try as much as possible to wipe feces away from the peri-area, not into it;- Nursing staff should try to keep the trash contained in the bags and not loose on the floor;- We don't recommend the nursing staff use more than one swipe per wipe and don't leave the trash on the resident's bed. Don't push the used wipes down between the resident's legs. During an interview on 05/07/2026 at 8:08 A.M., Resident #6 said:- He/She thinks it would have been better if there had been another person with the nurse that day;- LPN B wasn't able to do it right and kept saying he/she was too hot;- The poor care made him/her feel very insecure, as if he/she didn't have the right help, as if it was his/her fault and it wasn't his/her fault. He/She was patient with LPN B;- LPN B should definitely get more training. During an interview on 05/07/2026 at 10:55 A.M., the Director of Nursing (DON) said:- Feces should be wiped away from the peri-area;- There should only be one swipe per wipe;- The dirty wipe shouldn't be left on the bed, between the resident's legs. They should be thrown in the trash;- She would expect two staff present for Resident #6's cares;- She would prefer the staff keeps trash to one bag if possible and the trash should not be spilling out into the floor;- All areas where feces touched should be cleaned, including peri-area folds. 2. Review of Resident #11's Quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Incontinent of urine; -Required maximum assist required from staff with toileting hygiene; -Diagnoses included: high blood pressure, malnutrition and high cholesterol. Review of the resident's care plan dated 02/09/26, showed: -Resident unable to perform ADL's independently related to unsteady balance and gait disturbance; -At risk for developing a pressure ulcer (also called a bedsore) related to incontinence; -Required assistance from nursing staff with personal hygiene. Observation on 05/05/26 at 7:00A.M., showed: -CNA B applied gloves and assisted resident with a transfer to toilet from wheelchair; -CNA B removed resident's saturated incontinence brief and disposed of it in the trash can; -After resident urinated, CNA B assisted resident to stand, pulled up clean brief and pants and then assisted with transfer to the wheelchair; -CNA B did not provide perineal hygiene to resident; -CNA B removed gloves and washed hands. During an interview on 05/07/26 at 8:06A.M., CNA B said that gloves should be changed between dirty and clean tasks and additionally, all areas where urine has touched need to be wiped, including the buttocks, because urine is bad for the skin and can lead to pressure sores. 3. Review of Resident #30's Quarterly MDS dated [DATE], showed: -No cognitive impairment; -Dependent on nursing staff for all hygiene cares, toileting and transfers; -Diagnoses included: Heart failure, high blood pressure and chronic pain. Review of resident's care plan dated 03/25/26, showed: -Assist of two staff and a mechanical lift required for all transfers; -Resident at risk for skin breakdown related to urinary incontinence; -Required perineal care and application of barrier cream (a specialized skincare product that protects skin from external irritants) after incontinence. Observation of CNA A and CNA F on 05/06/26 at 8:45A.M., showed: -Resident was assisted by staff to the toilet using a mechanical lift; -CNA A removed saturated incontinence brief and put brief in trash can; -After urinating in the toilet, resident was assisted to a standing position; -CNA A wiped resident 3 times in his/her front perineal area; -CNA A removed gloves, performed hand hygiene and applied new gloves while CNA F pulled up clean brief and pants; -Neither CNA A nor CNA F wiped the resident's buttocks or inner thighs; -Resident was assisted into wheelchair and set up at sink to brush hair and teeth; -Staff removed gloves, gathered trash and left room. During an interview on 05/06/26 at 9:00A.M., CNA F said that all areas where urine had touched needs to be wiped because urine on left on skin can cause problems like redness, rashes and sores. 4. During an interview on 05/07/26 at 8:26A.M., LPN A said: -Any area that urine has touched needs to wiped whether the resident was continent or incontinent; -If perineal care is not done properly, it can lead to skin breakdown and cause the resident to have an odor of urine; -He/She applied barrier cream to any resident that has had an incontinence episode; -Poor perineal care can lead to a urinary tract infection. 5. During an interview on 05/07/26 at 11:00A.M., the Director of Nursing said that all perineal areas need to be cleaned after urinary incontinence including penis, thighs and buttocks to help prevent discomfort and skin breakdown.

Based on observation, interview and record review, the facility failed to ensure proper storage and labeling of medications and biologicals when the facility had an open bottle of lorazepam (an anti-anxiety medication) with no open date for one resident (Resident #8) and three open bottles of stock medications used for multiple residents with no open date. Additionally, when the facility had three opened bottles of glucose control solution (solutions used for daily calibration/testing of bedside blood glucose machines) with no open date. This had the potential to affect all residents with orders for these medications. The facility census was 32.The facility did not provide a policy regarding storage and labeling of medications and biologicals. Review of the facilities undated Healthcare Professional Operator's Manual for the Medline Evencare ProView Blood Glucose Monitoring System (the blood glucose monitoring machine and products used by facility), showed: -Always check the expiration date of the control solution, do not use expired solution; -Record the date on the bottle when opening a new bottle of control solution; -Discard any unused control solution three months after the opening date; -Control solutions are good three months after opening date or until the last day of the month of expiration; whichever comes first. 1.Observation of the nurse's medication room on [DATE] at 9:25A.M., showed an opened bottle of lorazepam with no open date with a pharmacy label for Resident #8. Review of Resident #8's Comprehensive MDS (Minimum Data Set), a mandatory facility assessment completed by facility staff on [DATE]., showed:-Cognition was not intact;-Required staff assistance to provide medications;-Diagnoses: Anxiety, heart failure, diabetes. An observation of the Nurse medication cart located on the East Hall on [DATE] at 8:15A.M., showed: -An open bottle of Aspirin 81mg (used as a heart health supplement) with no open date; -An open bottle of acetaminophen 650 milligram (mg) (used for pain and fever) with no open date; -An open bottle of Vitamin B12 25 microgram (mcg) (a supplement) with no open date; -An open multi-use vial of high glucose control drops and two open multi-use vials of regular glucose control drops, each with no open dates. During an interview on [DATE] at 8:15A.M., Registered Nurse (RN) A said: -Staff were supposed to write the date on the bottle or container when opening for initial use; -He/She was unsure of how long glucose control drops are good for use after opening; -He/She would need to check with the Director of Nursing (DON) to find out what the facility policy is. During a follow up interview on [DATE] at 10:00, RN A said that he/she discarded the oral medications and discussed with the DON the guidelines for the glucose control drops and it was confirmed that the drops are good to use until the manufacturer's expiration date on each bottle. During an interview on [DATE] at 9:25A.M., Licensed Practical Nurse (LPN) A said he/she thought that multi-use bottles of medications are good for 28 days after opening and that medicines start to lose their efficacy if used past expiration dates. During an interview on [DATE] at 11:00A.M., the DON said that all medications should be dated with date they are opened. After opening, a multi-dose bottle of Lorazepam is good to use for 30 days.

Based on interview and record review, the facility failed to ensure an assessment of the Level I preadmission screening resident review (PASARR) assessment (used to identify individuals with mental illness or intellectual/developmental disabilities completed before admission to the nursing facility) was completed before admission for one resident (Resident #6). The affected one of 12 sampled residents. The facility census was 32.The facility did not provide a PASARR policy. 1. Review of Resident #6's Significant Change Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 03/27/26, showed:- Cognition was not intact;- Was dependent on staff for completing activities of daily living;- Diagnoses of Quadriplegia (paralysis affecting all four limbs), encephalopathy (brain disease that leads to altered mental status), schizophrenia, and psychotic disorder. Review of the resident's care plan, revised 03/31/26, showed:-He/She had the special instruction that stated Resident is on palliative services. Please do not use the term Hospice in front of resident instead use the term palliative;-He/She used psychotropic medications (medications that affect the mind, emotions, and behavior) and anti-anxiety medications related to schizophrenia, mood disorder with phsychotic features, and dementia with behavioral features;-He/She was totally dependent on staff for cares. Review of the resident's medical record showed that no documentation of a Level I PASARR had been completed. During an Interview on 05/07/2026 at 9:08 A.M., the MDS coordinator said;- The first authorization process is when the PASSAR gets collected and he/she would pick up the residents after that first process which was handled by the Administrator;- The facility got the resident placed on hospice and the resident was being helped with his/her mental health issues by seeing a social worker with hospice who is well versed in dealing with mental disorders. During an Interview on 05/07/2026 at 9:14 A.M., The Director of Nursing (DON) said:- The facility did not have social services at this time and there hadn't been one for six months;- The facility had been unable to locate a PASSAR for the resident. During an Interview on 05/07/2026 at 10:55 A.M., The DON said:- A PASSAR level one pre-screening should be completed on a resident before admission to the facility;- They had not been aware of the requirement to complete the screening but were aware now.

Based on observation, interview and record review, the facility failed to provide care and services that meet professional standards when the facility failed to properly document pain and urinary continence status on weekly assessments for one of 12 sampled residents (Resident #30). The facility census was 32.Review of Resident #30's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 04/08/26, showed:-No cognitive impairment;-Reported frequent pain;-Always incontinent of urine;-Dependent on nursing staff for all hygiene cares, toileting and transfers;-Diagnoses included: Heart failure, high blood pressure and chronic pain. Review of the care plan dated 03/25/26, showed:-Resident had chronic pain to arm, legs, and back due to osteoarthritis;-Staff to monitor and record pain characteristics every four hours while awake including quality (sharp, burning), severity (pain score 1-10), anatomical location, onset, duration and aggravating or relieving factors. Review of the Electronic Medical Record (EMR) showed:- Weekly Long-Term Care (LTC) Evaluation dated 04/19/26, documented by nursing staff, (with information gathered during verbal shift to shift report, as well as through documentation review), had no indications of pain (verbal or non-verbal) for the prior seven days and that the resident was continent of urine; -Nursing staff documented 04/13/26 to 04/19/26 the resident remained continent three shifts and was incontinent 18 shifts;- Weekly LTC Evaluation dated 04/26/26, was documented as having not pain for the prior seven days as well as being continent of bladder; -Nursing staff documented 4/20/26 to 4/26/26 the resident remained continent two shifts and was incontinent 17 shifts;-Weekly LTC Evaluation dated 05/03/26, documented by nursing staff, where resident is documented as continent of urine; -Nursing documentation from 04/27/26 to 05/03/26 that resident had remained continent five shifts and was incontinent 14 shifts;-Nursing staff documented 04/13/26-04/26/26 the resident rated his/her pain score, of 1 or more,14 out of the 56 physician ordered pain assessments, of which there was no additional information provided such as quality, onset, location. Review of the medication administration record (MAR) dated 04/2026 showed:- The facility staff documented 04/13/26-04/19/26: 28 administrations of scheduled oral pain medications, seven administrations of as needed oral pain medication, and 21 administrations of two types of topical pain relief (patch and cream);-The facility staff documented 4/20/26-4/26/26: 28 administrations of scheduled oral pain medications, five administrations of as needed oral pain medication, and 21 administrations of topical pain relief. During an interview on 05/07/26 at 10:40A.M., the resident said he/she had pain every day, for years, in several locations and preferred to take oral pain medications around the clock to prevent pain from getting bad. During an interview on 05/07/26 at 5:06A.M., Certified Nurse Aide (CNA) B said he/she documented each resident's continence status towards the end of each shift including this resident. During an interview on 05/06/26 at 8:20A.M., RN A said:-Pain medication should not be administered if the resident was reporting no pain;-He/She tried to not administer scheduled pain medication when resident reports no pain, but resident is insistent to prevent pain from returning, so he/she does administer the medication at resident's request; -It was not reasonable for a Weekly LTC Evaluation for this resident to indicate that he/she had no pain as he/she received scheduled pain medications multiple times each day. During an interview on 5/7/26 at 9:40A.M., the MDS Coordinator said he/she obtained information for the MDS submission from all areas of the EMR including continence information from the nursing documentation; and additionally, that he/she expected the facility staff documented accurately in all areas, as this can affect resident care including pain management, care plans and financial reimbursement. During an interview on 5/7/26 at 11:00A.M., the Director of Nursing said:-Pain score can be documented as zero when administering scheduled pain medications to assist with the prevention of recurring pain;-Pain score should never be a zero for an as needed pain medication;-A reported pain score of zero is acceptable for scheduled pain medications to keep pain at a tolerable level;-Weekly LTC Evaluations should indicate pain on residents that are on scheduled pain medications;-He/She expected staff to document accurately to ensure resident receives adequate care;-EMR documentation is used by facility, physicians and other service providers to gather information about residents.

Based on observations, interviews, and facility policy review, the facility failed to ensure the sanitizer used to sanitize food contact surfaces was at a level effective to sanitize the surfaces and failed to ensure food stored in the walk-in refrigerator and the refrigerator on the unit was labeled and discarded after the use-by date and/or expiration date for 38 census residents residing in and receiving food from the dietary department. This had the potential to result in food borne illness and cross contamination. The facility census was 37. Findings include: Review of the facility's policy titled, Food Receiving and Storage with a revised date of October 2018, revealed all food must be labeled with a use by date. The policy did not reveal how long they could keep open or leftover food. Review of the facility's policy titled, Food Brought into Resident's from Outside Sources with a revised date of 11/06/17, revealed once food has been opened it will be discarded within seven days and foods would be thrown out based on the use by or best by date marked on the container. 1. During an observation in the kitchen and interview on 12/30/24 at 9:11 AM, three of three green containers with sanitizer and wiping clothes tested zero parts per million (ppm) of quaternary sanitizer. The [NAME] stated he used them (wiping rags) to clean and sanitize the food preparation counters. He stated he filled the containers about one or two hours ago. One of the containers was on the dirty end of the three-compartment sink; one of the containers was under the food preparation counter; and one container was under the food preparation counter next to the stove. The Culinary Director (CD) assisted with testing the buckets on 12/30/24 at 9:11 AM and verified they were not at the right ppm to sanitize the counters and stated it should have been 400 ppm. During an observation and interview on 12/31/24 at 3:15 PM, the quaternary sanitizer in the sanitizing containers with the wiping clothes was tested with the assistance of the Cook. Two of the three containers located on the shelves below food preparation counters tested zero ppm. He verified he had been using the sanitizer to clean and sanitize the food preparation counters. Review of the Manufacturer's instructions printed on the gallon container of TMA [Tetramethylammonium] Quaternary Sanitizer, revealed the sanitizer should be prepared to be 150 to 400 ppm to sanitize food contact surfaces. 2. During an observation and interview on 12/30/24 at 9:14 AM, the walk-in refrigerator contained one package of sliced turkey wrapped in plastic wrap dated 12/22/24; one package of turkey wrapped in plastic wrap with no date; a plastic bag of bologna and a plastic bag of corn beef each, dated 12/22/24; and an opened partially used container of beef base with no expiration date and an opened date of 10/18/24 marked on it. In addition, there was a two-gallon container of open mayonnaise with an open date of 11/26/24 and the outside of the container was heavily soiled with mayonnaise residue on the outside of the container. The CD verified the dates and stated it was the facility policy to discard food seven days after it was open. 3. During an observation on 12/30/24 at 9:27 AM, the resident refrigerator located in the dining room on the unit, contained four (four-ounce containers) of yogurt. One of the yogurts had an expiration date of 12/07/24; one container had an expiration date of 12/11/24; and two of the containers had expiration dates of 12/21/24. The CD was present and verified this observation. During an interview on 12/30/24 at 9:15 AM the CD stated that food was supposed to be used by or discarded within seven days of opening.

Based on interview, record review, and facility policy review, the facility failed to ensure residents' right to participate in the care planning process was honored for two of two residents (Resident (R) 11 and R32) reviewed for care plans out of 16 sampled residents. This failure placed the residents at risk for the provision of care not being person-centered. Findings include: Review of the facility's policy titled, Care Plans - Comprehensive, Person-Centered, revised July 2024, revealed .Policy Interpretation and Implementation. 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .3. The IDT includes: a. The Attending Physician; b. A registered nurse who has responsibility for the resident; c. A nurse aide who has responsibility for the resident; d. A member of the food and nutrition services staff; e. The resident and the resident's legal representative (to the extent practicable); and f. Other appropriate staff or professionals as determined by the resident's needs or as requested by the resident. 4. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care. 1. During an interview on 12/31/24 at 9:37 AM regarding discussions about care and medications received or a care conference or care plan meeting, R11 stated, No, we haven't had any meetings. Review of R11's Admission Record from the electronic medical record (EMR) Profile tab showed a facility admitted [DATE] with medical diagnoses that included chronic ischemic heart disease, presence of cardiac pacemaker, fibula fracture, scoliosis, coagulation defect, atrial fibrillation, gastroesophageal reflux disease (GERD), hypertension, insomnia, history of transient ischemic attack, and cerebral infarction. Review of R11's December 2024 Medication Administration Record (MAR) from the EMR Orders tab showed R11 received an anticoagulant medication for atrial fibrillation. Review of R11's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/23/24 showed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicative of moderate cognitive impairment. Review of the EMR Progress Notes tab filtered for the subject of Care Plan Conference Summary notes on 12/31/24 at 12:28 PM showed no documentation. Review of the EMR Miscellaneous tab revealed a care plan conference letter scheduled for 01/02/25. Further review of R11's Progress Notes and Miscellaneous tab did not show evidence of the provision of her baseline care plan goals. During an interview on 12/31/24 at 2:00 PM, the MDS Coordinator (MDSC) stated R11 might not have had a care conference in the first three weeks as she (R11) had wanted to go home. Other than the care plan meeting coming up, the MDSC confirmed it had been over three months, and she would look for something. At 3:33 PM, the MDSC stated there was no signed baseline care plan, so she was unsure if R11 had been provided that document and confirmed there had not been a care plan meeting yet. 2. During an interview on 12/30/24 at 11:44 AM regarding whether care and medications were discussed or if there had been any care plan conferences, R32 responded, No, they don't talk to me. and stated she doesn't remember any care conferences. Review of R32's Admission Record from the EMR Profile tab showed a facility admitted [DATE] with medical diagnoses that included a knee periprosthetic fracture, dementia, posthemorrhagic anemia, sleep disorder, pain, chronic kidney disease (CKD), osteoporosis, and glaucoma.The facility census was 37. Review of R32's quarterly MDS with an ARD of 10/14/24 documented a BIMS score of 12 out of 15, indicative of moderate cognitive impairment. Review of the EMR Progress Notes filtered for Care Plan Conference Summary notes elicited no documentation and no care plan invitation letters were found under the Miscellaneous tab. A baseline care plan was found under the Miscellaneous tab, but the signature was not legible to know who received the copy. During an interview on 12/31/24 at 3:28 PM, MDSC stated R32 was on the list for a care plan letter but was planning on going home, then that changed, she was going to stay and the care plan meeting got missed. The MDSC confirmed no care plan conference has been held yet. During an interview on 01/02/25 at 3:47 PM, the Director of Nursing (DON) stated, Participating in care plans is ideal for residents and anyone the resident chooses. The DON stated an expectation they (residents) be involved and have an opportunity to meet with the interdisciplinary team.

28154 Based on record review, interview, and facility policy review, the facility failed to ensure the Ombudsman was notified two of two residents (Resident (R) 31 and R35) reviewed for emergent hospital transfer out of 16 sample residents. As a result of this failure, the residents would not have the added protection and/or advocacy of the Ombudsman's office to monitor the potential possibility of an inappropriate facility-initiated transfer or discharge. Findings include: Review of the facility's policy titled, Transfer or Discharge - Emergency, revised October 2024, revealed the policy did not address the required Ombudsman notification. Review of the facility's policy titled, Requirements for Emergency Discharge, revised October 2024, revealed: .Policy Interpretation and Implementation. 1. Notice before transfer. Before a facility transfers or discharges a resident, the facility must: a. Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. 1. During an interview on 12/30/24 at 12:39 PM, R31 stated she had been to the hospital at least once, they thought I was having hallucinations back in May and then been there regarding the catheter and getting it out. Review of the facility electronic medical record (EMR) Census tab revealed a status of Hospital Paid Leave on 05/17/24 and 07/23/24. Review of R31's Admission Record from the EMR Profile tab revealed a facility admitted [DATE] with medical diagnoses that included atherosclerotic heart disease, obstructive and reflux uropathy, thrombocytopenia, type II diabetes, chronic obstructive pulmonary disease (COPD), and history of transient ischemic attack (TIA), and cerebral infarction. Review of R31's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/24 documented a Brief Interview for Mental Status (BIMS) score of 15 out of 15; indicative of being cognitively intact. Review of the facility EMR Progress Notes tab revealed a Transfer to Hospital Summary on 07/23/2024 at 7:30 AM, for R31 related to him becoming dizzy and then experiencing a change in responsiveness. A progress note dated 05/17/24 at 11:35 AM, revealed R31 being transferred to the emergency room related to a critical low hemoglobin level. Review of the facility provided reports to the Ombudsman on 01/02/25 at 9:00 AM did not show R31 was included in the May or July list of named transfers or discharges. During an interview on 01/02/25 at 10:22 AM, the Social Services Director (SSD) confirmed the printed reports provided was the printout of the report that was attached to the Ombudsman email. After reviewing the two reports, the SSD confirmed R31 was not included in either the May or July transfer or discharge reports printed. At 10:46 AM, the SSD stated she generated the reports again without success; had called her corporate office who also generated the reports unsuccessfully for R31; but it was discovered that both residents (R31 and R35) had paid bed holds. The SSD stated an EMR ticket was generated to discover the reason the reports did not include the paid bed hold residents showing on the reports.The facility census was 37. During an interview on 01/02/25 at 4:00 PM, the Executive Director expressed an expectation that the Ombudsman would be notified of all transfers and discharge residents monthly. 2. Review R35's Nurse's Note, dated 09/25/24 and located under the Progress Note tab of the EMR, revealed R35 was transferred to the hospital due to a change in condition and becoming non-responsive. According to the Nurse's Note, dated 09/27/24, she remained in the hospital until 09/27/24 when she was readmitted to the facility. During an interview on 01/02/25 at 10:22 AM, the SSD provided the list of discharges she emailed to the ombudsman on 10/03/24 at 11:20 AM for September 2024. The list did not include R35's name. She stated the list provided was the list she sent to the ombudsman, and she verified the resident's discharge in September was not included on the list. During an interview on 01/2/24 at 11:34 AM, the Ombudsman verified via telephone that she was not notified of R35's September discharge or transfer to the hospital.

Based on interview, record review, and facility policy review, the facility failed to ensure one of six residents (Resident (R) 5) had documented indications for an increase of an antipsychotic medication and failed to attempt a gradual dose reduction of the antipsychotic medication without clinical rationale of 16 sample residents. This failure had the potential for R5 to not receive the lowest effective dose of atypical antipsychotic medication.The facility census was 37. Findings include: Review of the facility's policy titled, Psychoactive Drug Monitoring, dated 01/21, revealed .Procedures. 1. Residents receive a psychoactive medication only if supporting documentation is provided in the medical record .6. All of the following conditions are satisfied prior to initiation and/or continuation of therapy: A. Possible reversible causes for the resident's distress have been ruled out. B. Use results in maintenance or improvement in the resident's functional status. C. Long-term daily use has been accompanied by unsuccessful gradual dosage reductions, unless clinically contraindicated. D. The need for and response to therapy are monitored and documented in the resident's medical record. E. If the resident's condition has not responded to treatment or has declined despite treatment, it is important to evaluate both the medication and the dose to determine whether the medication should be discontinued or the dosing should be altered, whether or not the facility has implemented gradual dose reduction(s) as required, or tapering. Review of R5's Admission Record from the electronic medical record (EMR) Profile tab showed a facility admitted [DATE], a readmitted [DATE], with medical diagnoses that included congestive heart failure (CHF), dementia, and generalized anxiety disorder. Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/27/24 documented a Brief Interview for Mental Status (BIMS) score of three out of 15, indicative of severe cognitive impairment. Review of R5's EMR Orders tab revealed an order, dated 09/27/24, for Seroquel (generic name quetiapine, an atypical antipsychotic medication) of 50 milligrams (mg) three times per day. Review of an Order Summary, effective 09/01/24, from the EMR Orders tab showed R5 had been receiving Seroquel 50mg in the morning and 25mg at bedtime. Review of the EMR September 2024 Medication Administration Report (MAR) and Treatment Administration Report (TAR) from the Orders tab, along with August and September Progress Notes from the EMR Progress Notes tab did not show an increased number of behaviors. During an interview on 01/02/25 at 8:30 AM regarding R5's Seroquel increase, the Director of Nursing (DON) stated, Hospice ordered the increase [of Seroquel], I didn't ask them for justification. At 10:20 AM, the DON provided behavior monitoring for the month of September 2024 that documented out of 90 chartings; 16 incidents of care rejection (one where with education she accepted her medication), one of repetitive movement, one biting, one kicking/hitting, and one pushing. Review of the documentation provided by the facility included a note from the Hospice Nurse on 09/27/24 at 1:53 PM, revealed Received a call from the patient's daughter [name of the non-healthcare power of attorney daughter (HCPOA)], she reports that her mother's behaviors are becoming more difficult to manage. She has concerns that staff will have difficulty providing cares while she is recovering from surgery and cannot be there. She is ready to increase Seroquel dose and/or frequency. Spoke to [name] NP [Nurse Practitioner] who gave the order to increase the dose to 50 mg t.i.d. [three times a day]. Phone call to [name] RN [Registered Nurse] at [Facility name], gave her the order. Review of the progress notes provided by the facility as indication for use revealed: -8/10/24 1712 [5:12 PM] Resident agitated today. Refused cares throughout the day. Cursed at this nurse and other staff with attempts to provide cares and even attempted to swat at CNA [Certified Nurse Aide] with hand. Dtr [Daughter] was concerned this morning that floor to bathroom was wet and res pants were wet. Spoke with CNAs . -08/25/24 1042 [10:42 AM] Res had shower this morning. More agitated than usual. She continues to have a decrease in urine and bowel output. Fluids encouraged. Will cont to monitor. -09/02/24 1106 [11:06 AM] Res more agitated this morning when giving her medications. Pushed nurses hand away. Was able to educate her on the importance of taking her medications which led her to finally taking them. -09/14/24 0438 [4:38 AM] CNA reported resident refusal when attempt was made to assist in changing visibly wet pants, this writer attempted as well, offering resident snacks per family request. resident non complaint [sic] with staff, and began attempting to hit this writer, unable to redirect resident at this time. Staff will try at a later time. Review of R5's EMR Progress Notes showed on 10/25/24 at 11:37 AM by the DON, revealed Note Text: Spoke with res [resident] and family about trail [sic] dose reduction for Seroquel order as she does not have an appropriate diagnosis. Res remains on hospice and family not agreeable at this time. Review of R5's Care Plan from the EMR Care Plan tab showed a focus of: I take anti-psychotic medication for Behavior management with an intervention of Consult with pharmacy, MD [doctor] to consider dosage reduction when clinically appropriate at least quarterly initiated 01/20/24. During an interview on 01/02/25 at 3:42 PM regarding the indications for the doubling of the atypical antipsychotic dose for R5, the DON responded, Clinically, I understand what the daughter is saying but clinically probably not. The DON stated it would be ideal if indications for use for psychoactive medications were documented.

Based on observation, interview, facility policy review, and Centers for Disease Control and Prevention (CDC) reference, the facility failed to ensure one undated opened vial of Mantoux tuberculin purified protein derivative (PPD) of three vials in the refrigerator was dated for residents' use. This failure could lead to inaccurate tuberculosis testing by the potential for a false positive (or false negative) result due to the components of the PPD solution being degraded.The facility census was 37. Findings include: Review of the facility's policy titled, Storage of Medications and Biologicals dated ,d+[DATE], revealed: Policy. Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Review of the CDC Mantoux Tuberculin Skin Test, page 6, located at the website address: https://stacks.cdc.gov/pdfjs/web/viewer.html?file=https://stacks.cdc.gov/view/cdc/25732/cdc_25732_DS1.pdf, reviewed on [DATE], revealed .The label should indicate the expiration date. If it's been open more than 30 days or the expiration date has passed, the vial should be thrown away and a new vial used . Observation of the medication room located in the Nurse's Station on [DATE] at 9:28 AM revealed two Mantoux Tuberculin testing fluid boxes in a resealable plastic bag. One vial was still sealed (had the vial cap on) and the other vial was missing the cap (or open) with no open date on the vial or box; a third vial in a box in the refrigerator was open and had a documented open date. Licensed Practical Nurse (LPN) 1 present for the observation confirmed at 9:33 AM the box stated to discard 30 days after opening and there was no open date on the one open PPD vial; LPN1 set the vial aside to be discarded. During an interview on [DATE] at 3:44 PM, the Director of Nursing (DON) stated an expectation that when [a vial] was opened it was to be dated and when expired, discarded.

Based on observation, interview, record review, and facility policy review, the facility failed to accommodate one of one resident's (Resident (R) 11) dietary preferences reviewed for food choices of 16 sampled residents. This failure had the potential to result in reduced meal consumption and may potentially affect the residents' nutritional or health status. The facility census was 37. Findings include: Review of the facility's policy titled, Food and Nutrition Services, revised October 2018, revealed: Policy Statement. Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Policy Interpretation and Implementation. 1. The multidisciplinary team will assess each resident's nutritional needs, food likes and dislikes, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization .3. Reasonable efforts will be made to accommodate resident choices and preferences. Review of R11's Admission Record from the electronic medical record (EMR) Profile tab showed a facility admitted [DATE] with medical diagnoses that included chronic ischemic heart disease, permanent atrial fibrillation, presence of cardiac pacemaker, and history of transient ischemic attack, and cerebral infarction. Review of R11's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/23/24 showed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicative of moderate cognitive impairment. During an interview on 12/31/24 at 9:38 AM, R11 stated, I have CHF [congestive heart failure] a lot of stuff I'm eating I shouldn't have. I get bacon every morning and I shouldn't have it. R11 pointed out a list of foods she should not have posted on her bulletin board and said, I've told the staff here, they said they couldn't do it. Observation of the posted paper showed bacon was on the list as a 'do not eat' food. Observation of R11's breakfast tray on 01/02/25 at 8:17 AM showed one piece of French toast and two slices of bacon. Review of the tray card showed handwritten on the paper: French Toast, Bacon, Cranberry Juice. The tray card also contained a Notes section under the diet order that stated, NO BACON and under dislikes was listed bacon. During an interview on 01/02/25 at 8:20 AM regarding the handwriting on the tray card, the Dietary Aide (DA) that served the morning meal stated she wasn't sure where the handwriting came from, then stated, That's nursing. When asked if she reviewed the Notes or Dislikes sections of the tray card, DA stated, Well no, well sometimes. During an interview on 01/02/25 at 8:22 AM, the Director of Nursing (DON) stated the CNAs (Certified Nurse Aides) tell them [residents] what is on the menu and write down the choices. During a follow-up interview on 01/02/25 at 9:15 AM, R11 reviewed the tray card and denied requesting bacon for breakfast. During an interview on 01/02/25 at 9:20 AM the Restorative Aide (RA) stated, It was me, she requested sausage, and I wrote down bacon. When asked if she did the breakfast orders every day, RA responded, No, I was just helping out the CNAs this morning.

Based on interviews and record review, the facility failed to send a written copy of transfer or discharge notice to a representative of the office of the State Long-Term Care Ombudsman. This affected two of 12 sampled residents, (Resident #22 and #39). The facility census was 35. Review of the facility's policy for transfers and discharges, notice to the Ombudsman, reviewed January 2018, showed: - The facility will send resident transfer and discharge list to the Ombudsman Office monthly; - The facility will print a monthly transfer/discharge list for the previous month from their electronic medical record (EMR); - Transfer/discharge list will be electronically (email) mailed to the Ombudsman office; - The facility will keep a copy of the sent email to show it was completed. 1. Review of Resident #39's baseline care plan, dated 12/14/22, showed: - The resident was a full code; - The resident was on a diuretic (medicine causing increased passing of urine), also on a blood thinner; - The resident required assistance of one staff with transfers and bed mobility; - Used oxygen at three liters per nasal cannula (3L/NC); - Planned to discharge to home; - PT/OT to restore strength to go home and be independent with care; Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/28/22, showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility, transfer and dressing; - Required extensive assistance of one staff with toilet use; - Always continent of bowel and bladder; - Diagnoses included atrial fibrillation (an irregular, often rapid heart rate that causes poor blood flow), congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body), anxiety, and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's progress notes, dated 12/28/22, showed: - At 9:15 A.M., the resident was observed ambulating in the hallway with therapy, in good spirits and reports feeling well. Resident noted with 1+ edema (swelling) to bilateral lower extremities and continues with orders for additional diuretic at this time; - At 10:00 A.M., the resident called the nurse into the room and observed to be upset. Resident states an afro American woman came in and told him/her to keep an eye on the swelling or he/she would end up in the hospital. Resident upset and requesting to go to the emergency room for evaluation. Resident noted with chronic shortness of air and recently hospitalized for COPD exacerbation (an acute increase in the severity of the illness) and admitted with trace of edema. Case Manager spoke with family and resident about concerns and the resident continues to request to be sent to the emergency room . 911 called at approximately 11:19 A.M., and the resident left with the ambulance at approximately 11:30 A.M. Family aware of transfer. Review of the resident's medical chart on 3/9/23 showed: - The resident was admitted to the facility on [DATE]; - The resident was transferred to the hospital on 12/28/22; - The record did not indicate if the Ombudsman had been notified of the transfer to the hospital. 46987 2. Review of Resident #22's comprehensive MDS dated [DATE] showed: - Cognitively intact - Diagnoses: multiple sclerosis (nerve damage that effects mobility and communication between the brain and body), Hydronephrosis of right and left kidney (excessive build up of urine in the kidney that is unable to drain from the kidney into the bladder), Chronic respiratory failure (when lungs cannot get enough oxygen into the blood ), pneumonia (Fluid and infection of the lung). Review of the resident's updated care plan, dated 2/18/23, showed: - Independent with decision making and intact cognition. - Dependent of Oxygen at all times. - Dependent of staff to manage bilateral nephrostomy tubes (Tubes that drain urine from the kidney into a collection bag.) - Dependent on staff assist of one person for all personal hygiene, grooming, and transfers. - Frequent hospitalization s for care of chronic conditions. Review of the resident's medical record on 3/9/23 showed: - The resident was discharged to the hospital on 8/9/22. - The resident was discharged to the hospital on 11/1/22. - The resident was discharged to the hospital on 12/30/22. - The resident was discharged to the hospital on 2/12/23. - The resident was discharged to the hospital on 2/21/23. - The resident was readmitted on [DATE]. - There was no record in the medical record that the local Ombudsman had been notified. Review of the nursing progress notes on 3/9/23 showed: - No documentation by the nursing staff that the local Ombudsman was notified. During an interview on 3/8/23 at 3:44 P.M., the resident said: - He/she was unaware of the Ombudsman or their role in the facility. - His/her family is always aware when he/she leaves the facility. 3. During a telephone interview on 3/3/23 at 11:51 A.M., the Ombudsman said: - The facility has not been sending their transfer and discharge logs; - The last log received was in June, 2022. During an interview on 3/9/23 at 10: 45 A.M., the Social Service Director said: - That communication to the local Ombudsman is done monthly by email. - That she was unaware that it had been since June that the Ombudsmen had received any notification of discharges or transfers. - She was unable to find any emails on her computer showing any correspondence with local Ombudsman. - A previous social service staff member managed the discharge and transfer communications with the Ombudsman, and that she would now be taking on this role. - She was unable to produce any type of correspondence with the Ombudsman related to transfers and discharges. During an interview on 3/9/23 at 11:13 A.M., the Director of Nursing (DON) said: - The staff do send a transfer form with the resident or responsible party and reviewed the form the facility used; - When the resident is transferred or discharged from the facility, the Ombudsman should be notified. During an interview on 3/9/23 at 11:55 A.M., the Administrator said: - He was sure that the monthly discharge and transfer report had been going out to the local Ombudsman, since he has a reminder on his computer calendar. - He would be checking into what had happened with the monthly reports.

Based on observation, interview, and record review, the facility failed to administer medications with a less than 5% medications error rate. Facility staff made 13 medication errors out of 25 opportunities for error resulting in a 52% medication error rate. Facility failed to ensure staff did not crush medications that are recommended by the manufacturer to not be crushed. Facility staff failed to stay with a resident until all of his/her polyethylene glycol had been finished. Facility staff failed to give a resident his/her calcium pill instead gave a Vitamin C pill. Facility staff failed to administer the correct dose of Voltaren gel to a resident's bilateral shoulders. Facility staff failed to apply lacrimal pressure to the eyes per policy after instilling eye drops. Facility staff to apply the correct amount of eye drops per eye per physician's orders. This affected six sampled residents (Residents #12 and #22). The facility census was 35. Review of undated Medication Administration Competency: General Guidelines policy showed: - Compare order in the MAR (medication administration record) or TAR (treatment administration record) to the label on the medication three times before administration. Correct medication should be verified by visual check of medication, label, and MAR/TAR prior to administration. Review of undated Medication Administration Competency: Oral Medications policy showed: - Offer medications(s) to resident based on resident's preference/ability to swallow, medications may be given all at once or individually; - Remain with the resident until ALL medication is swallowed or dissolved. Medication should not be left at bedside or with resident; - If indicated, crush medications only after: a. Ensuring the medication is NOT on the Do Not Crush list; - Do not crush: a. Enteric coated medications; b. Sustained release medications; - When pouring and measuring liquid oral medications, pour correct amount of medication into a graduated measuring cup placed on a flat surface; measure at eye level to ensure accuracy. Review of undated Medication Administration Competency: Eye Drops/Ear Drops policy showed: - Hold the dropper tip directly over the eye, taking care to avoid touching the eye or eyelid; if dropper touches eye, it becomes contaminated and should be replaced; - Instruct resident to look upward; place prescribed number of drops into the pocket, continuing to hold the eyelid for one minute to allow the medication to distribute throughout the eye. If resident blinks or drop lands on cheek; repeat administration; - Policy does not state a certain amount of time to apply lacrimal pressure. Review of undated Medication Administration Competency: Topical Medications policy showed: - Clean the skin. Remove old medication residue, debris, scales, dried blood, etc. If necessary, saturate a gauze pad with solvent and wipe in the direction of hair growth to remove paste, cream or ointment from the area; - The topical medication policy did not show how to properly measure out Voltaren cream. Review of an undated GoodRx Polyethylene Glycol Dosages website showed: -The typical dose is 17 grams (1 packet or 1 capful) mixed in 4 to 8 ounces of a beverage and then taken by mouth once a day. Review of undated Voltaren Arthritis Pain website showed: - There are different amounts for upper and lower body pain. - For upper body areas, squeeze gel from the tube equal to the amount shown on the upper body section of the dosing card (2.25 inches). - For lower body areas, squeeze gel from the tube equal to the amount shown on the lower body section of the dosing card (4.5 inches). Review of undated Lorazepam (Oral Route) website showed: -Do not crush, break, or chew it. Review of undated Vitamin B12 Capsules or Tablets website showed: - If you are taking the tablets, do not chew, cut, or crush this medication. Review of Medline Plus Trusted Health Information For You-Senna website dated 2/15/18 showed: - If you are taking certain Senna products (Ex-Lax(R) regular ormaximum strength tablets or Perdiem Overnight Relief), swallow the pills whole with a glass of water; do not split, chew, or crush them. Review of undated Tylenol Extended Release (ER) Tablet-Uses, Side Effects, and More website showed: - Do not crush or chew extended-release tablets. Doing so can release all of the drug at once, increasing the risk of side effects. Swallow the tablets whole. Review of Potassium Supplement (Oral Route, Parenteral Route) website dated 3/1/23, showed: - Do not crush or chew the capsule. Swallow the capsule whole with a full (8-ounce) glass of water. Review of Hydroxyurea (Oral Route) dated 2/1/23, showed: - Swallow the capsule or tablet whole. Do not crush, break, chew, or open it. Review of How and When To Take Folic Acid dated 4/5/22, showed: - Swallow the tablets whole with a drink of water. Review of undated Pediatric Magnesium (Mag-Ox(R)) Uses and Side Effects showed: - Do not crush or chew magnesium oxide tablets. It is best to take magnesium supplements with or just after a meal to improve absorption. 1. Review of Resident #12's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff), dated 1/31/23, showed: - Brief Interview of Mental Status (BIMS is a test used to get a quick snapshot of how well you are functioning cognitively at the moment) score of 14 out of 15; - Active diagnosis of dysphagia (a disorder characterized by difficulty in swallowing); - Resident has no signs or symptoms of possible swallowing disorder. Review of resident's medication administration (MAR) dated for February 2023, showed: - Potassium chloride tablet Extended Release (ER) 1 milliequivalent ([NAME]), give 1 tablet by mouth in the morning for written potassium replacement. Do not crush; - Tylenol (Acetaminophen ER) 8-hour arthritis pain tablet Extended Release, 650 milligrams (mg), give 1 tablet by mouth; three times a day for pain. Do not crush; - Calcium oral tablet 500 mg (Calcium). Give 1 tablet by mouth two times a day for supplement; - Polyethylene glyool 3350 powder. Give 17 gram (g) by mouth in the morning for constipation. Mix in 6 to 8 ounces of water or juice, hold for loose stools; - Voltaren gel 1 % (Dlclofenao Sodium). Apply to bilateral shoulders topically three times a day for pain. Apply 2 g per shoulder; - Ativan tablet 0.5 mg (LORazepam). Give 0.5 mg by mouth as needed for anxiety; - Senna tablet 8.6 mg (sennosides) Give 1 tablet by mouth in the morning for constipation; - Folic acid tablet 1 mg. Give 1 tablet by mouth in the morning for increased nutrient needs; - The resident did not have an order for Vitamin C and Vitamin B12; - The resident did not have an order for Hydroxyurea. Observation on 3/7/23 at 8:43 A.M. showed Registered Nurse (RN) A do the following: - Popped Ativan, Vitamin C, Vitamin B12, senna, Tylenol ER, potassium chloride ER, folic acid and other medication into a small bag and crushed them then mixed the crushed meds into vanilla pudding and gave the pudding to the resident; - Filled the lid of the polyethylene glycol container half full of polyethylene glycol and added it to a 6 ounce cup of water; - Without the guidance of a measuring device to measure out the Voltaren gel, he/she squeezed an unknown amount of gel onto the resident's bilateral shoulders and rubbed the gel in; During an interview on 3/7/23 at 2:53 P.M. RN A said calcium is the same thing as Vitamin C. All medications are crushed, but staff do not crush extended release. The pharmacy tells the staff to crush the pills. The order for Voltaren gel said just apply gel to bilateral shoulders, but did not specify an amount of gel. To measure 17 grams of polyethylene glycol, he/she filled the lid of the medication to the middle inside ring and not to the top of the lid. During an interview on 3/9/23 at 11:13 A.M., Director of Nursing (DON) said calcium is not the same as Vitamin C. If calcium is ordered it should be administered. They have a list of do not crush medications. On the physician's orders, it should state whether the medicine can be crushed or not. If enteric coated (EC) or ER, we do not crush. The pharmacist helps us and he/she puts it on the pharmacy recommendation. Magnesium oxide can be crushed if it is not EC. He/she thought senna can be crushed. Potassium ER should not be crushed. Folic acid and Vitamin b12 can be crushed. Each individual order on the MAR should say not to crush. It should be on the supplemental order as well. Voltaren gel comes with a plastic ruler and you squeeze it out on the ruler to the 2 gm mark. 2. Review of undated Artificial Tears Solution - Uses, Side Effects, and More website showed: - To apply eye ointment/drops/gels: Wash hands first. To avoid contamination, be careful not to touch the dropper or top of the ointment tube or let it touch your eye. Always replace the cap tightly after each use. Tilt your head back, look up, and pull down the lower eyelid to make a pouch. For drops/gels, place the dropper directly over the eye and squeeze out 1 or 2 drops as needed. Look down and gently close your eye for 1 or 2 minutes. Place one finger at the corner of the eye near the nose and apply gentle pressure for two minutes. This will prevent the medication from draining away from the eye. Review of Resident #22's significant change in condition MDS, dated [DATE], showed: - BIMS score of 15 out of 15 meaning no cognitive impairment; - Active diagnosis of dry eye. Review of resident's POS, dated 2/1/23, showed: - Artificial Tears Ophthalmic Solution 1% (Carboxymethyloellulose Sodium (0phth)) Instill 1 drop in both eyes two times a day for dry eye. Review of resident's MAR, dated for February 2023, showed: - Artificial Tears Ophthalmic solution 1% (Carboxymethyloellulose Sodium (0phth)) Instill one drop in both eyes two times a day for dry eye. Observation on 3/7/23 at 9:45 A.M. of RN B showed: - He/she put two drops in each eye of artificial tears. - The tip of the container touched the bottom lid of both eye lids; - Did not apply enough lacrimal pressure after instilling the eye drops. During an interview on 3/7/23 at 4:32 P.M. and 3/8/23 at 9:25 A.M. RN B said: - The eye drop container does not touch any part of the eye. The patient closes their eyes and apply pressure. - Did not know the correct amount of time to hold pressure, but figured about 30 seconds to one minute to apply pressure to the eyes when giving eye drops. Whatever the order says to put in, is however many eye drops we put in. During an interview on 3/9/23 at 11:13 A.M. DON said staff should apply lacrimal pressure (pressure on the lacrimal sac) for one to two minutes. If the order says for one eye drop that is what should be administered.

Based on observations, interviews, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care which affected two of 12 sampled residents (Resident #10 and #33). The facility census was 35. 1. Review of the facility's perineal care policy, dated 2019, showed, in part: - The purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; - Wash the perineal area, wiping from front to back; - Separate the perineal folds and wash area downward from front to back; - If the resident had an indwelling catheter (a sterile tube inserted into the bladder to drain urine), gently wash the juncture of the tubing down the catheter about three inches; - Continue to wash the skin folds moving from the inside outward and use downward [MEDICAL CONDITION]; - Do not reuse the same wash cloth or wipe; - Wash the rectal area thoroughly, wiping from the base of the skin fold towards and extending over the buttocks; - Separate and cleanse all the skin folds. 2. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/1/19, showed: - Cognitive skills severely impaired; - Required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use and personal hygiene; - Upper extremity impaired on one side; - [DIAGNOSES REDACTED]. Review of the resident's care plan, revised 1/7/20, showed; - The resident was unable to perform ADLs independently due to limited mobility with history of fracture to left arm/wrist; - Required the assistance of two staff for toileting; - Required the assistance of peri-care and barrier cream. Observation on 1/7/20, at 11:12 [NAME]M., showed Certified Nurse Aide (CNA) D and CNA B provided incontinent care in the following manner: - CNA D and CNA B washed their hands and applied gloves; - CNA D picked the trash can up with his/her gloved hand and placed it by the bed; - CNA D wiped across the resident's pubic area and with the same area of the wipe, wiped down the perineal folds; - CNA D used the same area of a new wipe and cleaned different areas of the perineal folds; - CNA B and CNA D removed their gloves, washed their hands and applied new gloves; - CNA B turned the resident on his/her side; - CNA D wiped around the rectal area; - CNA D used a new wipe and wiped front to back then used the same area of the wipe and wiped up one side of the resident's leg; - CNA D turned the resident onto his/her other side; - CNA B removed the wet incontinent brief; - CNA B wiped from front to back and placed a clean incontinent brief on the resident; - CNA D did not separate clean all areas of the skin and did not clean the buttocks. During an interview on 1/9/20, at 10:04 [NAME]M., CNA D said: - He/she should have separated and cleaned all areas of the skin where urine had touched; - He/she should not use the same areas of the wipe to clean different areas of the skin. 3. Review of Resident #33's quarterly MDS, dated [DATE], showed: - Cognitive skills moderately impaired; - Required extensive assistance of two staff for bed mobility; - Dependent on the assistance of two staff for transfers and toilet use; - Always incontinent of bowel and bladder; - [DIAGNOSES REDACTED]. Review of the resident's care plan, revised 1/7/20, showed it did not address incontinent care for the resident. Observation on 1/7/20, at 10:04 [NAME]M., showed: - CNA F removed the resident's wet incontinent brief; - CNA F wiped from front to back and used the same area of the wipe to clean the rectal area; - CNA F used a new wipe and used the same area of the wipe to clean the folds of the buttocks and applied barrier cream to the buttocks; - CNA F placed a clean incontinent brief on the resident; - CNA F did not provide peri-care to the front perineal folds and did not clean all areas of the skin where urine had touched. During an interview on 1/9/20, at 9:58 [NAME]M., CNA F said: - Should separate and clean all areas of the skin where urine had touched; - Should use one wipe, one swipe; should not use the same area of the wipe to clean different areas of the skin. 5. During an interview on 1/9/20, at 2:41 P.M., the Director of Nursing (DON) said: - Staff should separate and clean all areas of the skin where urine or feces has touched; - Staff should not use the same area of the wipe to clean different areas of the skin and should wipe from front to back.

Based on observations, interviews, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when transferring three of 12 sampled residents (Residents #10, #16 and #21) during the use of a mechanical lift and during a gait belt (safety device and mobility aid used to provide assistance during transfers, ambulation or repositioning) transfer. The facility census was 35. 1. Review of the facility's safe lifting and movement of residents policy, revised (MONTH) (YEAR), showed, in part: - In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents; - Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; - Staff will document resident transferring and lifting needs in the care plan. Such assessments shall include: resident's preferences for assistance, resident's mobility (degree of independency), resident's size, weight bearing ability, cognitive status, whether the resident is usually cooperative with staff and the resident's goals for rehabilitation. 2. Review of Resident #21's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/10/19, showed: - Cognitive skills severely impaired; - Required extensive assistance of two staff for bed mobility, transfers, toilet use and personal hygiene; - Had a Foley catheter; - [DIAGNOSES REDACTED]. Review of the resident's care plan, revised 1/6/20, showed: - The resident was unable to perform activities of daily living (ADLs) independently due to being non-ambulatory and confusion with Alzheimer's diagnosis; - The resident was totally dependent on one to two staff for transfers; - The resident can stand and pivot at times; - The care plan did not specify what device to use to assist the resident with transfers. Observation on 1/8/20, at 8:06 [NAME]M., showed: - The resident sat in his/her wheelchair in the bathroom; - Certified Nurse Aide (CNA) F placed the gait belt around the resident's waist; - CNA [NAME] and CNA F grabbed the back of the gait belt, it slid up in the back between the resident's shoulder blades and transferred the resident onto the toilet; - CNA F grabbed the back of the gait belt and stood the resident up; the gait belt slid up between the resident's shoulder blades and over the resident's breasts, while CNA [NAME] provided incontinent care; - Then transferred the resident into the wheelchair and propelled him/her to the side of the bed; - CNA [NAME] and CNA F grabbed the side of the gait belt and transferred the resident onto the side of the bed; the gait belt slid up between the resident's shoulder blades and over the resident's breasts; - CNA [NAME] removed the gait belt and assisted the resident to lie down on the bed. During an interview on 1/9/20, at 9:43 [NAME]M., CNA [NAME] said: - The gait belt should not slide up; it should be tight enough to get two fingers under it; - Should place one hand on the back of the gait belt and one hand on the side of the gait belt. During an interview on 1/9/20, at 9:58 [NAME]M., CNA F said: - The gait should not slide up, it should be tight enough to get fingers under it; - Should place one hand on the side of the gait belt and one hand on the back of the gait belt. 3. Review of the undated manufacturer's guidelines for the Invacare stand up patient lift, showed, in part: - The legs of the stand up lift MUST be in the maximum open position for optimum stability and safety; - Invacare recommends locking rear swivel casters ONLY when positioning or removing the sling from around the patient; - Invacare does NOT recommend locking of the rear casters of the patient lift when lifting an individual. Review of Resident #10's quarterly MDS dated [DATE], showed: - Cognitive skills severely impaired; - Required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use and personal hygiene; - Upper extremity impaired on one side; - [DIAGNOSES REDACTED]. Review of the resident's care plan, revised 1/7/20, showed; - The resident was unable to perform ADLs independently due to limited mobility with history of fracture to left arm/wrist; - The resident was a two-person transfer with the Hoyer lift (mechanical lift). Observation on 1/7/20, at 11:12 [NAME]M., showed: - CNA B and CNA D assisted the resident to sit on the side of the bed; - CNA D placed the lift pad around the resident's waist and fastened it; - CNA D placed the sit-to-stand lift (a lift that allows residents who can bear weight to transfer from a sitting position to a standing position) under the bed with the legs closed; - CNA D raised the resident up in the sit-to-stand lift, backed the lift away from the bed and opened the legs to go around the resident's locked wheelchair and lowered the resident into his/her wheelchair; - CNA B and CNA D unhooked the resident from the lift. During an interview on 1/9/20, at 10:04 [NAME]M., CNA D said: - The brakes on the sit-to-stand lift should be locked when raising and lowering the resident; - The legs of the lift should be open when under the bed and when moving with the resident. 4. Review of the undated manufacturer's guidelines for the Invacare 450 mechanical lift, showed, in part: - Do not lock or block the casters when lifting; - To ensure stability while lifting or transferring a patient, the patient lift legs must be locked in the maximum open position. Review of Resident #16's care plan, revised 5/21/19, showed: - The resident was unable to perform ADLs independently; the resident was non-ambulatory; - The resident required a Hoyer lift with assistance of two staff for transfers. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Required extensive assistance of one staff for bed mobility; - Dependent on the assistance of two staff for transfers; - Required extensive assistance of two staff for toilet use; - [DIAGNOSES REDACTED]. Observation on 1/7/20, at 9:19 [NAME]M., showed: - The resident sat in his/her broda chair (type of reclining wheelchair); - CNA A opened the legs of the lift and placed them around the broda chair; - CNA A and CNA B hooked the resident up to the lift pad and locked the broda chair; - CNA A locked the casters on the lift; - CNA A raised the resident up in the lift, backed away from the broda chair, closed the legs of the lift and moved across the room to the side of the bed; - CNA A left the legs of the lift closed, locked the casters on the lift and lowered the resident onto the bed; - CNA A and CNA B unhooked the resident from the lift pad; - CNA A and CNA B provided incontinent care then placed the lift pad under the resident; - CNA B placed the lift under the bed with the legs closed and locked the casters; - CNA A and CNA B hooked the resident up to the lift; - CNA B unlocked the brakes and raised the resident up in the lift; - CNA B backed away from the bed with the legs closed and moved to the broda chair; - CNA B opened the legs of the lift to go around the broda chair; - CNA B locked the casters on the lift and locked the broda chair; - CNA B lowered the resident into the broda chair and both unhooked the resident from the lift. During an interview on 1/9/20, at 9:39 [NAME]M., CNA A said: - The casters or brakes should be unlocked; - The legs of the lift should be open when moving with the resident or when the lift is under the bed. During a telephone interview on 1/9/20, at 2:52 P.M., CNA B said: - The Hoyer is used by two staff and the casters should be unlocked; - The legs of the lift should be open when moving with the resident or when the lift is under the bed. 5. During an interview on 1/9/20, the Director of Nursing (DON) said: - The brakes or casters on the lift should be locked when lifting the resident from the bed; - The legs of the lift should be open when under the bed or moving with the resident in the lift; - The gait belt should not slide up in the back between the shoulder blades or in the front over the resident's breasts; - The staff should have the resident sit down and readjust the gait belt; - Staff should place one hand on the front of the gait belt and one hand on the back of the gait belt.

Based on observations, interviews, and record review, the facility failed to assure staff provided catheter (a sterile tube inserted into the bladder to drain urine) care in a manner to prevent a urinary tract infection [MEDICAL CONDITION] or the possibility of a UTI when staff failed to clean the catheter tubing and drainage spout appropriately and placed the graduate (a clear plastic container with markings used to collect and measure fluids) directly on the floor which affected one of 12 sampled residents (Resident #21). The facility census was 35. 1. Review of the facility's competency checklist for urinary catheter care, revised (MONTH) 2019, showed, in part: - Provide perineal care; - Spread the skin folds with the non-dominant hand, clean the catheter at point of insertion into the opening to cleanse the entire circumference of the catheter. 2. Review of Resident #21's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/10/19, showed: - Cognitive skills severely impaired; - Required extensive assistance of two staff for bed mobility, transfers, toilet use and personal hygiene; - Had a Foley catheter; - [DIAGNOSES REDACTED]. Review of the resident's care plan, revised 1/6/20, showed: - The resident was unable to perform ADLs independently due to being non-ambulatory and confusion with Alzheimer's diagnosis; - The resident was not toileted; - The resident had poor trunk control and had to be checked and changed; - Had a Foley catheter in place due to [MEDICAL CONDITION] bladder (lack of bladder control due to brain, spinal cord or nerve problem) and pressure ulcer on his/her sacral area (large heavy bone at the base of the spine). Observation on 1/8/20, at 8:06 [NAME]M., showed: - Certified Nurse Aide (CNA) F propelled the resident into his/her bathroom; - CNA [NAME] and CNA F used the gait belt (safety device and mobility aid used to provide assistance during transfers, ambulation or repositioning) and transferred him/her from the wheelchair onto the toilet; - The resident had diarrhea in his/her incontinent brief and in the toilet; - CNA F stood the resident up with the use of the gait belt; - CNA [NAME] removed the soiled incontinent brief and placed a clean incontinent brief on the resident; - Fecal material remained on the seat of the toilet and in the back of the new incontinent brief; - CNA [NAME] provided peri-care to the buttocks and rectal area; - CNA [NAME] did not separate and clean all the front perineal folds; - CNA [NAME] did not clean the catheter tubing; - CNA F pulled up the incontinent brief with a drop of fecal material in the back of the brief; - CNA [NAME] and CNA F transferred the resident into the wheelchair and transferred the resident into the bed; - CNA [NAME] placed the graduate directly onto the carpeted floor; - CNA [NAME] removed the drainage spout from the sleeve, opened it and emptied 200 milliliters (ml) in the graduate, wiped the drainage spout with a dry wash cloth and replaced it in the sleeve. During an interview on 1/9/20, at 9:43 [NAME]M., CNA [NAME] said: - He/she should have separated and cleaned all areas of the skin where feces had touched; - He/she should have put a clean incontinent brief on the resident; - He/she should have anchored the catheter tubing and cleaned it; - The graduate should have been placed on a clean barrier; - The catheter port should have been cleaned with an alcohol wipe. 3. During an interview on 1/9/20, at 2:41 P.M., the Director of Nursing (DON) said: - Staff should separate and clean all areas of the skin where urine or feces has touched; - Staff should anchor and clean down the catheter tubing away from the body; - Staff should place the graduate on the barrier; - Staff should have cleaned the drainage spout with an alcohol wipe.