Every finding on record at Magnolia Ridge Health and Rehabilitation Center

Based on observation, interview, and record review the facility failed to ensure staff used appropriate personal protective equipment (PPE) and performed hand hygiene upon entering and exiting residents rooms while providing care to residents on contact precautions to prevent the possible spread of infection and communicable diseases for 2 residents, Resident #6 and #78, of 3 residents reviewed for transmission based precautions, for transporting soiled linens, and for urinary catheter care and maintenance for 1, Resident #99, of 3 residents reviewed for urinary catheter care. Findings include: 1) During observation on 5/5/2026 in the memory care unit at 2:02 PM, Staff D, Floor Technician/Housekeeping picked up the soiled trash behind the nurses station and held it to his body to remove the excess air out of the soiled trash bag and twisted it around 5 times then put it in a large gray bin that read soiled linen only that had the lid open, then he went into the soiled utility room and took out the soiled linen bags and held it to his body to remove the excess air out of the soiled linen bags and added it to the soiled linen only gray bin with the soiled trash bags. Hand hygiene was not observed before or after completion of task, as he left the memory care unit, Staff D touched the access code buttons and the doors to exit the memory care unit. During interview on 5/6/2026 at 9:51 AM, Staff D, Floor Technician/Housekeeping stated that he was assigned to the unit to pick up soiled utility linen and trash and put it in a gray large bin designated for soiled linen only which he kept the lid open, he stated he picked up the soiled trash behind the memory care unit nurses station and the soiled utility room and held the trash to his body to take the excess air out of the trash bags and twisted the bags five times without using gloves or PPE or without completing hand hygiene prior to exiting the memory care unit. Staff D stated that he did touch the access code buttons and the doors of the memory care unit after handling soiled linen and trash. During an interview on 5/06/2026 at 9:33 AM, Staff E, Housekeeping Director, stated that her expectations when taking out the soiled utility linens and soiled trash that the staff do not touch the trash to their body, they should use proper hand wash handing or disinfecting of hands. I am not happy with the floor tech because I saw him doing this before and have verbally educated him not to do so. During an interview on 5/06/2026 at 9:34 AM, Staff F, Assistant Housekeeping Director, stated that her expectations was that infection control practices should be followed and using hand hygiene frequently is important to prevent infections. Review of the policy and procedure for infection control read, to establish and maintain an effective Infection Control Prevention and Control Program designed to provide safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections among residents, staff, visitors, volunteers and contracted personnel. 2) Review of Resident #6's admission record documents diagnosis that included aftercare following joint replacement surgery, klebsiella pneumonia as the cause of diseases classified elsewhere, and urinary tract infection. Review of Resident #6's physician orders dated 5/5/2026 read, Contact precautions for DX [diagnosis] ESBL [Extended-Spectrum Beta-Lactamase] in urine every shift for 28 days. Nurse to verify correct door signage and equipment present. During an observation on 5/05/2026 at 7:18 AM, Resident #6's room door was observed without isolation signage or personal protective equipment [PPE] near the door or in the hallway indicating contact isolation. During an observation on 5/05/2026 at 8:42 AM, Resident #6 had no contact isolation signage at the door or available personal protective equipment on or near the doorway. Staff K, Licensed Practical Nurse (LPN) and Staff N, Certified Nursing Assistant (CNA) were observed entering Resident #6's room without gown or gloves and assisting the resident. During an interview on 5/05/2026 at 12:45 PM, Staff K, LPN stated, There should have been isolation signs up this morning. I did not know that she was on precautions until just a little while ago. We should have had the signs on the door and donned PPE of a gown and gloves every time we enter to do anything. I did not use PPE until I found this out. I did not get in report that she was on isolation. During an interview on 5/05/2026 at 12:53 PM, Staff N, CNA, stated, I did go in her [Resident #6's] room without PPE before the sign was on the door. I wasn't told she was on isolation. I should have had on a gown and gloves. 3) Review of Resident #78's physician order dated 5/1/2026, read, Contact precautions for DX ESBL in urine every shift until 05/09/2026. Nurse to verify correct door signage and equipment present. During an observation on 5/4/2026 at 1:13 PM, there was signage indicating enhanced barrier precautions for Resident #78 on the doorway of Resident #78's room. During an observation on 5/5/2026 at 7:33 AM, there was enhanced barrier precautions signage on the doorway of Resident #78, Staff L, Certified Nursing Assistant (CNA) entered Resident #78's room without a gown and gloves to deliver the residents breakfast tray. During an observation on 5/5/2026 at 7:58 AM, Staff L, CNA entered Resident #78's room without donning gown and gloves and removed the breakfast tray. During an interview on 5/5/2026 at 8:35 AM, Resident #78 stated, The staff have not been using a gown or gloves when caring for me or changing the sheets. I know I have a UTI (urinary tract infection). During an interview on 5/5/2026 at 11:32 AM, Staff L, CNA, stated, I did not know that she was on isolation, contact isolation. I did not get that information, usually the staff will get notified and we will immediately put the sign up and get the PPE (personal protective equipment). I should have worn a gown and gloves every time I entered the room. During an interview on 5/5/2026 at 11:36 AM, Staff M, LPN, stated, I will look because I didn't think she is on contact isolation. After reviewing the physician orders. Staff M, LPN stated, We should be using a gown and gloves for contact isolation. I don't know why the sign is not there. It's the wrong sign and staff won't be able to know what to do unless the right sign is up. During an interview on 5/7/2026 at 6:45 AM, the Director of Nursing (DON) stated, All residents on isolation should have the right sign and staff should follow the transmission based precautions policy. They should have had on a gown and gloves. Review of the policy and procedure titled, Isolation - Isolation Precautions Overview, last approval date of 1/2026 read, Purpose: To provide a system of isolation precautions to prevent the transmission of infection. To prevent the transmission of infectious diseases. Function guideline . two tier transmission based precautions, either airborne, droplet, or contact precautions, will be used for residents with known or suspected infections. Isolation precautions will be used only to the extent necessary to prevent transmission of disease. Procedure 1. The guidelines contain 2 tiers of precautions, standard precautions and transmission based precautions (airborne, droplet and contact precautions): Transmission- based precautions – Consist of measures designed to be used in addition to standard precautions to further reduce the risk of disease transmission. There are three types of transmission based precautions. Contact precautions-designed to reduce the risk of epidemiologically important microorganisms by direct or indirect contact: i. Direct contact transmission involves skin to skin contact and physical transfer of microorganisms to a susceptible host. 4) During an observation on 5/4/2026 at 10:21 AM, Resident #99 was lying in bed. The resident's bed was at the lowest position, and the urinary catheter bag was resting on top of the floor mat. The urinary catheter did not have a privacy cover. Review of Resident #99's physician order dated 3/21/2026 read, Check the catheter and tubing for kinks and flow of urine. Secure tubing to prevent pulling out/trauma. Q [every] shift every shift for surveillance. Review of Resident #99's physician order dated 3/21/2026 read, Enhanced Barrier Precautions for supra pubic catheter every shift. Wear gloves and a gown for the following High-Contact Resident Care Activities: Dressing, Bathing, Transferring, Changing Linens, Providing Hygiene, Changing Briefs or Assisting with Toileting. (EBP [enhanced barrier precautions] is required for residents with indwelling medical devices, wounds, or colonization with an MDRO [multidrug-resistant organism]) every shift for Prophylaxis. During an interview on 5/6/2026 at 10:59 AM, Staff I, Licensed Practical Nurse (LPN) stated, The urinary catheter bag should be where it is not touching the floor at all for infection control purposes. He [Resident #99] is a fall risk, his bed has to be all the way down, so it is tricking when hanging the foley bag not to get back flow and not to touch the fall mats. I do not know how to solve that issue where it is not touching the floor and not cause him issues. During an interview on 5/6/2026 at 4:30 PM, the Director of Nursing (DON) stated, Normally the bag will be hung to where is not touching the floor. Unless the patient moves it around. During an interview on 5/7/2026 at 8:39 AM, the DON stated, The catheter bag should not be touching the ground, or it should be in a position that is not touching. We are talking about another type of bag to serve as a barrier for the resident. During an interview on 5/7/2026 at 9:37 AM. the Infection Preventionist stated, The catheter bag should not be touching the floor because there is bacteria and germs that can get into the line and travel to the bladder and we don't want that. For [Resident #99' name] we can place the bag maybe on a non-movable item or provide an extra barrier in order for the bag not to be in contact with the floor. Review of the facility policy and procedure titled Indwelling Catheter, with a last review date 1/2/2026 read, Purpose: To ensure indwelling catheter use in residents in clinically indicated, managed to promote optimal resident outcomes, and discontinued as determined appropriate.

Based on observation, interview, and record review, the facility failed to promote and maintain an environment that enhanced resident dignity and respected resident privacy for residents in 3 of 9 hallways (300's, 400's and 700's hallways) reviewed for resident rights. Findings include: 1) During an interview on 05/04/2026 at 11:12 AM, Resident #13 stated, The staff came into my room last night around 4:00 AM, and [Staff H, Registered Nurse (RN)'s name] and another staff member took some items out of my drawer. They told me they were getting medications out of the room because state was coming in the morning. I am not sure what all they took. During an interview on 05/05/2026 at 8:00 AM, Resident #89 stated, The staff came into my room and went through all of my belongings and took some of my personal items, snacks and my brush. They told me that state was coming in the morning, so they had to go through all of my belongings. I felt like it was a major violation of my privacy. During an interview on 05/04/2026 at 9:50 AM, Resident #105 stated, I caught one of the CNA's (Certified Nursing Assistant) going through my belongings last night. She said she was taking an inventory. I am not sure what her name was. It is upsetting because I have had some items stolen in the past here, and I was worried they could be stealing from me again. During an interview on 05/05/2026 at 4:00 PM, the Administrator stated, We do routine room checks periodically on 11-7 shifts to pull excessive linen. Were residents upset? Sure, maybe. Every day is survey readiness. The fact that residents are saying because of state we are always getting ready for state, so that could have been said at any time. I think there is opportunity here to reapproach that practice, and if that will be our practice moving forward, we will need to do some education with the residents and staff. It would be appropriate to go through resident's belongings if they are notified first. I do not know how it was presented or if the residents were notified first. During an interview on 05/05/2026 at 4:05 PM, the DON (Director of Nursing) stated, We were doing audits on the rooms. The staff only took out supplies such as towels. I spoke to [Resident #13's name's] family and explained it was just towels, wash cloths, and linens that were taken. It was [Staff H, RN's name] and [Staff B, LPN's (Licensed Practical Nurse) name] that went through the rooms. During an interview on 05/07/2026 at 8:00 AM, Staff H, RN stated, We went into resident's rooms Sunday night because we were getting state-ready and taking out excess linens and straightening up. We put hairbrushes and sprays in the bathroom, and we were bagging up medications and putting their names on them. A lot of the residents were okay with it, and some were not okay with it. When they woke up and asked what we were doing, we explained to them what we were doing. We do that every so often, but it is not a weekly thing. For the past 2 to 3 weeks, I have been explaining to the CNA's that we need to declutter. We did not give any of the residents advanced notice that we were going to go through their rooms. Some woke up, some didn't. During an interview on 05/07/2026 at 9:45 AM, the Administrator stated, We don't have policies for personal property or resident rights. Review of admission packet provided by Administrator, not dated, read, Addendum 10 Resident's [NAME] of Rights. Every resident of the Facility shall have the following rights: m. The right to have privacy in treatment and in caring for personal needs; to close room doors and to have facility personnel knock before entering the room, except in the case of an emergency or unless medically contraindicated; and to security in storing and using personal possessions. 2) During an interview on 05/04/2026 at 2:20 PM, Resident #136 stated, I have had a rough day. I was woken up at 3 AM in the morning. Two nurses came into my room and started searching through my things. They were saying state was coming into the building. They were waiting for you. Review of Resident #136's Minimum Data Set annual assessment dated [DATE] documented in Section C, cognitive patterns: BIMS [Brief Interview for Mental Status] 15 [cognitively intact]. During an observation on 5/4/2026 at approximately 3:10 PM, there was a family member standing at the nursing station talking loudly and upset stating they went into the room in the middle of the night, and they were going through her stuff. Later the family member was identified as [Resident #13's representative]. During an interview on 5/7/2026 at 7:45 AM, Staff B, Licensed Practical Nurse (LPN), stated, We went into resident rooms to look for linen, extra towels, and tidy up the rooms if they had combs and things like that we put them in their bins. We also look for creams and lotions. This happened throughout the night. We will knock and if the resident is sleeping, we try to go in quietly. During an interview on 5/7/2026 at 7:53 AM, Staff J, LPN, stated, I worked Sunday [5/3/2026] night. Staff were going into resident rooms to search for items such as extra linen. Normally they will do this every couple of weeks. They will have a big clean out and they will go through the cabinets, and it happened to be that Sunday. They did not give us warning that they would be doing that Sunday night so we could not give the resident warning that they would be rummaging through their things. 3) During observations conducted on 05/04/2026 at 10:13 AM, Resident #38's urinal containing urine was observed on the resident's bedside table. During an interview on 05/04/2026 at 12:18 PM, Resident #38 stated, My room smells like urine the CNA does not change my urinal in between uses, it is embarrassing to me. During observations conducted on 05/05/2026 at 9:23 AM, Resident #38's urinal containing urine was observed on the resident's bedside table. During an interview on 05/05/2026 at 9:23 AM, Resident #38 stated, I feel embarrassed having the urinal on my bedside table. During observations conducted on 05/05/2026 at 11:40 AM, Resident #38's urinal was observed on the bedside table full with urine. [see photographic evidence]

Based on observation, interview and record review the facility failed to provide pain medications and follow physician orders for pain medication for 1, Resident #6, of 3 residents reviewed for pain management. Findings include:Review of Resident #6's admission record documents diagnosis that include aftercare following joint replacement surgery, klebsiella pneumonia as the cause of diseases classified elsewhere, urinary tract infection, presence of right artificial knee joint, unilateral primary osteoarthritis left knee, rheumatoid arthritis unspecified. Review of Resident #6's nursing progress note dated 5/4/2026 at 1940 (7:40 PM) read, admitted from hospital. Physician notified of admission, orders reviewed and verified. Resident representative notified of admission. The resident is currently taking opioids. Review of Resident #6's physician orders dated 5/5/2026 read, Oxycodone HCL[Hydrochloride] Oral Tablet 15 MG (milligrams) (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for pain scale 6-10. Review of Resident #6's physician orders dated 5/5/2026 read, Oxycodone HCL Oral Tablet 15 MG (Oxycodone HCL) Give 1 tablet by mouth four times a day for nonacute pain. During an observation on 5/5/2026 at 7:18 AM, Resident #6 was observed in bed with facial grimacing, wincing and moaning when attempting to move their legs. During an interview on 5/5/26 at 7:18 AM, Resident #6 stated, My pain is 10 out of 10, they don't have my medication yet, it's on order. During an observation on 5/5/2026 at 8:42 AM, Resident #6 had facial grimacing, wincing and moaning when attempting to move. During an interview on 5/5/2026 at 8:42 AM, Resident #6 stated, My pain is a 10 out of 10. I haven't had any pain medicine since I got back (from the hospital) last night. They know, they said it hasn't been delivered yet. Review of the [Name of the automated medication dispensing system] inventory Oxycodone 15 mg has an inventory of 6 tablets. There were no medications accessed from the machine on 5/4/2026 or 5/5/2026 prior to 9:00 AM. Review of the medication administration record for May 2026 documented no oxycodone 15 mg administered from 5/4/2026 through 5/5/2026 at 9:00 AM. During an interview on 5/5/2026 at 12:07 PM, Resident #6 stated, I can't understand why it took so long and why I had to wait so long (for the pain medication). I asked the night nurse for the medicine too. During an interview on 5/5/2026 at 12:45 PM, Staff K, Licensed Practical Nurse (LPN) stated, I know [Resident #6's name] very well. I realized that she was in pain and I called pharmacy to see when she would get medicine. I think there was some problem with the script (prescription). She has not had any medication since admission prior to getting the new prescription. She was in pain. She has chronic pain. During an interview on 5/7/2026 at 6:25 AM, the Director of Nursing stated, We did not give her oxycodone. I'm not sure why. We do have it in the [Name of the Automated medication dispensing machine]. It could have been taken from there. The nurse should have called pharmacy and gotten medication for her (Resident #6).

Based on observation, interview, and record review, the facility failed to obtain physician orders to provide wound care for 2, Residents #38 and #199, of 2 residents, reviewed for skin conditions. Findings include: During an observation on 5/4/26 at 9:51 AM, Resident #38 was sitting at bedside. Resident #38 lower leg right extremity had a 2x2 had a dressing that was not dated, and the gauze around the wound was loose. [see photographic evidence] During an interview conducted on 05/05/2026 at 9:49 AM, Resident #38 stated, My dressing does not get changed as often as it should. The last time the dressing was changed was approximately one week ago. Review of Resident #38's physician orders did not document wound care dressing change orders in place. Record review of Resident #38's wound care progress notes for dated 4/16/26 read Primary Dressing 1: Calcium Alginate and Dressing Frequency: Daily for the left foot digit 2 and left foot digit 3 wounds. Record review of Resident #38's wound care progress notes dated 4/23/26 read Primary Dressing 1: Calcium Alginate and Dressing Frequency: Daily for the left foot digit 2 and left foot digit 3 wounds. Record review of Resident #38's wound care progress notes dated 4/30/26 read Primary Dressing 1: Calcium Alginate and Dressing Frequency: Daily for the left foot digit 2, left foot digit 3, left lower posterior leg, and right lower lateral leg wounds. Record review of Resident #38's wound care progress notes dated 4/30/26 further read, Plan for both lower legs: Cleanse with normal saline or wound cleanser. Protect peri-wound with skin protectant. Apply calcium alginate to open areas and cover with rolled gauze/tape daily and PRN if soiled. Record review of Resident #38's wound care progress notes dated 4/30/26 read No dressing in place prior to examination for the left foot digit 2 and left foot digit 3 wounds. Record review of Resident #38's treatment administration record (TAR) failed to show active completed documentation for Calcium Alginate dressing treatments after 04/17/2026, despite continued wound care documentation dated 04/23/2026 and 04/30/2026 referencing daily Calcium Alginate dressing treatments. During an interview on 5/6/26 at 9:36 AM, the Director of Nursing (DON), stated, The order for Calcium Alginate Dressing should have been documented and corrected. 2) During an observation on 5/4/2026 at 9:48 AM, Resident #199 was lying in bed. Resident #199 left arm had a 2 x 2 dressing that was not dated, slightly lifted on the lower left-hand corner and had light golden stain. [photographic evidence obtained] During an interview on 5/4/2026 at 9:48 AM, Resident #199 stated, I got cut with something, I cannot remember with what. It happened here. When asked if changed daily Resident #199 stated, Not that I am aware of. During an observation on 5/5/2026 at 8:01 AM, Resident #199 was lying in bed. Resident #199's left arm had a 2 x 2 dressing that was not dated, slightly lifted on the lower left-hand corner and had light golden stain. [photographic evidence obtained] Review of Resident #199's physician orders did not document wound care dressing change orders in place. Review of Resident #199's progress note dated 5/4/2026, read, Resident's skin check was completed prior areas of skin impairment were indicated as follows: no prior areas noted. No new areas of skin impairment noted on completion of skin check. During an observation on 5/5/2026 at 12:00 PM, Staff A, Licensed Practical Nurse (LPN) confirmed Resident #199 had a dressing on his left arm. Staff A, LPN removed dressing which had dried dark brown dried drainage stain. During an interview on 5/5/2026 at 12:00 PM, Staff A, LPN, stated, We are supposed to do a change in condition when there is a skin concern, notify the md [medical doctor], take picture with our tablet of the area. If we are putting on a dressing, we need an order and the dressing should be dated and initialed. I don't know what it was looking at it. But looking at the dressing and the drainage it looks like the dressing is old, old. I do not see an order for dressing changes for [Resident #199's name]. During an interview on 5/6/2026 at 4:38 PM, the Director of Nursing stated, When staff identify skin issues, they must do a change of condition unless it comes from the hospital. Dressing changes should be done depending on doctor orders or prn [as needed] if soiled. Dressing should have orders in place. When doing a skin sweep the nurse should look under the dressing in place and see what is under the dressing. The staff should see if it has healed or if there is infection. During an interview on 5/7/2026 at 7:45 AM, Staff B, LPN, stated, I do not recall seeing a dressing when I did the skin sweep. [skin sweep was dated 5/4/2026] Review of the facility policy and procedure titled Wound Care, with a last review date of 1/2/2026 read, Purpose: To provide consistent assessment, monitoring, documentation, and implementation of therapeutic interventions for a resident receiving wound care. Equipment: treatment supplies as per physician orders.

Based on observation, interview and record review the facility failed to ensure resident assessments were completed accurately to reflect the resident's status for 4 out of 12 residents reviewed. Findings Include: 1) Review of Resident #17's Minimum Data Set [MDS] admission assessment dated [DATE], Section I, active diagnoses did not include glaucoma, atrial fibrillation [A-fib] and protein malnutrition. Review of Resident #17's admission record documented resident was admitted on [DATE] with diagnosis that included unspecified glaucoma [onset date 04/15/2026] unspecified atrial fibrillation [onset date 04/15/2026] and unspecified protein-calorie malnutrition [onset date 04/15/2026]. During an interview on 05/06/2026 at 12:41 PM, Staff C, RN [Registered Nurse] MDS Lead, stated, Section I of the MDS should have had protein malnutrition, glaucoma and A-fib for [Resident #17's Name]. 2) Review of Resident #34's MDS admission/medicare 5 day assessment dated [DATE], Section K documented weight loss of 5% in one month or 10% in six months. Review of Resident #34's weights dated 4/14/2026 documented 138 LBS [pounds] [No other weights were documented for the current admission. During an interview on 5/6/2026 at 12:19 PM, the Registered Dietitian stated, Looks like for some reason that was filled out by our MDS coordinator. I cannot speak to that, I think I would have coded no, because it doesn't look that he [Resident #34] is triggering weight loss for the parameters the assessment is asking. Review of Resident #34's MDS admission/medicare 5 day assessment dated [DATE], Section N Medications documented a total of 4 insulin injections. Review of Resident #34's physician order dated 4/14/2026 read, Insulin Glargine Subcutaneous Solution Pen-Injector 100 Unit /ML [milliliters] (Insulin Glargine) Inject 20 unit subcutaneously at bedtime for type 2 diabetes. Review of Resident #34 medication administration record for the month of April 2026 for Insulin Glargine documented administration on 4/14/2026 through 4/19/2026. A total of 6 injections. Review of Resident #34's MDS admission/medicare 5 day assessment dated [DATE], Section I Active Diagnoses did not document Benign Prostatic Hyperplasia [BPH] as diagnosis. During an interview on 5/6/2026 at 12:27 PM, Staff C, MDS Lead RN, stated, It looks like the person who fills out that portion [Section K] is the registered dietitian I don't see a weight loss and maybe it was falsely triggering for a weight loss. Looking at the weight loss, no, it is not correct. Typically to capture certain diagnosis, we have to move the assessment day and move back the signature and then we will go ahead and sign for it we shouldn't because we should make sure it is correct. The BPH was not on the diagnosis, but we should be looking at everything, even the doctors notes. The diagnosis should have been included in the active diagnosis list. He received more than 4 injection that would need to be modified. 3) Review of Resident #143's MDS quarterly assessment dated [DATE], Section I Active Diagnosis did not include depression as an active diagnosis. Review of Resident #143's physician order dated 1/24/2026, read ,Sertraline HCI Tablet 100mg (milligrams) give 2 tablets by mouth at bedtime for depression. Review of Resident #143's physician order dated 1/24/2026, read, Trazadone HCI Oral Tablet 100mg give 1 tablet by mouth at bedtime for insomnia r/t [related to] depression. During an interview on 5/6/2026 at 12:44 PM, Staff C, MDS Lead RN, stated, We should have included depression in the active diagnosis list. 4) Review of Resident #136's MDS annual assessment dated [DATE], Section I Active Diagnoses did not document depression as an active diagnosis. Review of Resident #136's admission record documented the resident was admitted on [DATE] with diagnosis that included depression [onset date 11/25/2025]. During an interview on 5/6/2026 at 12:41 PM, Staff C, MDS Lead RN, stated, The diagnosis should have been included in the assessment, the resident was being administered Trazodone. During an interview on 5/7/2026 at 11:00 AM, the Director of Nursing stated, We do not have an MDS policy we follow the RAI [Resident Assessment Instrument].

Based on interview and record review the facility failed to notify resident representatives of a change in condition for weight loss for 1, Resident #7, of 7 residents reviewed for nutrition and for 1, Resident #161, of 3 residents reviewed for pressure ulcers.Findings include: Review of Resident #7's admission record documented diagnosis that include displaced intertrochanteric fracture of right femur subsequent encounter for closed fracture with routine healing, muscle weakness generalized, cognitive communication deficit, dysphasia oropharyngeal phase, encounter for other specified surgical aftercare, unspecified protein calorie malnutrition, acute respiratory failure with hypoxia, hypokalemia, chronic obstructive pulmonary disease unspecified, type 2 diabetes mellitus without complications, gastroesophageal reflux disease without esophagitis. Review of Resident #7's physician orders dated 4/9/2026, read, Weekly Weights every day shift every Thur [Thursday] for monitoring for 4 weeks. Review of Resident #7's weights documented on 4/9/2026 a weight of 180.2 pounds (lbs), on 4/10/2026, a weight of 180.0 pounds, and on 4/21/2026, a weight of 163.5 pounds. Review of the dietary assessment dated [DATE] read, RD Progress Note - Significant Weight Loss CBW [current body weight]: 163.8 lbs (BMI - 24.9) Wt [weight] hx [history]: -9.1% (-16.4 lbs) x 1 month. During a telephone interview on 5/05/2026 at 6:12 PM, Resident #7's representative stated, I was not notified or called about my father's weight loss after being hospitalized or any measures they have put into place for making sure he doesn't have any additional weight loss. I do want to know these things. I do think I should be told about his care and what they are doing and how they are addressing this weight loss. During an interview on 5/06/2026 at 11:44 AM, the Registered Dietician stated, I did order weekly weights for him [ Resident #7]. They have not been done. I will only notify a family member if they are present at the bedside if they have a significant weight loss. The nurses will also do this. I did not notify his son about the weight loss or about any dietary changes we have made. I would expect that the residents get weighed as its ordered and it would be documented when they refuse a weight. During an interview on 05/07/2026 at 6:15 AM, the Director of Nursing stated, We should be completing the weights weekly, we should be telling his son about his weight loss and what new measures were put in place. Review of the policy and procedure titled, Weight Management, last approval date of 01/2026 read, Guidelines: Residents are weighed on admission, readmission, and then weekly for four weeks after admission or readmission, unless otherwise indicated to monitor the resident's clinical condition. Purpose: To monitor for weight changes. To evaluate and monitor nutritional status of resident. Procedure: 7. If weight varies more than 5 lbs reweigh. Documentation: 2. Notify the charge nurse or physician of all weight changes of 5 lbs. 3. Record weight on all appropriate forms and initial. Review of the policy and procedure titled, Notification of Change in Condition, last approval date of 01/2026 read, Purpose: When a resident is determined to have a change in condition, the licensed nurse will evaluate the resident and notify the representative/resident and the health care provider. Procedure: 3. The licensed nurse is to notify the family/legal representative/resident regarding the resident's change in condition and any new plan of care. 5. The licensed nurse is to document the notification of change to the family/legal representative/resident and Health Care Provider in the medical record. 2) During an interview on 05/06/2026 at 5:57 PM, resident representative for Resident #161 stated, They told me at the meeting that [Staff G, LPN's name] had found the chin wound on Friday 4/24. That day I said ok, if he saw the wound at that time, why was it not properly evaluated and the family notified? Review of Resident #161's skin check note dated 04/24/2026 read, Resident's skin check was completed prior areas of skin impairment were indicated as follows: ulcer (diabetic, venous, arterial, DTI [deep tissue injury]. Patient has a wound in her chin due the pressure of collar. Upon completion of skin check new areas of skin impairment were noted. Review of Resident #161's physician order dated 04/24/2026 read, Wound care consult with [name of third party wound care provider] as needed. Patient has a wound on her chin due the pressure of her collar. Review of Resident #161's progress notes showed no documentation the resident representative was notified about the new wound to Resident #161's chin on 04/24/2026. During an interview on 05/07/2026 at 8:12 AM, Staff G, LPN [Licensed Practical Nurse] stated, We do weekly skin checks. I checked [Resident #161's name] and saw a wound on her chin. I made a wound care consult, and put wound care orders in. I do not remember if I called the family. During an interview on 05/07/2026 at 8:15 AM, the Director of Nursing stated, When a resident has a new wound I expect the nurse to do a change of condition, notify the doctor, get orders, and notify the family.

Based on observation, record review, and interview, the facility failed to ensure staff used appropriate personal protective equipment (PPE) while performing midline care for the residents who were on enhanced barrier precautions (EBP) to prevent the possible spread of infection and communicable diseases for 1 of 2 residents reviewed for intravenous (IV) therapy (Resident #4). Findings include:During an observation on 11/20/2025 at 10:05 AM, Staff A, Licensed Practical Nurse (LPN), entered Resident #4's room, performed hand hygiene with hand sanitizer, and donned gloves. Staff A proceeded to turn off the IV pump and then disconnected the IV tubing from Resident #4's midline. Staff A wiped the midline port with an alcohol wipe and flushed 10 milliliters of normal saline into the midline. Staff A wiped the midline port with another alcohol wipe and applied a green cap to the midline. Staff A doffed the gloves and performed hand hygiene using hand sanitizer on her way out of the room. Staff A did not wear a gown.During an interview on 11/20/2025 at 10:07 AM, Staff A, LPN, stated, Enhanced barrier precautions are for residents with certain types of infection, wounds, and catheters. I've also seen enhanced barrier precautions used for feeding tubes. I don't normally wear a gown for midlines or IVs. I just wear gloves.During an interview on 11/20/2025 at 12:00 PM, the Director of Nursing stated, I expect nurses to use enhanced barrier precautions every time they take care of a resident who has a break in their skin, G-tubes [gastric tubes], wounds, IVs, PICC [peripherally inserted central catheter] lines, and foley catheters.Review of Resident #4's physician order dated 11/18/2025 read, Enhanced Barrier Precautions for wounds, IV every shift. Wear gloves and a gown for the following High-Contact Resident Care Activities: Dressing, Bathing, Transferring, Changing Linens, Providing Hygiene, Changing Briefs or Assisting with Toileting. (EBP is required for residents with indwelling medical devices, wounds, or colonization with an MDRO [multi-drug-resistant organism]). every shift for Prophylaxis.Review of the facility policy and procedure titled Clinical Guidelines, PPE in Use to Prevent Spread of MDROs dated 10/2024 read, Purpose: Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MRDOs). Procedure: 1. Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. 2. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of organisms that employs targeted gown and glove use during high contact resident care activities. 3. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Chronic wounds or indwelling medical devices, regardless of MDRO colonization status.

Based on observation, interview, and record review, the facility failed to ensure food products were stored properly in the main kitchen and 1 of 6 nourishment rooms, 700 Hall Nourishment Room. Findings include: During an observation while conducting the initial tour of the main kitchen with the Dietary Assistant on 12/2/2024 at 9:26 AM, there were two unlabeled and undated bags of unidentified patties with one bag being open and unsealed, and one unlabeled and undated bag of mixed vegetables in the reach-in cooler. During an interview on 12/2/2024 at 9:30 AM, the Dietary Assistant stated that the food items should be labeled, dated and the bags needed to be sealed. During an observation on 12/2/2024 at 9:40 AM, the ice machine had a brownish color, soft buildup at the lip of the inside top rim of the maker. During an interview on 12/2/2024 at 9:40 AM, the Dietary Assistant confirmed that the ice machine had a buildup. During an observation of 700 Hall Nourishment Room with the Dietary Assistant on 12/2/2024 at 10:25 AM, there were plastic wrapped burritos and one opened ice cream container in the freezer that were not labeled or dated. During an interview on 12/2/2024 at 10:25 AM, the Dietary Assistant stated the food should be labeled and dated. Review of the facility policy and procedure titled Cleaning Ice Machines and Equipment last reviewed in July 2024 read, Purpose: The ice machine and equipment (scoops) will be cleaned on a regular basis to maintain a clean, sanitary condition. Procedure . 7. The ice scoop and the container will be washed and sanitized at least weekly or as needed in the dishwasher and allowed to air dry. Review of the facility policy and procedure titled Food Storage Overview last reviewed in July 2024 read, Purpose: Food is stored by methods designed to prevent contamination. Procedure . Refrigerator Storage . 14. Refrigeration . c. Foods are to be covered, labeled and dated including month, day, and year . Freezer Storage . 15. Frozen Foods . c. All foods should be covered, labeled and dated including month, day and year. Discard frozen leftovers after 6 months. Review of the facility policy and procedure titled Resident's Food Storage last reviewed in July 2024 read, Purpose: Food or beverage brought in from outside sources for storage in facility pantries, refrigeration units, or personal room refrigeration units will be monitored. Procedure: 1. Food or beverages brought into the facility for individual consumption will be labeled and dated.

Based on observation, interview, and record review, the facility failed to prevent possible aspiration and/or vomiting when staff failed to verify the gastrostomy tube (G-tube) placement prior to water and medication administration for 1 of 8 residents observed for medication administration, Resident #160. Findings include: During an observation on 12/4/2024 at 1:50 PM, Staff B, Licensed Practical Nurse (LPN), administered water into Resident #160's G-tube and allowed it to drain via gravity. Staff B did not aspirate the resident's stomach content to verify for correct G-tube placement prior to the administration of the water. Staff B then administered 10 milliliters (ml) of Guaifenesin Syrup (cough syrup) and allowed it to flow in via gravity and flushed the G-tube with water. During an interview on 12/4/2024 at 1:58 PM, Staff B, LPN, stated, It used to be the standard that we would check for tube placement by aspirating fluid, but we don't do that anymore. During an interview on 12/5/2024 at 2:35 PM, the Director of Nursing (DON) stated, The process for administering medications through the gastrostomy tube, the nurse would crush the medications separately and mix them with water. They would check for placement by putting air through and listening with a stethoscope. If they hear it [air], it is correct. They would also assess for residual; they would pull back with the syringe. They would flush in between each medication [with water] and after the administration. Review of the facility's policy and procedure titled Enteral Feeding Tube: Medication Administration last reviewed in July 2024, read, Purpose: To describe routine care of a gastric feeding tube including tube cleansing, placement verification, residual check and administer medications in an accurate and safe manner . Procedure . 13. Verify placement and patency of feeding tube prior to administering medication. 14. Verification of placement will occur by the following method: Connect piston syringe to end of feeding tube; Slowly pull back on syringe to aspirate gastrointestinal content.

Based on record review and interview, the facility failed to ensure resident assessments were accurate for 2 of 7 residents reviewed, Residents #27, and #90. Findings include: 1) Review of Resident #90's admission record showed the resident was initially admitted on [DATE] and readmitted on [DATE]. Review of Resident #90's Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed the resident is receiving anticoagulant medication under Section N0415- High-Risk Drug Classes: Use and Indication. Review of Resident #90's physician orders showed an order for Eliquis Oral Tablet 2.5 milligram by mouth twice daily for DVT (Deep Vein Thrombosis) with the start date of 9/7/2024 and end date of 10/7/2024. There was no active order for anticoagulant medication. During an interview on 12/5/2024 at 10:36 AM, the Regional Minimum Data Set (MDS) Coordinator confirmed that Resident #90 did not have an active order for anticoagulant. 48708 2) Review of Resident #27's admission record showed the resident was initially admitted on [DATE] and readmitted on [DATE]. Review of Resident #27's Entry MDS dated [DATE] showed the admitted [DATE] under section A1900- admitted . During an interview on 12/5/2024 at 10:45 AM, the Regional MDS Coordinator stated that the admitted on the Entry MDS for Resident #27 was incorrect. The admitted listed was from her previous stay on 5/6/2022.

Based on observation, interview, and record review, the facility failed to ensure staff followed appropriate infection prevention and control practices and used appropriate personal protective equipment (PPE) during medication administration via gastrostomy (G-tube) to prevent the possible spread of infection and communicable diseases. Findings include: During an observation on 12/4/2024 at 8:30 AM, Staff A, Registered Nurse (RN), placed liquid medication, oral medications, and an inhaler on the overbed table for Resident #162. There was a urinal, which was half full of a dark yellow liquid, on the overbed table. Staff A did not remove the urinal or provide a barrier or clean surface between the urinal and the medications. During an interview on 12/4/2024 at 8:35 AM, Staff A, RN, stated, I should have emptied the urinal. During an interview on 12/4/2024 at 11:47 AM, the Director of Nursing (DON) stated, I would advise the nurse not to use a surface where there were bodily fluids, such as urine, to store medications for administration. I would consider it an infection control issue. If they chose to use that surface, I would advise them to get rid of the fluid and sanitize the surface first. During an observation on 12/4/2024 at 3:08 PM, Staff C, LPN, administered a bolus dose of an enteral feeding via Resident #7's G-tube. Staff C was wearing gloves. Staff C did not use any other PPE. Review of Resident #7's physician order dated 6/11/2024 read, Enhanced Barrier Precautions for G-tube every shift for prophylaxis. During an interview on 12/5/2024 at 2:35 PM, the DON stated, Residents with a G-tube would be on enhanced barrier precautions. Nurses should wear gloves and a gown, and depending on the situation, goggles or a face shield for splashing. Review of the facility policy and procedure titled Isolation - Precautions Overview; SNF [Skilled Nursing Facility] & ALF [Assisted Living Facility] last revised in July 2024, read, Purpose: To provide a system of isolation precautions to prevent the transmission of infection; To prevent the transmission of infectious diseases . Procedure . Enhanced Barrier Precautions [EBP]- refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] that employs targeted gown and glove use during high contact resident care activities . EBP are indicated for residents with any of the following . Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. Review of Center for Diesase Control and Prevention (CDC) website for Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html showed it read, Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring a dressing.

Based on record review and interview, the facility failed to complete comprehensive assessments for the Admission Minimum Data Set (MDS) for 4 of 9 residents reviewed, Residents #41, #57, #112, and #176. Findings include: 1) Review of Resident #41's admission record documented an admitted [DATE]. Review of Resident #41's MDS Entry assessment dated [DATE] documented a status of accepted. There was no documentation of a completed or accepted Medicare 5-day assessment. Review of Resident #176's admission record documented an admitted [DATE]. Review of Resident #176's MDS Entry assessment dated [DATE] documented a status of accepted. There was no documentation of a completed or accepted Medicare 5-day assessment. Review of Resident #112's admission record showed the resident was admitted on [DATE] and discharged home on 8/16/2024. Review of Resident #112's electronic medical records showed no discharge MDS completed. During an interview on 12/5/2024 at 10:00 AM, the Regional MDS Coordinator stated, The admission assessment should be opened between days one and eight. It was opened this morning. It should be completed by day 14. When asked if Resident #41 and Resident #176's admission assessments were in compliance with date requirements, the MDS Coordinator stated, It was not opened between days one and eight, so no. The Regional MDS Coordinator confirmed that discharge MDS assessment was not completed for Resident #112 and stated, We have 21 days after discharge to complete the Discharge MDS. 50695 2) Review of Resident #57's progress notes showed the resident was discharged home with his daughter on 8/20/2024. Review of Resident #57's electronic medical records showed no discharge MDS completed for the discharge on 8/20/2024. During an interview on 12/5/2024 at 10:22 AM, the Regional MDS Coordinator stated, [Resident #57's name] does not have a discharge [MDS Assessment] for 8/20 [2024], but he should have one.

Based on observation, interviews, and record reviews, the facility failed to ensure that resident records were complete and accurate for 1(Resident #3) of 3 residents reviewed. Findings include: 1. During an observation on 2/15/2024 at 1:50 PM, Resident #3 requested pain medication from Staff C, License Practical Nurse (LPN). Staff C, LPN did not discuss with Resident #3 pain characteristic, location, or request Resident #3 to rate his pain on a scale of 1 - 10. Staff C, LPN left the room and returned at 1:56 PM and administered Hydrocodone Acetaminophen Tablet 5-325 mg (milligrams) to Resident #3. Staff C, LPN did not discuss pain location, characteristic of the pain or request Resident #3 to rate his pain on a pain scale of 1-10. Staff C, LPN was observed documenting on the electronic medication record medication given and did not document pain scale rating. During an interview on 2/15/2024 at 1:52 PM, Resident #3 stated I'm always in pain and right now my pain is a 11 on scale of 1 -10. During an interview on 2/15/2024 at 1:57 PM, Staff C, LPN stated, I've taken care of [Resident #3's name] for years and he always tells me that his pain in a 7 on a scale of 1-10 so I don't ask him anymore and do not document a pain rating. I should ask him and will in the future and document it. Review of Resident #3's physician's order dated 1/20/2024 read, Hydrocodone-Acetaminophen Tablet 5-325mg Give 1 tablet by mouth every 4 hours as needed for chronic pain 6-10. Review of Resident #3's physician's order dated 1/19/2023 read, Document for verbal/non verbal pain level then code which # intervention used below (must have 1 non pharmacological code) 1)1:1 2)massage 3)activities 4)food/drink 5)redirection/reassurance 6)deep breathing/relaxation 7)quiet area/rest period 8)therapy 9)heat/ice if ordered 10)PRN(as needed)/routine medication 11)none 12)other see note. every shift for Pain observation. Review of the daily shift pain level monitoring documentation on the Medication Administration Record (MAR) for February 2024 documented no pain rating for Resident #3 except for 2/6/2024 on the evening shift. Review of the MAR for Resident #3 for February 2024 read, Hydrocodone-Acetaminophen Tablet 5-325mg Give 1 tablet by mouth every 4 hours as needed for chronic pain 6-10. There was no documentation of a pain rating on prior to administering Hydrocodone-Acetaminophen on 2/1/2024, 2/5/2024, 2/7/2024 times 3, 2/8/2024 times 2, 2/11/2024, 2/13/2024, 2/14/2024, and 2/15/2024. Review of Resident #3's care plan dated 6/27/2022 read, The resident has potential for pain related to neuropathy, lower back pain, liver cirrhosis and phantom pain right with interventions including administer analgesia per physician order and evaluate the effectiveness of pain interventions. During an interview on 2/15/2024 at 3:22 PM the Director of Nursing confirmed that the physician's orders for [Resident #3's name] dated 1/20/2024 for Hydrocodone-Acetaminophen Tablet 5-325mg ( milligram) for 1 tablet by mouth every 4 hours as needed for chronic pain 6-10 was not followed as ordered. There was no nursing assessment of pain monitored or rate of pain on a scale of 1 - 10 as ordered. There was no documentation related to pain rating noted in the chart. Nurses are to complete a pain assessment on the resident when the resident complains of pain, document the pain on a scale of 1-10 and then follow up and reassess the pain on the pain scale of 1-10 within 1 hour after administering the medication and document assessments in the electronic medication administration record (EMAR).

Based on observation, interview, and policy and procedure review the facility failed to ensure medications were locked to permit only authorized personnel to have access. Findings include: During an observation on 02/14/2024 at 9:22 AM it showed there was a medication cart that was facing toward a resident's room on the 600 hall. The staff member in the room was not facing the medication cart, looked up, saw this writer, and then entered the bathroom. There were no other staff present in the area. The Administrator was walking by and when asked if there was a concern related to the medication cart, the Administrator walked around the cart, and verified the lock was not engaged and there was no staff member present. Staff A, Licensed Practical Nurse (LPN), the staff member in the room, returned to the cart at 9:24 AM. During an interview on 02/14/2024 at 9:23 AM the Administrator stated, The medication carts should be locked. During an interview on 02/14/2024 at 9:24 AM Staff A, LPN, in front of the Administrator, stated, I wasn't aware I had left the cart unlocked. According to the P & P [policy and procedure] the medication cart is to be locked at all times when I'm not at it. During an observation on 02/14/2024 at 9:28 AM a staff member was observed at the treatment cart in front of the nurses' station located on the 500 hallway. The employee removed a plastic bag that was labeled with a resident's name and medication. The employee walked away from the cart and started up the hallway. The treatment cart was observed unlocked and unattended. During an interview on 02/14/2024 at 9:28 AM the Registered Nurse/Case Manager (RNCM) stated, There are medications kept in the treatment cart. I don't know if it is supposed to be locked. I'm a nurse and all medications should be locked so the cart should be locked. I don't know how to lock it. I thought I would need to have a key to lock it. I was getting something for a CNA [Certified Nursing Assistant]. It was some nystatin powder; she was going to take it to [Staff A, LPN's name] for a resident. When asked when the employee unlocked the cart to get the medication did she have to use a key, the RNCM stated, I didn't unlock it, it was unlocked when I went to get the medication. I don't know who unlocked it or how long it had been unlocked. It should have been locked. Since it was not locked anyone could have access to the medications. Review of the policy and procedure titled, Medication Storage and Labeling read, Medications and biologicals in medication rooms, carts, boxes, and refrigerators were maintained within: Secured (locked) locations, accessible only to designated staff.

Based on interviews and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 (Resident #4) of 3 residents reviewed for pain management. Findings include: Review of Resident #4's admission record documented the resident was admitted on [DATE] with diagnoses that included left femur fracture, left knee pain, heart disease and history of falls. Review of Resident #4's physician's order dated 11/29/2023 read Hydrocodone 5-325mg (milligrams) give 1 tablet by mouth every 4 hours as needed for acute pain 6-10. Review of Resident #4's physician's order dated 12/10/2023 read Hydrocodone 5-325mg (milligrams) give 1 tablet by mouth every 6 hours as needed for nonacute pain 6-10. Review of Resident #4's Medication Administration Record (MAR) for 12/1/2023 through 12/31/2023 documented Resident #4 was administered Hydrocodone 5-325 mg for pain four times when pain was assessed and rated less than parameters written by the physician. Hydrocodone 5-325 mg was administered on 12/2/2023 with a documented pain level of 5, 12/9/2023 with a documented pain level of 4, 12/13/2023 with a documented pain level of 3, and 12/18/2023 with a documented pain level of 5. During an interview on 2/15/2024 at 1:24 PM, Physician A, MD [Resident #4 primary physician] stated I was never informed that the patient was given oxycodone when her pain was rated less than the parameters in which it was ordered. I never approved of the medication to be given for any other reason and I did not receive any calls from the nurses. During an interview on 2/15/2024 at 2:38 PM, the Director of Nursing stated, Physician orders were not followed. [Resident #4's name] was administered the narcotic Hydrocodone 5-325 mg 4 times when pain was not rated within the parameters of the physician's order [pain level 6-10]. Pain is to be assessed on a scale from 1-10 and documented each shift, before administering pain medication, and after administering pain medication for reassessment. Review of the policy and procedure titled Pain Assessment and Management dated 11/2023, read Purpose. Based on the comprehensive assessment of a resident, this facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. Pain Management Procedure. 4. Identifying target signs and symptoms (including verbal reports and non-verbal indicators from the resident) and using standardized assessment tools can help the interdisciplinary team evaluate the resident's pain and responses to interventions and determine whether the care plan should be revised.

Based on observation, interview, and record review the facility failed to ensure food products were stored in a safe and sanitary manner and failed to ensure dishes and utensils were cleaned under sanitary conditions in the main kitchen and in 2 of 2 nourishment rooms. Findings include: A tour of the kitchen was conducted on 8/21/2023 beginning at 9:08 AM with the Cook. On 8/21/2023 at 9:17 AM, the Cook tested the chemical solution in the low temperature dishwasher that was being used to wash dishes. The parts per million (PPM) of the sanitizer solution registered 50 PPM free chlorine following two tests of the sanitizer solution. During an interview on 8/21/2023 at 9:17 AM, the Cook confirmed the parts per million (PPM) of the low temperature dishwasher registered 50 PPM free chlorine and the kitchen would need to use disposable dishware until the dishwasher could be repaired. On 8/21/2023 at 9:18 AM, the Cook tested the chemical solution in the 3-compartment sink that was being used to wash dishes. The parts per million (PPM) of the sanitizer solution registered 0 PPM free chlorine. During an interview on 8/21/2023 at 9:20 AM, the Cook confirmed the parts per million (PPM) of the sanitizer solution registered 0 PPM free chlorine and the dishes would need to be rewashed to be disinfected. On 8/21/2023 at 9:21 AM, there was an undated bag of pancakes and an undated bag of waffles in the reach in cooler. On 8/21/2023 at 9:22 AM, there was a loose slice of bread stored with packaged bread loaves, an undated plastic bag of mashed potatoes, an undated and unlabeled plastic wrapped food product, and an opened bag of potato chips stored in the food preparation area. On 8/21/2023 at 9:25 AM, on top of the gas stove grill there was a loaf of bread in a package that was not sealed, steel pans, and a cardboard box of plastic wrap. The gas stove grill was caked with a black substance and there was a brown substance splattered on the outer edges of the gas stove top. There were two pilot lights burning with a visible flame. On 8/21/2023 at 9:28 AM, a tour of the walk-in refrigerator was conducted with the Cook. There were three boxes of fresh strawberries. The strawberries had a white fuzzy matter on them. There were 74 boxes of nutritional supplement, some of boxes of supplement had thawed. There were no dates labeled on the thawed nutritional supplement boxes. During an interview on 8/21/2023 at 9:28 AM, the Cook confirmed the strawberries in the boxes had white fuzzy matter on them and should be discarded. She confirmed the thawed nutritional supplement should be used within 14 days of thawing, but the thawed containers of nutritional supplement did not have a thawed-on date entered on the carton. During an interview on 8/21/2023 beginning at 9:08 AM, the Cook confirmed all food products should be labeled, dated, and covered. She confirmed that materials should not be stored on the gas stove grill top and that the gas stove grill top needed to be cleaned. On 8/21/2023 at 9:37 AM, a tour was conducted of the nourishment room for the 400/500/600 halls with the Cook. There was an opened undated/unlabeled Styrofoam cup of a brown frozen substance in the freezer. There were red and brown splatters on the interior top of the microwave oven. On 8/21/2023 at 9:42 AM, a tour was conducted of the Bistro with the Cook. There were red and brown splatters on the interior of the microwave oven. On 8/21/2023 at 9:45 AM, a tour was conducted of the nourishment room for the 200/300 halls with the Cook. There was an undated/unlabeled plastic grocery bag of food, two 1 quart undated/unlabeled plastic containers of food, and there was one unlabeled glass container of a liquid substance dated 7/16/2023 in the refrigerator. There was one undated quart of ice cream in a takeout container stored in the freezer. During an interview on 8/21/2023 beginning at 9:37 AM, the Cook confirmed all food products stored in the nourishment rooms should be labeled, dated, and covered. Food preparation was observed on 8/23/2023 beginning at 11:21 AM with the Certified Dietary Manager Consultant. At 11:22 AM, the Dietary Aide was observed pureeing veal in a blender. The Dietary Aide placed her fingers on the blender top, touching the food surface interior of the blender top, and lifted the blender top from the food preparation counter. The Dietary Aide then touched the exterior of the blender and the food preparation countertop with the same gloved hand. Once the veal was blended, the Dietary Aide used her same gloved hand to scoop the pureed veal out of the blender into a pan for service to the residents. During an interview on 8/23/2023 beginning at 11:22 AM, the Dietary Manager Consultant confirmed the Dietary Aide should not have touched the interior of the blender top that comes into contact with the food product and should not have used her same gloved hand to scoop the pureed veal out of the blender. Review of the facility policy titled Food Storage Overview, last reviewed 1/11/2023 read, Food is stored by methods designed to prevent contamination. Review of the facility policy titled Resident's Food Storage, last reviewed 1/11/2023 read, Food or beverage brought in from outside sources for storage in facility pantries, refrigeration units, or personal room refrigeration units will be monitored and 1. Food or beverages brought into the facility for individual consumption will be labeled and dated. Record review of the policy titled Dietary Services Monitoring/Action Plan, last reviewed 1/11/2023 read The Registered Dietician and/or Dietary Manager conducts ongoing monitoring of the Dietary Department for appropriate production, serving, storage, sanitation and cleanliness. This includes reviewing all equipment and monitoring meal service for appropriate temperatures, following of menus, and alternatives offered. The policy specified 12. Verify equipment is free from grease buildup, all items cleaned after use and stored appropriately.

Based on observation, interview, and record review the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 6 of 8 medication carts, and failed to ensure medications were secure. Findings include: 1) During an observation on [DATE] at 9:09 AM with Staff A, License Practical Nurse (LPN) of the 600 Hall medication cart there was open bottle of Pro-stat not labeled with an open date, a bottle of Latanoprost with an open date of [DATE], and an open bottle of Latanoprost with no open date. Review of the manufacturer's recommendation for Pro-Stat read, Record date on bottom of container upon opening. Discard 3 months after opening. Review of the manufacturer's recommendation for Latanoprost read, You may keep the opened bottle in the refrigerator or at room temperature for up to 6 weeks. During an interview on [DATE] at 9:17 AM Staff A, LPN stated, Medication should be dated once opened. I think eye drops are good for 30 days after opening. If medication is expired, it should be taken off the cart and a new one ordered. 2) During an observation on [DATE] at 9:21 AM with Staff B, LPN of the 400 Hall medication cart there was an open bottle of Alphagan 0.1% eyed drops with no open or expiration date and three orange-colored pills loose in the med cart. On top of the medication cart was a drink tumbler and crackers. Review of the manufacturer's recommendation for Alphagan read, Write the date on the bottle when you open the eye drops and throw out any remaining solution after four weeks. During an interview on [DATE] at 9:26 AM Staff B, LPN stated, The eye drops should have been dated once opened. I think they are good for 30 days. The med cart should not have loose medication. I don't know about the crackers, the drink is mine it should not be there. 3) During an observation on [DATE] at 9:30 AM with Staff C, LPN of the 100 Hall medication cart there was a bottle of Latanoprost eye drops labeled with an open date of [DATE] and an Advair inhaler with an open date of [DATE]. Review of the manufacturer's recommendations for Advair read, Safely throw away Advair in the trash 1 month after you open the foil pouch or when the counter reads O, whichever comes first. During an interview on [DATE] at 9:34 AM Staff C, LPN stated, When medication expires it should not be kept in the med cart. The Advair is good for 1 month after you open it. 4) During an observation on [DATE] at 9:39 AM with Staff D, Registered Nurse (RN) of the 300 Hall medication cart there was an open prednisolone AC [acetate]1% eye drops with no open or expiration date, an open bottle of Latanoprost with no open or expiration date, and an open insulin glargine pen with no open or expiration date. Review of the manufacturer's recommendations for prednisolone AC read, You should dispose of any unused eye drops 30 days after you first opened the bottle. Review of the manufacturer's recommendations for glargine insulin read, Once you open your insulin, it takes about 28 days to expire. During an interview on [DATE] at 9:44 AM Staff D, RN stated, All medication should be dated once opened. Especially the insulin since they have different days of expiration. 5) During an observation on [DATE] at 9:54 AM with Staff E, LPN of the 700 Hall medication cart there was an open bottle of Ketorolaci with no open or expiration date, a bottle of saline nasal spray that was not in the original package and had no open or expiration date, and two loose pills in a medication cup in the draw of the medication cart that was not labeled. Review of the manufacturer's recommendations for Ketorolaci eye drops read, Throw away eye drops 28 days after opening the bottle. This is because the preservatives inside can start to break down and allow bacteria to grow. During an interview on [DATE] at 9:57 AM Staff E, LPN stated, I had just placed those medications there it is just vitamins. I was pulling the medication for a resident and another one came to ask for their meds and I stopped and did the other person. Medication should be dated and stored in original packaging. 6) During an observation on [DATE] at 10:08 AM with Staff F, LPN of the Memory Care Unit medication cart there was an open bottle of Timolol with an open date of [DATE], a bottle of Latanoprost with an open date of [DATE], a bottle of Refresh Tears with an open date of [DATE] and was not in the original container, an open insulin lispro pen with no open date or expiration date, and an open Lantus Solostar [glargine] with no open date or expiration date. During an interview on [DATE] at 10:11 AM Staff F, LPN stated, Medication should have an open date and expiration date. If expired, it should be taken off the medication cart and the pharmacy contacted for medication. During an observation on [DATE] at 10:45 AM Resident #8 was lying in bed. Resident #8 had a Vicks VapoStick, Desitin ointment, and Calmoseptine ointment at bedside. Review of Resident #8's physician orders did not document an order for medication self- administration. Review of Resident #8's care plan did not document a focus for medication self-administration of medication. During an observation on [DATE] at 11:15 AM Resident #112 was lying in bed. Resident #112 had Fluticasone Propionate Nasal Spray at bedside. Review of Resident #112's physician orders did not document an order for medication self-administration. Review of Resident #112's care plan did not document a focus for medication self-administration. During an interview on [DATE] at 8:14 AM the Director of Nursing (DON) stated, Medication should be dated and utilized for the allotted period of time. Any expired medication should be removed from the cart. Loose medication and person drinks or foods are not allowed on medication carts. Review of the facility policy and procedure titled Drug Labeling with a last review date of [DATE] read, Purpose: All drugs and biologicals must have legible labels. Procedure: 6. Medications in containers having no labels must be destroyed in accordance with the facility's procedure governing the destruction of medication. Review of the policy and procedure titled Medication Expiration after Opening read in part, Medications below should be dated when opened. Lispro, Glargine, Advair, Prostat. Review of the facility policy and procedure titled Storage of Medications with a last review date of [DATE] read, Policy: Medications and biologicals are stored safely, and properly, following manufacture's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts and medication supplies are locked when not attended by persons with authorized access. H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal .

Based on record review and interview, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) was completed for 1 of 5 residents Resident #95, reviewed with a possible serious mental disorder, intellectual disability Findings include: Review of the electronic health record for Resident #95 documented the resident was admitted to facility on 2/8/23 with diagnoses including fracture of upper and lower end of left fibula, mood affective disorder, cognitive communication deficit, schizophrenia and hypertension. Review of Resident #95's care plan dated 2/8/23 documented focus: The resident has a potential for behavior problem related to schizophrenia. Review of Resident #95's medical record contained an encounter form from [Name of the afterhours clinic] dated 1/17/23 which documented Resident #95 with the diagnosis of schizophrenia, dementia, and bipolar disorder. Review of Welcome Meeting Questionnaire from [Name of Health Care Provider] dated 2/9/23 documented Resident #95 as having a diagnosis of schizophrenia. Review of Resident #95's PASRR screening dated 2/08/23 does not document Resident #95 having a diagnosis of schizophrenia. Review of Resident #95's PASRR screening dated 2/13/23 does not document Resident #95 having a diagnosis of schizophrenia. During an interview with the Director of Nursing conducted on 8/22/23 at 12:30 PM, she stated, We should have completed a new Level I [PASRR] screening when she [Resident #95] was documented with a diagnosis of schizophrenia on 2/8/23. Review of the policy and procedure titled, Admissions Guidelines Manual, dated 2018 and updated on 01/11/23 read, Submitting a Level I PASRR request . Section 2. Enter Case Details 2. The Request Detail section is required. Please select PASRR Level I (or PASRR Level I Resident Review, if this review is for an existing nursing facility resident with significant change in condition).

Based on record review and interview, the facility failed to ensure assessments were completed accurately for 2 of 7 residents, Residents #140 and #7 reviewed for hospitalization . Findings include: Review of Resident #7's Minimum Data Set Assessment (MDS) dated [DATE] documented under Section O, the resident was receiving tracheostomy care while a resident in the facility. Review of Resident #7's medical record diagnoses list does not document Resident #7 being dependent on the use of a tracheostomy. During an interview with the Director of Nursing (DON) conducted on 08/24/23 at 10:00 AM, she stated, [Resident #7's name] has never had a tracheostomy. Review of Resident #140's electronic health record showed Resident #140, age 77 was admitted to the facility on [DATE] and left the facility against medical advice (AMA) on 7/26/23. Review of Resident #140's AMA form dated 7/26/23 at 9:23 PM showed it was signed by Resident #140's spouse and witnessed by two facility staff. Review of Resident #140's Discharge Minimum Data Set Assessment (MDS) dated [DATE] documented under Section A 2100 Resident #140 as being discharged to an acute hospital. During an interview with the MDS Coordinator conducted on 08/24/23 at 10:20 AM, she stated, [Resident #140's name] was signed out AMA by her spouse and Resident #7 does not have a tracheostomy in place and never has had one. When we are completing the assessments, we follow the Resident Assessment Instrument (RAI) for MDS completions.

Based on observation, interview, and record review the facility failed to provide care and services for central venous catheters in accordance with professional standards of practice for 1 of 4 residents, Resident #291. Findings include: Review of Resident #291's medical record documented the resident was admitted to the facility with the following diagnoses: unspecified fracture of shaft of humerus, right arm, malignant neoplasm of unspecified bronchus or lung, malignant neoplasm of brain, history of falling, fracture part of neck of right femur, chronic obstructive pulmonary disease, obstructive sleep apnea, and pulmonary embolism without acute cor pulmonale. During an observation on 8/21/2023 at 1:14 PM Resident #291 was resting in bed with a right arm soft cast. Resident #291 had a right subclavian single lumen central line, the date on the dressing was 8/17/2023; there was gauze over the insertion site that was covered with a transparent dressing. During an observation on 8/23/2023 at 8:09 AM Resident #291 was resting in bed. The right subclavian central line dressing was dated 8/17/2023, there was gauze under the transparent dressing that was covering the insertion site. During an observation on 8/24/23 at 06:15 AM of Staff L, Registered Nurse (RN) administering medication to Resident #291 via the right subclavian central line; the date on the dressing read 8/17/2023 and had gauze covering the insertion site under a transparent dressing. The transparent dressing was rolling up off the resident's skin at the edges. Review of the physician orders dated 8/15/2023 read, Piperacillin Sod-Tazobactam 4-0.5 gm (gram) use 4.5 gm IV (intravenously) every 6 hours for skin and soft tissue infection. There was no physician order for central line dressing changes contained in Resident #291's medical record. During an interview on 8/24/23 at 06:15 AM Staff L, Registered Nurse (RN) stated, The central line dressing does have a date of 8/17/23 and it does need to be changed. There should not be any gauze under the dressing, or it would need to be changed every two days. We should get orders for dressing changes when residents are admitted . During an interview on 8/24/23 at 6:58 AM the Director of Nursing (DON) stated, All dressings for PICC's [peripherally inserted central catheter] or central lines should have dressing change orders to change every seven days. Central line dressings should not have gauze under them, they will need to be changed every two days if they do. I do not know why she [Resident #291] does not have dressing change orders. Review of the policy and procedure titled, Central Venous Catheter Dressing Changes with an approval date of 1/11/2023 read, Policy: Central venous catheter dressings will be changed at specific intervals, or when needed to prevent catheter-related infections that are associated with contaminated, loosened soiled, or wet dressings. General Guidelines: 1. Apply and maintain sterile dressing on intravenous access devices. Dressings must stay clean, dry and intact. Explain to the resident that the dressing should not get wet. 4. After original insertion of CVAD (central venous access device), the dressing will consist of gauze and TSM (transparent semipermeable membrane). This will be changed within 24 hours. Replace with sterile transparent dressing.