Every finding on record at Lindsay Gardens Nursing & Rehabilitation

Based on interview and record review, the facility failed to ensure its policy and procedure was followed when staff failed to report abuse for one of three sampled residents (Resident 1) timely. This failure resulted in a delay in the abuse investigation and the potential for residents to be at risk of abuse.Findings:During a review of Resident 1's admission Record (AR) dated 8/5/26, the AR indicated Resident 1 was admitted on [DATE] with diagnoses that included cognitive communication deficit (trouble with communication caused by a problem with brain thinking skills like attention, memory and executive function), transient cerebral ischemic attack, unspecified (temporary blockage of blood flow to part of the brain) and old myocardial infarction (happens when blood flow to part of the heart muscle stops or slows down way too much).During a review of Resident 1's Brief Interview for Mental Status (BIMS-used to measure a nursing home resident's basic thinking and memory skills) dated 5/20/26, the BIMS indicated, Score: 15 (normal thinking and memory, no or very little impairment).During an interview on 8/5/26 at 10:35 a.m. with Resident 1, Resident 1 stated Certified Nursing Assistant (CNA) 1 left him laying in urine three to five hours on more that one occasion and he reported it weeks ago to Director of Staff Development (DSD) and nothing was done.During an interview on 8/5/26 at 12:01 p.m. with Social Service Director (SSD), SSD stated on 7/29/26 Resident 1 reported that CNA 1 refused to change him when he was soiled. SSD stated Resident 1 was referred to DSD and went to DSD office to talk to her. During an interview on 8/5/26 at 12:04 p.m. with Receptionist/admission Assistant (RT/AA), RT/AA stated on 7/29/26 Resident 1 reported that during the night CNA 1 answered his call light and he had requested to be changed. CNA 1 told him she was in the middle of her rounds and didn't have time to change him and turned off the call light and walked out leaving him in urine down to his knees. RR/AA stated she let the DSD know that Resident 1 needed to speak to her regarding the incident and Resident 1 went with the DSD to her office. RR/AA stated Resident 1 came back after talking to DSD and stated DSD was upset and was yelling at him. RR/AA stated she felt the allegations made by Resident 1 were verbal abuse and neglect and reported the allegations to the corporate compliance hotline on 7/29/26 and to the Administrator on 8/3/26. RT/AA stated she did not know if anything was done regarding the allegations.During an interview on 8/5/26 at 12:19 p.m. with SSD, SSD stated allegations of abuse were to be reported to the Ombudsman, state licensing agency, law enforcement and APS (adult protective services) within two hours or 24 hours if there is no injury.During an interview on 8/5/26 at 12:31 p.m. with Administrator, Administrator stated he was the abuse coordinator and when there was an allegation of verbal abuse and/or neglect the staff are expected to report the allegation to him or any manager. Administrator stated he was unaware of the abuse allegations made by Resident 1 and per policy the allegations should have been reported to state licensing agency, Ombudsman, APS, law enforcement, Resident 1's responsible party, and the medical director within two hours of becoming aware of the allegation if involving abuse or resulting in serious bodily injury. During an interview on 8/5/26 at 1:19 p.m. with Director of Nursing (DON), DON stated she was unaware of Resident 1's allegations and when the allegation of abuse was made the staff should have reported it to the Administrator or her so a full investigation could have been completed.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating undated, the P&P indicated, All reports of resident abuse.neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management.If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury.within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on interview and record review, the facility failed to ensure financial abuse was reported to the state agency for one of three sampled residents (Resident 1). This failure resulted in an incomplete investigation.Findings:During a review of the Report of Suspected Dependent Adult/Elder Abuse (SOC341-form used to document suspected physical, sexual, financial, neglect .) dated 7/13/26, the SOC341 indicated, Victim.(Resident 1).reported type of abuse.financial.Resident has a share of cost and his SSA (social security) checks are going directly into a bank account. Which the son has access. Contacted son three times.balance is 7,392 (dollars) that is owed.written report.Ombudsman.[NAME] police department. APS (adult protective services) .During an interview on 8/3/26 at 11:46 a.m. with Office Manager (OM), OM stated Resident 1 had a past due balance that was not being paid and she filed an SOC341 to the Ombudsman, [NAME] Police Department and APS. OM stated she was unaware she was required to report to the state agency.During a concurrent interview and record review on 8/3/26 at 12:05 p.m. with Administrator, the facility's Policy and Procedure tilted Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating, dated 7/26 was reviewed. Administrator stated he was aware of Resident 1's past due balance and an SOC341 was filed with the Ombudsman, [NAME] Police Department and APS. Administrator stated per facility policy the state agency was not notified of the allegation of financial abuse and they should have been. During a review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating, dated 7/26, the P&P indicated, Any suspicion of resident abuse, neglect, exploitation, theft/misappropriation of resident property, or injury of unknown source must be reported immediately to the administrator and to other officials according to state law and federal regulations.The administrator or designee must immediately report the allegation to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility.

Based on interview and record review, the facility failed to follow its policy and procedure when physician orders were not entered correctly in the electronic medical record (EMR) and wound treatments were not being documented on the Treatment Administration Record (TAR) for one of three sampled residents (Resident 1). This failure resulted in the medical record being inaccurate. Findings:During a review of the Order Review Report (ORR) dated 4/1/26-4/30/26, the ORR indicated, Tx (treatment) coccyx (tailbone) cleanse w/dws (dermal wound spray-used to clean wounds), pat dry, apply Medihoney (medication used to treat wounds) and foam dressing q (every) shift.order date.4/23/26.Tx (Treatment) bilateral toes and bilateral ankles: cleanse w/ (with) dws, pat dry, and apply betadine (topical medication used to prevent infections) qshift.Order date.4/23/26.During a review of Resident 1's TAR, dated [DATE], the TAR indicated there were no documented treatments to Resident 1's coccyx, bilateral toes and bilateral ankles.During a review of Resident 1's Care Plan (CP) dated 4/23/26, the CP indicated, Resident has a pressure ulcer to (sacrococcyx) and is at risk for further breakdown and/or slow, delayed healing related to advanced aging process.Interventions/Tasks.Administer treatment as ordered.During a review of Resident 1's CP dated 4/23/26, the CP indicated, Skin: resident has a venous stasis ulcer to (bilateral toes and ankles) and is at risk for further breakdown and/or slow, delayed healing related to advanced aging process.Interventions/Tasks.Administer treatment as ordered.During a concurrent interview and record review, on 5/19/26 at 11:58 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's clinical record was reviewed. LVN 1 was unable to find documentation of the wound treatments being documented when administered. LVN 1 stated when the treatments were administered they should have been documented on the TAR.During a concurrent interview and record review, on 5/19/26 at 12:07 p.m. with Director of Nursing (DON), Resident 1's clinical record was reviewed. DON was unable to provide documentation of the wound treatments when administered. DON stated the physician orders were entered incorrectly and were not indicated to appear on the TAR when administered and they should have been. DON stated when the treatments were administered, they should have been documented on the TAR.During an interview on 5/19/26 at 12:34 p.m. with Assistant Director of Nursing (ADON), ADON stated she was unable to provide evidence of Resident 1's treatments being documented after administration.During an interview on 5/20/26 at 4:40 p.m. with LVN 2, LVN 2 stated she was the nurse that was on duty when Resident 1 was admitted to the facility on [DATE]. LVN 2 stated Resident 1 was admitted with wounds. LVN 2 stated when she administered wound treatments they should have been documented on the TAR.During an interview on 5/29/26 at 8:52 a.m. with LVN 3, LVN 3 stated when Resident 1 was admitted to the facility on [DATE], Resident 1 was admitted with several wounds. LVN 3 stated he was the one that entered the treatment orders into the EMR when Resident 1 was admitted but the orders were entered incorrectly and they did not appear on the TAR for administration. LVN 3 stated the wound treatments should have been documented on the TAR when he administered them.During a review of the facility policy and procedure (P&P) titled, Wound Care (WC) dated 4/2026, the P&P indicated, the purpose of this procedure is to provide guidelines for the care of the wounds to promote healing.Documentation.The following information should be recorded in the resident's medical record.the type of wound care given.the date and time the wound care was given.the name and title of the individual performing the wound care.

Based on observation, interview, and record review the facility failed to develop and implement and revise a comprehensive care plan (CP) for three of 33 sampled residents (Resident 61, Resident 81 and Resident 36). This failure had the potential to result in Resident 61, Resident 81, and Resident 36 having an unrecognized change in condition and adverse health outcomes. Findings: During a concurrent observation and interview on 1/6/26 at 12:10 p.m. with Dietary Manager Assistant (DMA) in the kitchen, Resident 61's lunch meal plate contained a taco with a flour tortilla and ground pork, lettuce and tomatoes, a number (#) 12 scoop (1/3 cup) of beans and one slice of wheat bread. DMA stated Resident 61 requested an alternate meal versus the planned renal/CCHO (Consistent Carbohydrate) diet of 3 oz (ounces) of pork, 1 oz. pear sauce, #12 scoop polenta (cornmeal), 1/2 cup broccoli, one wheat roll, 1/2 cup diet (sugar free) canned pears. DMA stated the facility did not have meal alternatives available that have been evaluated and/or modified for therapeutic diets. DMA stated the Dietary Manager instructed dietary staff to serve Resident 61 the available meal alternative whenever he asked for it because he had a signed contract/form. DA showed the alternative meals available to serve to Resident 61 upon his request that was posted on a board located inside DMA's office in the kitchen that indicated, Mon [Monday] – grilled cheese & tomato soup, Tue [Tuesday] – Tacos, Wed [Wednesday] – Chicken Nuggets, Thur [Thursday] Chef Salad, Fri [Friday] – Pizza, Sat [Saturday] Chicken Patty.Sun [Sunday] – Soup & Biscuit. DMA stated those alternatives were provided by the Dietary Manager and they were not incorporated into a facility policy and procedure or typed up and posted, but that was the alternative meal schedule that kitchen staff followed. During a concurrent observation and interview on 1/6/26 at 12:26 p.m. with Resident 61 in his room, Resident 61 was lying in bed covered with a blanket. Resident 61 stated he did not want to eat because he was not feeling well. During an interview on 1/7/26 at 4:06 p.m. with Resident 61, Resident 61 stated he was feeling better today. Resident 61 stated he wants to eat everything. Resident 61 stated he liked tacos and beans. Resident 61 stated he did not care if tomatoes were on his tacos or not as that was not so important to him. Resident 61 was asked if he might be willing to follow some things on a therapeutic diet while other food items he may want served in an authentic manner (not modified), and he said yes, while nodding his head up and down. During a review of Resident 61's Diet Waiver, dated 3/7/23, the diet waiver form indicated, I understand that my doctor, registered dietician, or speech therapist for reasons for my health and medical treatment, has ordered or recommended a diet of: CCHO/Renal related to the diagnoses of Chronic Kidney Disease. I understand that not following the prescribed diet may be detrimental to my health and well-being and could cause medical complications. I understand that the reason for the order or recommendation for the diet is to provide softest diet. I do not wish to follow the diet that has been ordered or recommended for me by my doctor, dietician or speech therapist. I also understand that my doctor, dietician, or speech therapist and this facility are not responsible for any harm that I may suffer as a result of refusal to follow my ordered or recommended diet. I understand this may include choking, aspiration, weight loss, declining nutritional status, skin issues, up to and including death. I therefore declare that it is my intention to not follow my ordered or recommended diet and request that I be provided with food of my choice by my family, friends and this facility. The Diet Waiver was signed by Resident 61, a witness and a physician. During a review of Resident 61's Diet Order Summary, dated 6/24/25, the diet order indicated, CCHO, Renal diet, Regular texture, thin liquids consistency. During a review of Resident 61's meal tray card (resident specific meal directions for dietary and nursing staff including food likes and dislikes) the following food likes/dislikes and food preferences were noted: Breakfast – None, Lunch & Dinner – Please send a burrito when fish is on the menu; dislikes fish. During a concurrent interview and record review on 1/7/26 at 3:20 p.m. with the Director of Nursing (DON), Resident 61's IDT (Interdisciplinary Team, a group of health care professionals that meet to discuss resident care)Care Plan Report, initiated on 6/1/25, was reviewed. The care plan report indicated, Focus: Resident has CCHO diet but is sometimes noncompliant with this and likes to eat burritos regularly. Has signed a release form to eat a liberal diet of choosing. Goal: Resident will be allowed to have diet of his choosing with minimal conflicts, Intervention/Tasks: Liberal diet with a CCHO framework as much as feasible. Will encourage compliance with CCHO diet. Monitor food intake and chart q [every] shift routinely. Monitor glucose as ordered. RD [Registered Dietician] to follow as needed, quarterly and annual. DON stated there was no documentation on the care plan for noncompliance of CCHO diet, initiated on 6/1/25 with a last care plan review completed date of 12/16/25, of noncompliance related to the renal portion of the diet order, nor did the care plan document risks of refusing to follow the ordered therapeutic CCHO/Renal diet order and any specific attempts to find and offer alternative approaches to help Resident 61 follow his therapeutic diet orders as close as possible while honoring Resident 61's preferences. DON reviewed Resident 61's care plan conferences, nursing progress notes, all IDT care plans and nutrition assessments and stated there were no documentation of any further discussion with Resident 61 related to the Diet Waver and his desires related to therapeutic diet since 2023, despite Resident 61 experiencing significant change of condition in 2025 to include a heart attack and acute kidney injury on top of chronic kidney disease. During a review of the facility's policy and procedure (P&P) titled, Food Substitutions For Residents Who Refuse The Meal, dated 2023, the P&P indicated, Policy: Residents will be provided a suitable nourishing alternate meal after the planned, served meal has been refused. Procedure: Nursing personnel will ask any resident who does not eat his meal or food item as to why he is not eating and offer a food substitution in accordance with the resident's diet order. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 2023, the P&P indicated, The care plan interventions should be derived from information obtained from the resident. with possible discretionary modifications resulting from the comprehensive assessment. The comprehensive, person-centered care plan should: a. Include measurable objectives and time frames; b. Describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing that the resident desires or that is possible, including services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights (including the right to refuse treatments). During a review of Resident 81's admission Record (AR), dated 1/8/26, the AR indicated, Resident 81 was admitted on [DATE] with a diagnosis of moderate depressive disorder and dementia (decline in mental ability). During a review of Resident 81's Brief Interview for Mental Status (BIMS,0-15 point assessment used in long-term care to quickly screen cognitive function), dated 11/06/25, the BIMS indicated, a score of three (intact 13-15, moderately impaired 8-12, and severe impairment 0-7). During an observation on 1/5/26 at 10:16 a.m. in Resident 81's room, Certified Nursing Assistant (CNA) 2 was providing care to Resident 81, CNA 2 asked Resident 81 if he wanted to go to the restroom and Resident 81 stated to CNA 2 he wanted some pussy. During an interview on 1/5/26 at 10:17 a.m. with CNA 2, CNA 2 stated Resident 81 spoke to some staff this way (confirmed resident stated pussy) but she was used to this language. During an interview on 1/5/26 at 10:25 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 81 was verbally inappropriate to some staff. During an interview on 1/7/26 at 11:44 a.m. with LVN 4, LVN 4 stated Resident 81 speaks inappropriately to staff but not to other residents. During an interview on 1/8/26 at 9:18 a.m. with CNA 3, CNA 3 stated Resident 81 can be aggressive and uses profanity towards staff when providing care like changing his clothes, showering and shaving. During a concurrent interview and record review on 1/8/26 at 10:48 a.m. with DON, Resident 81's CP's were reviewed. DON stated there was only a CP for Resident 81's negative behaviors. DON stated Resident 81 has negative and naughty behaviors. DON stated Resident 81 can express inappropriate verbalization to females and stated she was surprised there was not a CP for this behavior, and he should have a CP for sexual verbalization. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated March 2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 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 care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. During a concurrent interview and record review on 1/7/26 at 2:08 p.m. with Assistant Director of Nurses (ADON), Resident 36's Physician Orders (PO), (undated) were reviewed. ADON stated she could not find an order for Oxygen for Resident 36. ADON stated Resident 36 is receiving oxygen and should have had an order before it was administered. During a concurrent interview and record review on 1/7/26 at 2:16 p.m. with ADON, Resident 36's CP, dated 12/31/25 was reviewed. The CP indicated Oxygen: Resident requires the use of oxygen continuous related to shortness of breath. Wheezing, CHF [congestive heart failure, chronic condition of heart being unable to pump adequate amount of blood] date initiated 12/31/25.Administer oxygen at 2L [liter] via NC [nasal cannula] date initiated 12/31/25.Monitor oxygen saturation [oxygen levels in blood] via pulse oximetry [device used to measure oxygen levels] daily and PRN [as needed]. date initiated 12/31/25. ADON stated she was not able to find results of resident being monitored for oxygen saturation and stated the last oxygen saturation was documented on 10/17/25. ADON stated there were no recent oxygen saturation results documented and stated they were not implementing the CP and they should have been. During a review of the facility's P&P titled, Care plans, Comprehensive person-Centered, dated 2022, the P&P indicated, A Comprehensive, person-centered care plan that includes measurable objectives and time-tables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview and record review, the facility failed to: 1. Obtain a physician's order for two of six sampled residents (Resident 36 and Resident 84) prior to oxygen use. This failure had the potential for Resident 84 and Resident 36 to have serious health outcomes, including hypoxia (lack of oxygen) or oxygen toxicity (too much oxygen) causing lung damage and confusion. 2. Follow physician's orders for one of six sampled resident (Resident 84) when oxygen saturation levels were not monitored. This failure had the potential to result in missed early signs of low blood oxygen levels which could lead to potential organ damage, especially to the heart and brain. Findings: 1. During an observation on 1/5/26 at 12:22 p.m. in the facility dining room, Resident 36 was sitting at the dining table having her lunch. Resident 36 was using a nasal cannula (NC - a thin tubing with two prongs that are placed in the nose to deliver oxygen) with an empty oxygen tank attached to her wheelchair. During a concurrent observation and interview on 1/5/26 at 12:25 p.m. with Licensed Vocational Nurse (LVN) 6 in the facility dining room, LVN 6 checked the oxygen tank attached to Resident 36's wheelchair, LVN 6 stated the tank was empty and should have changed before bringing Resident 36 to the dining room. During a concurrent interview and record review on 1/7/26 at 2:08 p.m. with Assistant Director of Nurses (ADON), Resident 36's Physician orders (PO) were reviewed. ADON stated she could not find an order for oxygen for Resident 36. ADON stated Resident 36 is receiving oxygen and should have had an order before it was administered. During a concurrent observation and interview on 1/8/26 at 9:33 a.m. with Resident 84 in Resident 84's room, Resident 84 was receiving oxygen at 3 liters via a NC. Resident 84 stated she had been wearing continuous oxygen for years. During a concurrent interview and record review on 1/8/26 at 9:39 a.m. with LVN 8, Resident 84's PO, (undated) were reviewed. The PO indicated, Resident 84 did not have an order for oxygen. LVN 8 stated Resident 84 did not have a physician order for continuous oxygen use and should have had one. During an interview on 1/8/26 at 10:59 a.m. with Director of Nursing (DON), DON stated Resident 84 did not have a physician order for the use of oxygen and should have had one. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 2010, the P&P indicated, 1. Verify that there is a physician's order for this procedure, Review the physician orders or facility protocol for oxygen administration. 2. During a review of Resident 84's Order Review Report (ORR), dated 7/14/25, the ORR indicated, Monitor Pulse Oximetry [device used to monitor oxygen levels] q [every] shift: If O2 [oxygen] < [less than] 90 % [percent] administer O2 via NC. During a concurrent observation and interview on 1/8/26 at 9:33 a.m. with Resident 84 in Resident 84's room, Resident 84 was receiving oxygen at 3 liters via a nasal canula. Resident 84 stated she had been wearing continuous oxygen for years. Resident 84 stated staff check her vital signs once per night. Resident 84 stated she thinks staff need to check her oxygen levels more often. During a concurrent interview and record review on 1/8/26 at 9:39 a.m. with LVN 8, Resident 84's Medication Administration Record (MAR), dated January 2026 was reviewed. The MAR indicated Resident 84 did not have any oxygen saturation monitoring documented. LVN 8 stated resident oxygen saturation levels are checked in the mornings and during medications administration and should be documented in the resident MAR. LVN 8 stated Resident 84 did not have any oxygen saturation levels documented in her MAR. LVN 8 stated Resident 84's oxygen saturation levels should have been documented each shift. During a concurrent interview and record review on 1/8/26 at 10:58 a.m. with DON, Resident 84's MAR, dated December 2025 was reviewed. The MAR indicated, Monitor Pulse Oximetry q shift. If O2 < 90 % administer O2 via NC. The MAR had an X in each box that was meant to be documented in from 12/1/25 through 12/31/25. DON stated the X on the MAR indicated that the task was not completed. DON stated Resident 84's oxygen saturations had not been documented in the chart and should have been. During a review of the facility's P&P titled Oxygen Administration, dated October 2010, the P&P indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration.1. Verify there is a physician's order for this procedure. Review the physician's orders or facility protocol.Assessment.Before administering oxygen, and while the resident is receiving oxygen therapy, assess the following.vital signs.oxygen saturation.Documentation.the following information should be recorded in the resident's medical record.3. The rate of oxygen flow, route and rationale.6. All assessment data obtained.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled to work in the facility for at least eight consecutive hours a day, seven day per week. This failure had the potential to adversely affect resident care. Findings: During an interview on 1/7/26 at 8:58 a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated, there was an RN that worked on weekends, but was not sure if there was an RN scheduled to work on weekdays. During an interview on 1/7/26 at 9:03 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated there was an RN that worked weekends and the RN working on weekdays was the Director of Nursing (DON). During an interview on 1/7/26 at 9:10 a.m. with LVN 7, LVN 7 stated the facility had an RN who worked daily. LVN 7 stated the RN working was the DON.During an interview on 1/7/26 at 9:28 a.m. with Human Resources/Payroll Manager (HR/PM) and Administrator, Administrator stated she had been working in this facility since June 2025 and the facility has not had an RN working on the floor consistently. Administrator stated they utilize the DON for coverage. HR/PM stated the facility had one DON and two RN's. HR/PM stated there have been days when there was not an RN on the unit besides the DON.During an interview on 1/7/26 at 9:49 a.m. with Administrator, Administrator stated this was a 99-bed facility and the census averaged over 60 residents at all times. Administrator stated the facility did not have an RN to work daily on the weekdays and they should have had an additional RN besides the DON.During a concurrent interview and record review on 1/8/26 at 11:39 a.m. with HR/PM, RN 1 and RN 2's Time Sheets (TS) dated 10/1/25 to 1/7/26 were reviewed. The TS indicated, there were no RN's working in the facility on 10/1/25, 10/2/25, 10/3/25,10/8/25, 10/9/25, 10/10/25, 10/13/25, 10/14/25, 10/15/25, 10/16/25, 10/17/25, 10/21/25, 10/22/25, 10/24/25, 10/27/25, 10/29/25, 11/4/25, 11/5/25, 11/6/25, 11/7/25, 11/10/25, 11/11/25, 11/13/25, 11/14/25, 11/18/25, 11/19/25, 11/20/25, 11/21/25, 11/25/25, 11/26/25, 12/1/25, 12/2/25, 12/3/25, 12/4/25, 12/5/25, 12/8/25,12/9/25, 12/10/25, 12/11/25, 12/12/25, 12/15/25, 12/16/25, 12/17/25, 12/22/25, 12/23/25, 12/24/25, 12/30/25, 12/31/25 and 1/1/26.HR/PM stated there were multiple days per week when there was no RN working 8 consecutive hours besides the DON.Policy requested, facility failed to provide.

Based on observation, interview, and record review, the facility failed to ensure:1. The facility's 3-compartment procedure for manual dishwashing was followed by one of one sampled dietary aide (DA) 1 who washed one piece of foodservice equipment via the 3-compartment sink.2. One of five observed dietary employees (DA 2) washed their hands after a cross-contamination incident during the lunch tray line meal service for residents.These failures had the potential to place residents at risk of foodborne illness who received meals from the kitchen.Findings:1. During a concurrent observation and interview on 1/6/26 at 11:25 a.m. with DA 1 in the kitchen, DA 1 was observed washing a large mixing food container in the first sink of the 3-compartment sink. DA 1 then removed the container and placed it in the 3rd compartment sink that contained a sanitizing solution. DA 1 stated she did not use the 2nd compartment to rinse off the container after washing it because there was no foam on the container. During an interview on 1/6/26 at 3:55 p.m. with Dietary Manager Assistant (DMA), DMA stated DA 1 reported the above to her, and DMA stated she should have rinsed off the container in the 2nd compartment prior to placing the container in the 3rd compartment to sanitize. During a review of the facility's policy and procedure (P&P) titled, 3-Compartment Procedure For Manual Dishwashing, dated 2023, the P&P indicated, Procedure: The first compartment is for washing. Fill the first compartment with detergent per manufacturers instructions and hot water.Replace water when it becomes cloudy or dirty, the suds are gone, or when temperature falls below 110 degrees F [Fahrenheit]. The second compartment is for rinsing. Fill the second compartment with clean, clear hot water, (110 degrees F-120 degrees F).Immerse washed items and rinse thoroughly, making sure all detergent is removed. Replace water when it becomes cloudy or dirty, or when temperature falls below 110 degrees F. The third compartment is for sanitizing.During a review of the FDA Food Code (FDAFC), dated 2022, the FDAFC indicated, If washing in sink compartments.washed UTENSILS and EQUIPMENT shall be rinsed so that abrasives are removed and cleaning chemicals are removed or diluted through the use of water.During a review of the FDA Food Code Annex (FDAFCA ), dated 2022, the FDAFCA indicated, It is important to rinse off detergents, abrasive, and food debris after the wash step to avoid diluting or inactivating the sanitizer.2. During a concurrent observation and interview on 1/6/26 at 11:45 a.m. with DA 2 in the kitchen, DA 2 wore blue gloves and placed her hands in her pants pockets, removed her gloved hands from her pockets and proceeded to pick up a plate cover for a residents' lunch meal service. DA 2 then proceeded to cross her arms touching her skin and shirt and continued with lunch tray line, without removing her gloves to wash her hands and put on a clean pair of gloves. During an interview on 1/6/26 at 11:47 a.m. with DA 2, DA 2 stated she should not have placed her hands (even with gloves) in her pockets or touched her body. DA 2 stated, It's unsanitary. During an interview on 1/6/26 at 4 p.m. with DMA, DMA stated DA 2 reported the above to her, and DMA stated she should have removed her gloves and washed her hands. During a review of the facility's P&P titled, Hand Washing Procedure, dated 2023, the P&P indicated, Hand washing is important to prevent the spread of infection. When Hands Need To Be Washed: .after touching your hair or face.During a review of the FDAFC, dated 2022, the FDAFC indicated, When to Wash. Food employees shall clean their hands and exposed portions of their arms.immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and.to prevent cross contamination when changing tasks. Before donning gloves to initiate a task that involves working with food.

Based on observation, interview and record review, the facility failed to follow infection control standards when:1.A Water Management Program (WMP) was not implemented, for 32 of 32 sampled residents, when risk for growth of opportunistic waterborne pathogens (germs that grow well in water) was not assessed, areas for growth were not identified, and measures to prevent and monitor growth were not identified within the facility's water system. This failure had the potential to result in serious illness or death of residents, visitors and staff.2. Licensed Vocational Nurse (LVN) 4 failed to use aseptic technique for one of four sampled residents (Resident 5) when she introduced a syringe in Resident 5's mouth and then reintroduced the used syringe into the clean medication container. This failure had the potential to contaminate the medication container with bacteria and microorganisms.Findings: 1. During a concurrent interview and record review on 1/7/26 at 10:55 a.m. with Infection Preventionist (IP), the facility's policy and procedure (P&P) titled, Legionella [bacteria that can grow in man-made water systems like cooling towers and plumbing, especially in warm water] Water Management Program, dated September 2022 was reviewed. The P&P indicated, 5. The water management program includes the following elements: . b. A detailed description and diagram of the water system in the facility. c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria. d. The identification of situations that can lead to Legionella growth. e. Specific measures used to control the introduction and/or spread of Legionella. f. The control limits or parameters that are acceptable and that are monitored; g. A diagram of where control measures are applied; h. A system to monitor control limits and the effectiveness of control measures; i. A plan for when control limits are not met and/or control measures are not effective; and j. Documentation of the program. IP stated the facility does not have documentation of the water management program. IP was unable to verbalize areas within the facility that were assessed for risk, measures used to mitigate risk, acceptable control limits and parameters of the measures used, and how control limits and parameters were monitored. During an interview on 1/7/26 at 11:07 a.m. with Maintenance Director (MD), MD stated he did not have training regarding the WMP and prevention of Legionella growth. MD was unable to verbalize areas of the facility that were at risk for bacteria growth in the water system. MD was unable to verbalize measures used to mitigate and monitor the risk of growth. MD was unable to identify control limits and parameters for the measures used. MD stated there was no diagram or documentation of description of the facility water system with identified areas of concern for growth. During a review of the Center for Disease Control (CDC) document titled, Toolkit for Controlling Legionella in Common Sources of Exposure (LCT - Legionella Control Toolkit), dated 12/26/24, the LCT indicated, [S] Sediment [Mineral build-up in a water system that uses up disinfectant and encourages growth of bacteria] and biofilm [layer produced by germs that stick to and grow on moist surfaces; provides an environment for growth of bacteria including Legionella], Temperature [T], water Age [A], and disinfectant Residuals [R] (STAR) are the key factors that affect Legionella growth in potable [water that is safe for ingestion] water systems. A comprehensive WMP allows water system operators to layer a series of complementary control measures to create environmental conditions that prevent bacterial intrusion, growth, and transmission. Develop or refine a WMP with the following guidelines in mind: . Monitor temperature, disinfectant residuals, and pH [potential of hydrogen - measures a substance's acidity or alkalinity] frequently. Store hot water at temperatures above 140 degrees F [Fahrenheit] and ensure hot water in circulation does not fall below 120 degrees F. Store and circulate cold water at temperatures below the favorable range for Legionella 77–113 degrees F. Ensure a disinfectant residual [Chlorine (disinfectant added to tap water as a disinfectant to kill harmful bacteria) and Monochloramine (longer-lasting disinfectant)] is detectable throughout the potable water system. Flush low-flow piping runs and dead legs at least weekly and flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as-needed to maintain water quality parameters within control limits. Clean and maintain water system components, such as thermostatic mixing valves, aerators, showerheads, hoses, filters, and storage tanks, regularly. 2. During a review of Resident 5's Medication Administration Record, (MAR) dated 1/1/26 through 1/31/26, the MAR indicated, Morphine Sulfate (MS) (Concentrate) Oral Solution 20 mg (milligram)/ML (milliliter) (Morphine Sulfate Give 2.25 ml by mouth every 4 hours as needed for Severe pain 7-10 or SOB [shortness of breath] place under tongue or in cheek pocket. During an observation on 1/7/26 at 8:52 a.m. in Resident 5's room, LVN 4 administered Resident 5's MS oral liquid 2.25 ml under Resident 5's tongue. LVN 4 drew up one ml of MS in syringe and placed syringe under the tongue of Resident 5 and administered. LVN 4 with same syringe drew up another one ml of MS in the used syringe and administered under the tongue of Resident 5. LVN 4 then drew up another 0.25 ml of MS in same used syringe and administered the 0.25 ml under the tongue of Resident 5. LVN 4 then placed the used syringe in a plastic bag. During an interview on 1/7/26 at 9:56 a.m. with Director of Nursing (DON) and LVN 4, LVN 4 stated she had drawn up one ml of MS from container and then administered under Resident 5's tongue and then put the used syringe back into the MS container and drew up another one ml of MS and administered the morphine under the tongue of Resident 5 with the same syringe. LVN 4 stated she then used the same syringe to draw up 0.25 ml of MS and administered under the tongue of Resident 5. LVN 4 stated she should have disinfected the syringe in between putting the same syringe back into the container after administering the medication. DON stated LVN 4 should have cleaned the syringe after putting the syringe into Resident 5's mouth. During a review of the facility's P&P titled, Administering Medications, dated December 2012, the P&P indicated, Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.

Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 7) was provided dignified care when Resident 7's urine collection bag was not covered and was visible to other residents, staff and visitors. This failure had the potential to result in emotional distress for Resident 7.Findings:During an observation on 1/6/26 at 9:38 a.m. outside of Resident 7's room, a urine collection bag containing yellow liquid was hanging on the side of Resident 7's bed and was visible from the hallway.During a concurrent observation and interview on 1/6/26 at 9:43 a.m. with Licensed Vocational Nurse (LVN) 9, outside of Resident 7's room, a urine collection bag containing yellow liquid was hanging on the side of Resident 7's bed and was visible from the hallway. LVN 9 stated the collection bag needed a cover to provide privacy for Resident 7.During a review of Resident 7's Order Review Report (ORR), dated 1/8/26, the ORR indicated, Indwelling urinary (Foley [brand name of catheter, inserted into the bladder to drain urine]) catheter is in privacy bag and catheter leg strap on at all times.During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated August 2009, the P&P indicated, 3. Our facility will make ever effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

Based on observation, interview and record review, the facility failed to ensure two of two sampled residents (Resident 99 and Resident 87) were provided privacy when 24 hour video surveillance was used to monitor Resident 99 and Resident 87 without written consent. This failure resulted in the violation of Resident 99 and Resident 87's right to privacy and confidentiality and the potential to result in emotional distress.Findings:During a concurrent observation and interview on 1/5/26 at 11:12 a.m. with Licensed Vocational Nurse (LVN) 9, in the doorway of Resident 99's room, a round shaped item was hanging on the wall at the foot of Resident 99's bed. LVN 9 stated the item was a video camera used to monitor Resident 99. LVN 9 stated the monitor screen was at the nurses station allowing all staff to monitor Resident 99. During an observation on 1/5/26 at 11:12 a.m. a monitor screen was sitting on the counter at the nurses station, Resident 99 was visible lying in his bed. During a concurrent interview and record review on 1/8/26 at 11:53 a.m. with Director of Nursing (DON), Resident 99's medical record (MR) was reviewed. DON stated there was no consent form for video surveillance for Resident 99.During a concurrent interview and record review on 1/8/26 at 11:55 a.m. with DON, Resident 99's MR was reviewed. DON stated there were no Interdisciplinary Team (IDT - group of health care providers that meet to discuss resident care) notes indicating Resident 99 gave consent for video surveillance.During a concurrent interview and record review on 1/8/26 at 11:57 a.m. with DON, Resident 99's MR was reviewed. DON stated there was no physician order for video monitoring of Resident 99.During a concurrent interview and record review on 1/8/26 at 11:59 a.m. with DON, Resident 99's Care Plan (CP), dated 10/27/25 was reviewed. The CP did not indicate use of video monitoring as an intervention for care of Resident 99. DON stated the use of video monitoring needed to be on Resident 99's CP.During a concurrent observation and interview on 1/7/26 at 2:53 p.m. with LVN 7, in the doorway of Resident 87's room, a small round item was on the bedside table next to Resident 87's bed. LVN 7 stated the item was a video camera. LVN 7 stated both Resident 87 and Resident 99 have video cameras in their rooms to monitor and help prevent falls. LVN 7 stated the monitor screen was kept at the nurses station so she and other staff could monitor the residents.During a concurrent interview and record review on 1/8/26 at 12:03 p.m. with DON, Resident 87's MR was reviewed. DON stated there was no consent form for video surveillance for Resident 87.During a concurrent interview and record review on 1/8/26 at 12:05 p.m. with DON, Resident 87's MR was reviewed. DON stated there were no IDT notes indicating Resident 87 gave consent for video surveillance.During a concurrent interview and record review on 1/8/26 at 12:07 p.m. with DON, Resident 87's MR was reviewed. DON stated there was no physician order for video monitoring of Resident 87.During a concurrent interview and record review on 1/8/26 at 12:10 p.m. with DON, Resident 87's CP, dated 10/14/25 was reviewed. The CP indicated, Baby monitor Date Initiated 10/29/24 under interventions. DON stated the video surveillance intervention was started in October of 2024.During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated August 2009, the P&P indicated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . d. Privacy and confidentiality. 3. Our facility will make ever effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.During a review of the facility's P&P titled, Using Surveillance Equipment, dated December 2006, the P&P indicated, 1. Surveillance equipment is defined as any device that may monitor, record, or transmit sound, pictures, or other information . 2. Unless approved by the Administrator, and with the consent of the resident, surveillance equipment may not be installed in any resident room or treatment area.

Based on interview and record review, the facility failed to ensure one of 33 sampled residents (Resident 61) IDT (interdisciplinary team, group of health care professionals that meet to discuss resident care) comprehensive plan of care was updated and revised to reflect Resident 61's current health status, care needs and interventions. This failure had the potential for Resident 61 not to receive care that could negatively impact the quality of life/care. Findings:During a review of Resident 61's Nephrologist [a medical doctor who specializes in diagnosing, treating, and managing kidney diseases and disorders] Progress Note (NPN), dated 6/23/25, the NPN indicated, Acute [sudden onset] kidney injury [loss of kidney function] superimposed on chronic [long term] kidney disease [kidney's unable to filter waste and extra fluid from the blood as well as they should] and acute renal [kidney] failure and nutritional risk .good u/o [urinary output, which is a key indicator of proper kidney function].no edema [fluid retention], no swelling joints.During a concurrent interview and record review on 1/7/26 at 3:20 p.m. with Director of Nursing (DON), Resident 61's IDT comprehensive plan of care (CP) titled, renal failure r/t [related to] chronic kidney disease and acute renal failure, initiated on 6/27/25 with a target date of 3/16/26 was reviewed. The CP indicated, Interventions/Tasks: Monitor/document/report PRN [as needed] the following s/sx [signs and symptoms]: Edema, weight gain of over 2 lbs [pounds] a day. DON stated they have no way to monitor whether Resident 61 gained over 2 lbs of weight in a day since he was weighed one time a month. DON stated the CP needed to be updated and revised.During a concurrent interview and record review on 1/7/26 at 3:25 p.m. with DON, Resident 61's IDT CP titled, Nutritional Risk, date initiated 6/27/25 with a target date of 3/16/26, was reviewed. The CP indicated, Last Care Plan Review Completed 12/16/2025, Interventions/Tasks: Monitor intake and output [I&O's]. DON stated Resident 61 did not have an order for I&O's. DON stated nursing staff were not implementing Resident 61's I&O's as urinary output was not being quantified. DON stated Resident 61's CP needed to be updated and revised.During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated March 2022, the P&P indicated, The comprehensive, person-centered care plan should: Describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing that the resident desires or that is possible.The interdisciplinary team should review and updates the care plan: a. When there has been a significant change in the resident's condition; b. When the resident has been readmitted to the facility from a hospital stay, and c. At least quarterly, in conjunction with the required quarterly MDS [minimum data set] assessment.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Telephone Orders, when one of 33 sampled resident (Resident 10) physician telephone orders were not recorded in Resident 10's medical record. This failure resulted in Resident 10 not receiving recommended treatments and had the potential for skin breakdown. Findings:During an interview on 1/5/26 at 3:08 p.m. with Resident 10, Resident 10 stated he had an area on his buttocks that occasionally burns.During an interview on 1/7/26 at 3:01 p.m. with Licensed Vocational Nurse (LVN) 8, LVN 8 stated Resident 10's buttocks did not have any skin breakdown. LVN 8 stated Resident 10 did not have any treatments for his buttocks. LVN 8 stated a physician's order was required before applying a skin barrier cream. (creates a protective layer on skin to help prevent damage, rash and dryness). LVN 8 stated Physician 1 rounds on Thursdays with the Assistant Director of Nursing (ADON) and makes recommendations for residents with wounds and skin breakdown. LVN 8 stated the resident's primary physician is made aware of Physician 1's recommendations and orders are placed if the primary physician agrees.During a concurrent interview and record review on 1/7/26 at 3:08 p.m. with ADON, Resident 10's Progress Note (PN), dated 12/18/25 was reviewed. The PN indicated, Weekly wound assessment IDT [Interdisciplinary Team, healthcare professionals from different fields meet to coordinate resident care plans to ensure all aspects of resident physical, emotional and social needs are addressed].[Physician 1] in for weekly wound assessment, findings as follows.Sacro-coccyx [triangular shaped bone at the bottom of the spine, near buttocks] DTI [Deep Tissue Injury, damage to soft tissue underneath intact skin].TX [treatment] recommendations: Cleanse with NSS [normal Saline Solution, a sterile, non-irritating solution used to rinse and clean wounds], pat dry, apply barrier cream daily.[Physician 2] and IDT notified of recommendations and agreed with plan of care. ADON stated Resident 10 should be getting barrier cream applied to his Sacro-coccyx area daily. During a concurrent interview and record review on 1/7/26 at 3:12 p.m. with ADON, Resident 10's Treatment Administration Record (TAR) dated December 2025 and January 2026 were reviewed. ADON stated there were no treatment records for Resident 10's recommended daily use of barrier cream to the Sacro-coccyx. During a concurrent interview and record review on 1/7/26 at 3:14 p.m. with ADON, Resident 10's Order Review Report (ORR), dated 1/7/26 was reviewed. ADON stated Resident 10 did not have any physician orders for barrier cream to the Sacro-coccyx. ADON stated she had called Resident 10's primary doctor to inform him of Physician 1's recommendations on 12/18/25. ADON stated she had received telephone orders but did not document the orders in Resident 10's medical record. ADON stated she should have placed the orders. During a review of the facility's P&P titled, Telephone Orders, dated February 2014, the P&P indicated, Verbal telephone orders may be accepted from each resident's Attending Physician.Orders must be reduced to writing, by the person reviewing the order, and recorded in the resident's medical record.The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information.Telephone orders must be countersigned by the physician during his or her next visit.

Based on observation, interview, and record review, the facility failed to ensure one of 33 sampled residents (Resident 5) received treatment and services to bilateral feet. This failure resulted in Resident 5 having dry, flaky skin around toes, and feet, and long thickened untrimmed toenails and had the potential to cause skin breakdown and infection.Findings:During a review of Resident 5's admission Record (AR), dated 1/8/26, the AR indicated Resident 5 was admitted on [DATE].During a concurrent observation and interview on 1/6/26 at 9:06 a.m. with Resident 5 and Certified Nursing Assistant (CNA) 2, in Resident 5's room, Resident 5's feet were exposed and had dry flakey skin around toes and the top and bottom of both feet. Resident 5's toenails were long, thick and untrimmed, Resident 5 stated she had not seen a podiatrist and no one has taken care of her feet. CNA 2 stated Resident 5's toenails were very thick and yellow and green with dry scaly skin around toes and feet. CNA 2 stated the nurses take care of the residents feet.During a concurrent observation and interview on 1/6/26 at 9:12 a.m. with Licensed Vocational Nurse (LVN) 2, in Resident 5's room, Resident 5's feet were exposed. LVN 2 stated Resident 5 had thick, long nails on both feet, flaky skin around feet and toes. LVN 2 stated the expectation would be for lotion around the feet and for her to see a podiatrist, and to contact hospice (end of life care). LVN 2 stated her skin and nails had not been attended to as needed.During an interview on 1/8/2026 at 3:02 p.m. with Director of Nursing (DON), DON stated Resident 5 had not been provided proper foot care and the staff are to alert licensed staff even if a resident is receiving hospice care and this had not been done.During a review of the facility's policy and procedure (P&P) titled, Foot Care, dated March 2018, the P&P indicated, Residents will receive appropriate care and treatment in order to maintain mobility and foot heath. 1. Residents will be provided with foot care and treatment in accordance with professional standards of practice. 2. Overall foot care will include the care and treatment of medical conditions associated with foot complications. a4. Trained staff may provide routine foot care (e.g., toenail clipping) within professional standards of practice for residents without complicating disease processes. Residents with foot disorders or medical conditions associated with foot complications will be referred to qualified professionals.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled resident (Resident 68) head of bed (HOB) was elevated during G-tube feeding (gastrostomy tube, a small flexible tube surgical inserted through the abdomen and placed into the stomach to deliver nutrition, fluids, and medication directly into stomach). This failure had the potential to cause aspiration (liquid or food enters into the lungs instead of the stomach) for Resident 68. Findings:During an observation on 1/6/26 at 9:01 a.m. in Resident 68's room, Resident 68 was laying in bed with Jevity 1.5 (formula) running at 60 ml (milliliters) per hour. Resident 68's HOB was positioned below a 30-degree angle (approximate 15 degrees). Resident 68's bed did not have a device to indicate the angle of the HOB.During a concurrent observation and interview on 1/6/26 at 9:05 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 68's room, Resident 68's HOB was below a 30-degree angle while tube feeding was running at 60 ml/hour. CNA 1 stated Resident 68's HOB should have been elevated to 40 degrees while feeding was running. CNA 1 tried to find an indicator on Resident 68's bed to indicate the degree of the HOB. CNA 1 stated she could not find how elevated Resident 68's HOB was. CNA 1 stated, As long as her [Resident 68's] head isn't flat down during feedings.During an interview on 1/6/26 at 9:07 a.m. with Resident 68, Resident 68 stated her HOB is usually up, but today it isn't.During an interview on 1/6/26 at 9:08 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the HOB should be at a 90-degree angle when residents are receiving tube feedings.During a concurrent observation and interview on 1/6/26 at 9:10 a.m. with LVN 1 in Resident 68's room, Resident 68's HOB was below a 30-degree angle while tube feeding was running at 60 ml/hour. LVN 1 stated Resident 68's HOB was not elevated to a 30 degree angle. LVN 1 stated Resident 68's HOB should have been elevated during feedings. LVN 1 stated she could not tell how elevated Resident 68's HOB was because there was no indicator on Resident 68's bed.During a review of Resident 68's Order Review Report (ORR), dated 12/12/25, the ORR indicated, Enteral [tube feeding] Feed Order.TF [tube feeding] to run 17 hours/day.Jevity 1.5, run at 60 ml/ hour with 45ml/hour water flush.During a review of Resident 68's ORR, dated 12/10/25, the ORR indicated, KEEP HOB AT 45 DEGREES OR GREATER AT ALL TIMES.During a review of Resident 68's Care Plan Report (CPR), dated 12/9/25, the CPR indicated, Resident is at risk for enteral nutrition complications related to aspiration pneumonia [infection of lungs].Interventions.HOB elevated to at least 30 degrees.During a review of the facility's policy and procedure (P&P) titled, Enteral Feedings - Safety Precautions, dated November 2018, the P&P indicated, To ensure the safe administration of enteral nutrition.Preventing Aspiration.3. Elevate the head of the bed (HOB) at least 30 [degrees] during tube feeding and at least 1 [one] hour after feeding.

Based on observation, interview, and record review, the facility failed to ensure its policy and procedure (P&P) titled, Foods Brought by Family/Visitors provided sufficient guidance on safe refrigerated food storage and was followed for labeling resident's outside food brought into the facility. These failures had the potential to place residents storing outside food in the employees' breakroom refrigerator at risk of foodborne illness.Findings:During an interview on 1/5/26 at 10:30 a.m. with Licensed Vocational Nurse (LVN) 9, LVN 9 stated residents food brought in from the outside was stored in the employee's refrigerator in the employee breakroom. During a concurrent observation and interview on 1/5/26 at 10:31 a.m. with LVN 9 in the employee's breakroom, inside the refrigerator a white plastic bag that was tied with a container inside, and had 101A noted on the outside of the white plastic bag. LVN 9 stated outside food was stored in the white plastic bag for the resident in room [ROOM NUMBER]A. LVN 9 stated the white plastic bag did not have a resident's name on it and was not dated with a use by date. LVN 9 observed a thermometer inside the refrigerator and LVN 9 stated, It's 24 degrees F [Fahrenheit]. LVN 9 stated he did not know if there was temperature monitoring of the refrigerator for staff to be able to identify when the temperature may be out of range and unsafe to store food.During a concurrent observation and interview on 1/5/26 at 10:33 a.m. with Dietary Aide (DA) 3 in the employee's breakroom, DA 3 observed the white plastic bag labeled 101A. DA 3 stated they were not allowed to store food brought in from family or visitors in the refrigerators in the kitchen.During an interview on 1/7/26 at 4:30 p.m. with Director of Nursing (DON), DON stated there was no temperature monitoring of the refrigerator located in the employee's breakroom used to store resident food brought in from outside of the facility by family/visitors and there should have been.During a review of the facility's P&P titled, Foods brought by Family/Visitors, dated 5/28/25, the P&P indicated, Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. Policy Interpretation and Implementation: The dietician, nurse supervisor, or other designee will provide necessary education to the nursing staff on safe food handling practices and identify where this information is readily available for reference. The food service or nursing staff may assist with reheating or other preparation activities using safe food handling practices including safe reheating, hot/cold holding, handling of leftovers, and contamination avoidance. Food brought by family/visitors that is left with the resident to consume later is labeled and stores in a manner that is clearly distinguishable from facility prepared food.Containers are labeled with the residents name, the item and the use by date.During a review of the facility's P&P titled, Procedure For Refrigerated Storage, dated 2023, the P&P indicated, Refrigerator - 41 degrees F or lower.

Based on interview and record review the facility failed to develop a base line care for one of four sample resident (Resident 1) who was admitted with a left arm cast (a medical treatment used to support bone during healing process). This failure has the potential for Resident 1's left-ham cast to develop complications without staff awareness and unmet care needs. Findings:During a review of Resident 1's Progress Notes (PN), dated 10/22/25, the PN indicated, Resident 1 was admitted with a left arm cast.During a concurrent interview and record review on 12/15/25 at 12:15 p.m. with Director of Nurses (DON), Resident 1's clinical record was reviewed. DON confirmed Resident 1 was admitted with a left arm cast. DON was unable to find a care plan for Resident 1's left arm cast. During a review of the facility's policy and procedure (P&P) titled, Care Plans-Baseline, dated 3/22, the P&P indicated, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.

Based on interview and record review the facility failed to ensure a follow-up visit with orthopedic doctor (treats injuries and disease affecting bones, muscle, and etc.) was made for one for four sampled residents (Resident 1). This failure resulted in Resident 1 not being seen by an orthopedic doctor and potential for increased risk of complications, prolonged recovery, and worsening pain.Findings:During a review of Resident 1's Interdisciplinary Team (IDT) note, dated 10/23/25, the IDT indicated, She [Resident 1] does have a cast (a medical treatment used to support bone during healing process) in place to left arm. She will need ortho follow up. During a concurrent interview and record review on 12/15/25, at 1:27 p.m. with Licensed Vocational Nurse (LVN), LVN stated Resident 1 was admitted with a left arm cast. LVN stated Resident 1 had insurance issues and had difficulty looking for an orthopedic doctor. LVN stated Social Service Designee (SSD) was aware of the situation and did not do anything else to ensure Resident 1 had a follow-up appointment with an orthopedic doctor.During an interview on 12/15/25 at 1:40 p.m. with SSD, SSD stated she was not aware Resident 1 required a follow up orthopedic doctor. SSD stated no follow up with an orthopedic doctor was made for Resident 1.During a review of the facility's policy and procedure (P&P) titled, Referrals, Social Services, dated 12/2008, the P&P indicated, Social services shall coordinate most resident referrals with outside agencies.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure when restraint removal was not documented every 2 hours for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 ' s motion and exercise to be limited. Findings: During an observation on 8/23/24 at 11:30 a.m. in the hallway, Resident 1 was sitting up in a Geri chair (reclining chair on wheels) with a lap tray in use. During a review of Resident 1's Informed Consent For Use Of Restraints (ICFUOR) dated 5/19/23, the ICFUOR indicated, Recommended restraint: Geri chair with lap tray.Purpose for recommended restraint: comfort and safety.Recommended time/duration/usage: Q (every) 2 hrs (hours). During a review of Resident 1 ' s Minimum Data Set (MDS-assessment tool), dated 8/17/24, the MDS indicated, Physical Restraints.2 (Used daily) .chair prevents rising. During an interview on 9/10/24 at 1:54 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 utilized a Geri chair with a lap tray due to having multiple falls and a high fall risk. LVN 1 stated the lap tray was removed every two hours, but staff did not document when the lap tray was removed. During an interview on 9/10/24 at 2:01 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 utilized a Geri chair with a lap tray to help prevent falls. CNA 1 stated the lap tray was removed every two hours but was not documented. During a concurrent interview and record review on 9/10/24 at 2:59 p.m. with Director of Nursing (DON), Resident 1 ' s clinical record was reviewed. DON was unable to provide documentation of Resident 1 ' s lap tray being removed every two hours. DON stated when the lap tray was removed it should have been documented. During a review of the facility ' s policy and procedure (P&P) titled Use of Restraints dated 4/17, the P&P indicated, The following safety guidelines shall be implemented and documented while a resident is in restraints.The opportunity for motion and exercise is provided for a period of not less than ten (10) minutes during each two (2) hours in which restraints are employed.

Based on observation, interview, record review, facility policy review, and review of manufacturer's information, the facility failed to ensure the medication error rate was less than 5 percent (%). Observation of medication administration revealed there were 2 errors out of 35 opportunities, which resulted in a medication error rate of 5.71 %, affecting 2 (Resident #46 and Resident #77) of 5 residents observed during medication administration. Findings included: A facility policy titled, Administering Medications, revised in 12/2012, revealed, Medications shall be administered in a safe and timely manner, and as prescribed. Manufacturer's Instructions for Use Humalog ([NAME]-ma-log) (insulin lispro) injection, for subcutaneous use 3 mL [milliliter] or 10 mL multiple-dose vial (100 units per mL, U [units]-100 revealed, Step 11: Push down on the Plunger to inject your dose. The needle should stay in your skin for at least 5 seconds to make sure you have injected all of your insulin dose. An Admission Record revealed the facility admitted Resident #46 on 05/24/2021. According to the Admission Record, the resident had a medical history that included a diagnosis of type two diabetes mellitus with unspecified complications. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/29/2024, revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. Resident #46's Order Summary Report, listing active orders as of 07/18/2024, contained an order, started on 09/11/2021, to inject Humalog insulin 100 units per mL per a sliding scale (insulin orders in which the dosage of insulin depends upon the resident's blood glucose reading at the time of administration). According to the order, when the resident's blood glucose was 201-250 milligrams per deciliter (mg/dL), staff were to administer 4 units of Humalog insulin subcutaneously after meals for diabetes. During an observation of medication administration on 07/17/2024 at 11:39 AM, Licensed Vocation Nurse (LVN) #3 obtained Resident #46's blood glucose level, which measured 210 mg/dL and required four units of insulin per the resident's sliding scale insulin order. LVN #3 cleaned a small area on Resident #46's abdomen and administered the insulin without leaving the syringe in place for five seconds after the injection. An Admission Record revealed the facility admitted Resident #77 on 03/25/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of type two diabetes mellitus without complications. A quarterly MDS, with an ARD of 07/02/2024, revealed Resident #77 had a BIMS score of 1, which indicated the resident had severe cognitive impairment. Resident #77's Order Summary Report, listing active orders as of 07/18/2024, contained an order, started on 07/17/2024, to inject Humalog insulin 100 units per mL per a sliding scale. According to the order, when the resident's blood glucose was 201-250 mg/dL, staff were to administer 4 units of Humalog insulin subcutaneously after meals for diabetes. During an observation of medication pass on 07/17/2024 at 11:52 AM, LVN #3 obtained Resident #77's blood glucose level, which measured 208 mg/dL and required four units of insulin per the resident's sliding scale insulin order. During administration of the four units of insulin, LVN #3 cleaned a small area on Resident #77's abdomen and administered the insulin without leaving the syringe in place for five seconds after the injection. During an interview on 07/17/2024 at 3:15 PM, LVN #3 indicated he was aware he needed to pause after injecting insulin subcutaneously to prevent insulin from leaking out, which could change the number of units of insulin received. He stated he understood it was a medication error and had spoken to the Director of Nursing (DON) about the error. During an interview on 07/18/2024 at 10:07 AM, the DON stated she had spoken to LVN #3 after the medication pass about proper administration of insulin. She stated it was her expectation that medication be given according to the physician's orders, in the right manner. During an interview on 07/18/2024 at 9:43 AM, the Administrator stated it was his expectation that medications be given as ordered by the doctor and given the right way.

Based on record review, interview, and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the status of 1 (Resident #57) of 21 sampled residents. Findings included: A facility policy titled, Certifying Accuracy of the Resident Assessment, revised 11/2019, indicated, 2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. Different items on the MDS may have different observation periods. 4. The Resident Assessment Coordinator is responsible for ensuring that an MDS assessment has been completed for each resident. Each assessment is coordinated and certified as complete by the Resident Assessment Coordinator, who is a registered nurse. An Admission Record revealed that Resident #57 was admitted to the facility on [DATE]. According to the Admission Record, the resident had a medical history that included dependence on renal dialysis and chronic kidney disease. Resident #57's Order Summary Report, with active orders as of 07/18/2024, indicated the resident had an active order with a start date of 10/18/2023 for hemodialysis at a dialysis center every Monday, Wednesday, and Friday. Resident #57's Care Plan included a focus area, initiated 10/17/2023, that indicated the resident required hemodialysis related to end-stage renal failure. Interventions directed staff to ensure the resident was transported for hemodialysis at a dialysis center. A quarterly MDS, with an Assessment Reference Date (ARD) of 04/30/2024, indicated Resident #57 did not receive dialysis during the assessment period. During an interview on 07/15/2024 at 2:37 PM, the MDS Coordinator stated Resident #57 required dialysis and stated the quarterly MDS assessment was coded incorrectly. During an interview on 07/18/2024 at 9:14 AM, the Director of Nursing (DON) stated it was her expectation for residents' MDS assessments to be coded accurately. The DON stated the facility's MDS Coordinator was responsible for ensuring MDS accuracy. The DON stated MDS accuracy was important because the assessment drove everything, including billing. The DON confirmed Resident #57's MDS was inaccurately coded. She stated she assumed Resident #57's MDS regarding dialysis was a mistake because all of the resident's prior assessments were coded accurately. During an interview on 07/18/2024 at 9:38 AM, the Administrator stated it was his expectation for MDS assessments to be accurate and reflect the resident's current status.

Based on interview and record review, the facility failed to notify the physician of a change in condition for two of three sampled residents (Resident 1 and Resident 2) when the residents experienced episodes of [CONDITION(S)] (increased blood sugar). These failures resulted in Resident 1 being hospitalized and Resident 2 having the potential for adverse side effects. Findings: 1. During a review of Resident 1's Progress Notes (PN), dated 3/29/21, at 4:30 PM, the PN indicated, Resident is noted to have increase heart rate of 129 (normal range 60-100), B/P (blood pressure) 122/85 (normal range is less than 120/80), SPO2 (oxygen saturation in the blood) @ 96% (normal range 95-100 %) in room air, temp (temperature) 97.4 (normal range 97-99). Her face is flushed. Blood Glucose checked and glucometer (device used to determine the approximate concentration of glucose in the blood) states high. She is alert and responding at this time. Called MD [Medical Doctor] and received new orders to send to [hospital name] ER [emergency room ] for treatment and Eval. During a review of the History and Physical (H&P), dated 3/30/21, the [hospital] H&P indicated, Admit: 3/29/21. Assessment/Plan 1. AMS (altered mental status). DKA (diabetic ketoacidoses [sic]-a serious diabetes complication where the body produces excess blood acids. This condition occurs when there is not enough insulin in the body.). her blood sugar was 1130 [normal is 80-130 for a diabetic], she was diagnosed with hyperosmolar coma (serious condition caused by extremely high blood sugar levels) and started on insulin drip [medication infused through the vein to regulate the amount of glucose in the blood] and fluids. During a review of Resident 1's Order Review Report (ORR) from the facility, dated 3/1/21-3/31/21, the ORR indicated, Blood sugar check in the morning. During a concurrent interview and record review, on 4/12/21, at 11:40 AM, with the Director of Nursing (DON), Resident 1's Weights and Vitals Summary (WVS), dated 4/12/21, was reviewed. The WVS indicated, the following blood sugar results for Resident 1: 3/18/21 4:50 AM 264 mg/dL [milligrams/deciliter-unit of measure] 3/19/21 4:51 AM 326 mg/dL 3/20/21 5:01 AM 302 mg/dL 3/21/21 5:07 AM 420 mg/dL 3/22/21 4:49 AM 410 mg/dL 3/23/21 5:20 AM 386 mg/dL 3/24/21 5:02 AM 294 mg/dL 3/25/21 4:41 AM 434 mg/dL 3/26/21 4:58 AM 455 mg/dL 3/27/21 5:09 AM 415 mg/dL 3/28/21 5:10 AM 480 mg/dL 3/29/21 4:53 AM 454 mg/dL. Resident 1's blood sugars were greater than 250 for more than 12 days consecutively. DON confirmed the findings and stated the physician was notified on 3/25/21 of the elevated blood sugars but did not respond. On 3/26/21 the physician was notified of the elevated blood sugars and gave orders to change Resident 1's diet and draw labs. Before the labs could be drawn Resident 1 was sent to the hospital and admitted with DKA. DON stated, per facility policy the physician should have been notified when the blood sugars were elevated greater than 250 more than once in a 24-hour period and greater than 300 more than once in two consecutive days. During an interview on 4/12/21, at 11:20 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, the physician should be notified when a resident's blood sugar is greater than 250. LVN 1, stated she did not notify the physician when Resident 1's blood sugar was in the 400's because night shift was responsible to take Resident 1's blood sugar. During an interview on 4/12/21, at 11:25 AM, with LVN 3, LVN 3 stated, the physician should be notified when a resident's blood sugar is greater than 160 when the physicians order does not indicate parameters. During an interview on 4/13/21, at 11:09 PM, with LVN 2, LVN 2 stated, she had taken care of Resident 1 and Resident 1's blood sugar were checked every morning and would normally run in the 100 range. LVN 1 stated, Resident 1's blood sugars went up in the 400's. LVN 1 stated, Resident 1's Physician orders did not include parameters of when to notify the physician of elevated blood sugars but with no parameters, the physician should have been notified when the blood sugars were above 300. 2. During a review of Resident 2's ORR, dated 4/1/21-4/30/21, the ORR indicated, Novolog Solution (medication used to lower blood sugar) 100 Unit/ML [milliliters-unit of measurement] inject as per sliding scale (used to determine amount of insulin administered based on blood sugar results) : . 401-600 = 12 U (units) Notify MD . During a concurrent interview and record review, on 4/12/21, at 11:42 AM, with the Director of Nursing (DON), Resident 2's Weights and Vitals Summary (WVS), dated, 4/12/21, was reviewed. The WVS indicated, the following blood sugar results for Resident 2: 3/27/21 8:19 PM 402 mg/dL 4/4/21 11:55 AM 491 mg/dL 4/10/21 8:47 PM 436 mg/dL. Resident 2's blood sugars were greater than 401. DON confirmed the findings and was unable to provide evidence of the physician being notified of the elevated blood sugars. DON stated, the physician should have been notified. During a review of the facility's policy and procedure (P&P) titled, Nursing Care of the Older Adult with Diabetes Mellitus [Diabetes], dated 11/2020, the P&P indicated, Glycemic [blood sugar] Targets.Call as soon as possible when: 1. blood glucose values are regularly 70-100 mg/dL (for possible regimen adjustment); 2. blood glucose values are >250 mg/dL more than once within a 24-hr period; 3. blood glucose values are >300 mg/dL more than once over two consecutive days; reading is too high for glucometer . During a review of the facility's policy and procedure (P&P) titled, Change in Resident's Condition or Status, dated 5/17, the P&P indicated, A significant change of condition is a major decline or improvement in the he resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. b. Impacts more than one area of the resident's health status.

Based on observation, interview, and record review, the facility failed to follow CDC recommended practices (Preparing for COVID-19 in Nursing Homes.Cloth face coverings (cloth mask) are not considered PPE and should only be worn by HCP for source control, not when PPE is indicated) in the use of PPE when: a. One Receptionist (1) was not wearing facemask during screening of staff. b. One Graduate Vocational Nurse (GVN) 1 and one Licensed Vocational Nurse (LVN) 1 were wearing cloth mask (textile (cloth) covers are intended to keep the person wearing one from spreading respiratory secretions when talking, sneezing or coughing) inside the facility, next to the nurses station. c. One Physical Therapist (PT) 1 wearing cloth covering while providing resident care. d. One Certified Nursing Assistant (CNA) 1 was not wearing facemask while providing resident care, These failures have the potential to result in continued spread of infection (COVID-19) for 12 residents, staff, and visitors. Findings: a. During a concurrent observation and interview on 6/30/20, at 10 AM, with Receptionist 1, in the front lobby, Receptionist 1 was observed with no facemask while screening staff for COVID-19 symptoms and obtaining staff temperature. Receptionist 1 stated it was her job duty to screen all staff and visitors prior to entering the facility. Receptionist 1 stated she only interact with staff and was not required to wear any face covering when she was at her desk area performing her job duties in screening all staff and visitors. b. During a concurrent observation and interview on 6/30/20, at 10:04 AM, with GVN 1, she was observed wearing a cloth mask. GVN 1 stated she was told that it was ok to use cloth mask while in the facility. During a concurrent observation and interview on 6/30/20, at 10:06 AM, with LVN 1, she was observed wearing a cloth mask. LVN 1 stated she currently works with COVID -19 recovered residents and was given the option to wear either a facemask and/or cloth mask. c. During a concurrent observation and interview on 6/30/20, at 10:07 AM, with PT 1, she was observed exiting a resident room wearing a cloth mask. PT 1 stated she had just completed providing physical therapy to a resident and was told any face covering was acceptable to use while providing care to residents. d. During a concurrent observation and interview on 6/30/20, at 10:09 AM, with CNA 1, in Resident 1's room, CNA 1 was observed braiding Resident 1's hair. CNA 1 was observed not wearing any facemask. CNA 1 stated she was required to wear a facial mask at all times but did not know where she had placed her mask. CNA 1 stated, I get busy, it gets hot and sweaty, I take it off and I lose track of it. During a concurrent interview and record review on 6/30/20, at 10:14 AM, with DON and MDSC, DON stated the facility currently had no facemask shortage. DON stated the Receptionist should be wearing facemask at all times during her work hours and stated the facility practice was for all staff to wear facemask. DON stated for the month of June, 2020 the facility has had a total of seven staff tested positive for the COVID-19 virus and a cumulative of 73 residents have tested positive for the COVID-19 virus. DON stated there were currently two Infection Preventionist (IP's - are the person who specializes in preventing infections) in the facility and they are always going around making sure everyone is washing their hands, wearing appropriate PPE. DON was unable to provide documented evidence the IP's had completed staff monitoring on proper PPE use. During a review of the facility's mitigation plan titled, Coronavirus Disease 2019 (COVID-19) Mitigation Plan for Skilled Nursing Facilities (undated), the mitigation plan indicated, a. FACEMASKS vi. Homemade masks are not considered PPE, since their capability to protect staff is unknown. During a review of the Centers For Medicare & Medicaid Services (CMS) guidelines titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated on 6/19/20, indicated, HCP (Healthcare Personnel) should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. To reduce the number of times HCP must touch their face and potential risk for self-contamination, HCP should consider continuing to wear the same respirator or facemask (extended use) throughout their entire work shift, instead of intermittently switching back to their cloth face covering.