Every finding on record at Manila Healthcare Center

Based on record review, observation, interview, and facility policy review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for one (Resident #17) of two residents reviewed for EBP and failed to ensure hand hygiene was consistently implemented during incontinence care for one (Resident #46) of one resident reviewed for incontinence care.The findings include:Resident #17A review of Resident #17's Physician's Orders, dated 03/16/2026, revealed all medications were to be administered by way of (via) a Percutaneous Endoscopic Gastrostomy (PEG) tube, with a start date of 04/10/2024. The resident had an active order for EBP related to indwelling devices, with a start date of 06/24/2024. A review of Resident #17's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/2025, revealed a Staff Assessment for Mental Status (SAMS) score of 3, which indicated the resident was severely impaired and never/rarely made decisions. Resident #17's MDS also revealed the resident had a feeding tube while a resident.A review of Resident #17's Care Plan revealed the resident required tube feedings related to dysphagia, with interventions which included direction for staff to follow EBP, initiated on 04/21/2024.A review of Resident #17's electronic Medication Administration Record (eMAR) for 03/2026 revealed EBP related to indwelling devices with an order date of 06/24/2024. There were two 12-hour time slots listed on the eMAR:- On 03/18/2026, the first time slot of 12 hours, had a checkmark and Licensed Practical Nurse (LPN) #2's initials were in the box. The chart codes/follow up codes on the eMAR revealed a checkmark indicated administered.During an observation on 03/16/2026 at 1:40 PM, this surveyor observed there was no EBP signage posted, or Personal Protective Equipment (PPE), available outside of Resident #17's room. After entering the room, there was a feeding pump to the right of Resident #17's bed, that was not in use at this time.During an observation on 03/17/2026 at 12:33 PM, this surveyor observed there was still no EBP signage or PPE outside of Resident #17's room, nor any other indicator that the resident required EBP.During a concurrent observation and interview on 03/18/2026 at 12:26 PM, Registered Nurse (RN) #10 entered Resident #17's room to change Resident #17's percutaneous endoscopic gastrostomy (PEG) tube tubing. As the primary nurse, LPN #2 was busy at this time. RN #10 sanitized her hands and put on a pair of gloves. She then informed Resident #17 of the care she was about to perform and stated she needed to grab a cup of water, so RN #10 removed their gloves and exited the room. At 12:37 PM, RN #10 re-entered Resident #17's room and sanitized her hands and put on a new pair of gloves. She did not bring a gown into the resident's room to use and continued to perform the entire procedure of disconnecting the resident's previous enteral feeding bags and tubing with a new set of enteral feeding bags and tubing to Resident #17's PEG tube. During the procedure, RN #10 connected a 60 cubic centimeter syringe to Resident #17's PEG tube, to check for placement, without wearing a gown. RN #10 verified the resident was on EBP and stated that gloves were a part of EBP. When questioned if a gown was a part of EBP, RN #10 stated she had never worn a gown for hooking up a PEG tube. She then stated she was not informed that a gown was to be used when changing the lines on a PEG tube.During an interview on 03/18/2026 at 12:55 PM, LPN #2 stated Resident #17 should be on EBP, because the resident had a PEG tube and a [brand name] catheter. LPN #2 stated there was not a red dot by the resident's name (on the name placard next to the resident's door) to indicate Resident #17 was on EBP. LPN #2 stated the Treatment Nurse was responsible for posting the signage for residents on EBP.During an interview on 03/19/2026 at 11:12 AM, the Treatment Nurse stated she was responsible for putting up the signage for residents on EBP. She stated when she ran her list to check everyone, Resident #17 was out to the hospital, and she missed putting Resident #17's EBP information [signage] in place. A review of an Enhanced Barrier Precautions policy with a revision date of 08/2022, revealed gown and gloves were to be applied prior to performing high-contact resident care activity (as opposed to before entering the room). This EBP policy indicated examples of high-contact resident care activities which included device care or use, such as a feeding tube.A review of an EBP Competency Checklist revealed RN #10 completed the following items on the EBP checklist on 11/17/2025: the PPE required for EBP, and conditions which required the use of EBP; a feeding tube was included on this list.Resident #46A review of Resident #46's admission Record indicated the facility admitted the resident on 08/22/2023, with diagnoses which included dementia and Parkinson's disease.A review of Resident #46's quarterly MDS with an ARD of 02/02/2026, revealed a SAMS score of 3, which indicated the resident was severely impaired and never/rarely made decisions. Resident #46's MDS also revealed the resident was dependent for toileting, personal hygiene, could shower/bathe self, and was always incontinent of bowel and urine. A review of Resident #46's Lab Results revealed a urine analysis was performed on 02/12/2026, which indicated Escherichia Coli (bacteria normally found in intestines that could cause infection when found in the urinary tract) and extended-spectrum beta-lactamase (enzymes produced by a bacteria that make them resistant to common antibiotics) in the resident's urine, which required treatment with an antibiotic.During an observation on 03/18/2026 at 1:49 PM, Nurse's Aide (NA) #6 and Certified Nursing Assistant (CNA) #7 entered Resident #46's room to perform perineal (peri) care to the resident. CNA #7 had sanitized her hands and put on gloves before performing care to Resident #46. During the care, CNA #7 stated she needed more wipes to provide care to Resident #46. NA #6 then exited the room and came back in after a few minutes with a green package of unopened wipes. Without changing gloves and sanitizing her hands, CNA #7 received the package of wipes from NA #6, opened the package of wipes, placed the package of wipes on the over-bed table, and began to remove clean wipes from the package with the same gloves that she was wearing while using previous wipes to cleanse urine from Resident #46's skin. CNA #7 continued to use those same pair of gloves to pick up a bottle of perineum (area of skin located between the genitals and the anus) wash, sprayed the liquid to Resident #46's gluteal area, removed wipes from the package and cleansed Resident #46's gluteal areas. CNA #7 picked up the bottle of perineum wash and sprayed some liquid on Resident #46's rectal area and proceeded to cleanse loose brown feces from Resident #46's rectum. After CNA #7 was done with peri-care to Resident #46, without changing gloves, she placed a clean adult brief under the resident's right side, rolled Resident #46 to the left side, and then pushed a blue lift pad under the resident's back. Then CNA #7 and NA #6 repositioned Resident #46 to their right side, and NA #6 removed the blue lift pad and pulled the clean adult brief under the resident's left side, and then the resident was positioned on their back. After peri-care was completed, CNA #7 placed a yellowish-gold bottle of powder, and the bottle of perineum wash inside Resident #46's drawer and before removing and discarding their soiled gloves in the trash can.During an interview with CNA #7 on 03/18/2026 at 2:05 PM, she verified she was to sanitize her hands before and after entering a resident's room who was incontinent of urine and feces, when providing peri-care. She then verified she was supposed to change her gloves when she provided peri-care to anterior parts of a resident's peri-area and change gloves when performing care to the resident's back side. CNA #7 verified she was not supposed to use the gloves that she cleansed feces from the resident's skin with to remove clean wipes from a package and then confirmed she did not change her gloves during peri-care to Resident #46, because she was moving too fast. CNA #7 also stated she knew she was supposed to sanitize her hands during peri-care when moving to Resident #46, but she did not. She stated she had received training on how to perform peri-care to residents by shadowing a CNA at the facility for two to three weeks. She stated she had not performed any skills-checkoffs before caring for residents on her own.During an interview on 03/19/2026 at 2:43 PM, the Director of Nursing (DON) stated the nurses were in-serviced on EBP either by the Infection Preventionist or the DON quarterly, and if there were any changes. She stated the Infection Preventionist was responsible for posting EBP signage, but nurses knew what to do and where things were, therefore could place EBP signage. The DON stated the red dot [placed by the resident's name on the door tag outside of the room] was for staff to be aware of who was on EBP. She stated her expectations regarding CNAs and nurses following EBP was for the staff to put on PPE and if they had any questions, to ask for clarification. She stated her expectations for staff on hand hygiene during peri-care were to follow hand hygiene, per the training, and to do hand hygiene appropriately because this could lead to further issues. The DON then stated CNA #7 did receive training and she was asked to provide a skills checkoff for CNA #7 regarding peri-care. As of 03/19/2026 at 4:57 PM, the DON had not provided any trainings/education on peri-care for CNA #7.A review of a Perineal Care policy, revised 02/2018, revealed the purposes of this procedure were to provide cleanliness and comfort for the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.A review of a Handwashing/Hand Hygiene policy, revised October 2023, revealed hand hygiene is the primary means to prevent the spread of healthcare-associated infections.

Number of residents sampled: Number of residents cited: Based on interview and record review the facility failed to ensure that one (Resident #95) of one resident reviewed for self-determination, had the opportunity to exercise autonomy in choosing when to have medication administered. The findings include: Review of an admission Record revealed Resident #95 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease with (acute) exacerbation, congestive heart failure, pneumonia, vitamin deficiency, dizziness, and gastroesophageal reflux disease (GERD). Review of Resident #95's admission Minimum Data Set (MDS) revealed that the MDS was in progress. Review of the CMT Medication Administration Record (MAR) dated 03/16/2026 revealed that Resident #95 refused the following medications: an antibiotic, a high blood pressure medication, an allergy medication, vitamin, an iron supplement, an anticholinergic, a probiotic, a blood thinner, an antacid, an oral steroid, an antitussive, a diuretic and an antivertigo. The medications were coded on the MAR with the number two. The number indicated the medications were refused. During an interview on 03/16/2026 at 12:05 PM, Resident #95 indicated they had not received morning medications at that time. Resident #95 indicated that the nurse brought the morning medications to the room around 7:30 AM and the resident informed the nurse that it was too early to take 11 pills. Resident #95 indicated that they told the nurse to bring the medications back after they had eaten breakfast, which was around 9:00 AM-9:30 AM. Resident #95 stated they could not remember the name of the nurse. During an interview on 03/16/2026 12:08 PM, Licensed Practical Nurse (LPN) #8 indicated that Medication Technician (Med Tech) #9 went in to give Resident #95 their medications at 8:30 AM. LPN #8 indicated that Resident #95 wanted to wait until 9:00 AM, after breakfast, to take the morning medications. LPN #8 indicated that Resident #95 was informed that medications had to be taken between 7:00 AM and 9:00 AM. LPN #8 indicated that she notified the Nurse Practitioner (NP) at 12:00 PM that Resident #95 refused the morning medications. During an interview on 03/16/2026 at 3:13 PM, Resident #95 indicated that they took an antibiotic every day. Resident #95 indicated that it was important that medication was taken every day. During an interview on 03/18/2026 at 9:26 AM, the NP indicated that Resident #95 should be accommodated if the resident chose to take medications later than scheduled. The NP indicated she received a message on 3/16/2026 at 12:07 PM from LPN #8 indicating that Resident #95 did not take the medications. The nurse practitioner indicated that Resident #95 did not receive the scheduled antibiotic on 03/16/2026. The NP indicated that Resident #95's last dose of antibiotic should have been Monday 3/16/2026, however the last dose was administered on 03/17/2026. The NP indicated that LPN #8 should have administered Resident #95's diuretic, iron supplement, and high blood pressure medications. During an interview on 03/18/2026 11:06 AM, the Director of Nursing (DON) indicated that if Resident #95 requested medication to be administered after breakfast the provider should be contacted to change the medication times. The DON indicated that the resident's preference on the time that they would like their medications administered should be accommodated. The DON indicated that Med Tech #9 should have notified the nurse if Resident # 95 requested medications at a time that was different from the scheduled time. During an interview on 03/18/2026 at 2:11 PM, the Administrator indicated that the facility was Resident #95's home. The Administrator also indicated that it was Resident #95's choice to take medication at a different time than the scheduled time. During an interview on 03/19/2026 at 12:40 PM, Med Tech #9 indicated that if a resident requested their medication after breakfast, she would usually inform the nurse. Med Tech #9 indicated that she informed LPN #8 that Resident #95 did not take the morning medications. Med Tech #9 indicated that she had to leave the facility to work transportation for other residents. Med Tech #9 indicated that she asked LPN #8 to give Resident #95 the medications when Resident #95 finished breakfast. Med Tech #9 indicated that LPN #8 agreed to give Resident #95 the medications. During a phone interview on 3/19/2026 at 04:00 PM, LPN #8 stated that Med tech #9 LPN via phone asked her to give Resident #95 her medication on 3/16/2026.LPN #8 indicated that Med Tech #9 offered Resident #95 her medications, and the resident wanted to wait until 9:00 AM. LPN #8 indicated that Med Tech #9 put a lid on the medications and put it in the top drawer of the medication cart. LPN #8 indicated on 3/16/2026 at 9:40 AM that Med Tech #9 left the facility to do transport. LPN #8 indicated that she assumed Med Tech #9 had administered Resident #95 her medications. LPN #8 indicated that around 11:00 AM she discarded Resident 95's medications. LPN #8 indicated that she talked to Resident #95 later that day on 3/16/2026, and Resident #95 indicated that she did not get her morning medications. Review of a policy titled Administering Medication indicated that staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. The policy indicated that medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include honoring resident choices and preferences.

Number of residents sampled: Number of residents cited: Based on record review, interview and facility policy review, the facility failed to ensure a Comprehensive Care Plan was consistently implemented for one (Resident #17) of four residents reviewed. The findings include: Review of an admission Record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses which included epilepsy, restless leg syndrome and hemiplegia and hemiparesis (decreased sensation or mobility on one side of the body) affecting the right dominant side. Review of a quarterly Minimum Data Set with an Assessment Reference Date of 12/18/2025, revealed Resident #17 had a Staff Assessment for Mental Status score of 03, which indicated Resident #17 had severe cognitive impairment, never/rarely made decisions, and was dependent on staff for rolling left and right. Review of March 2026 Physician's Orders revealed Resident #17 was receiving comfort measures only. Review of a Care Plan with a revised date of 02/01/2020, revealed Resident #17 had an Activity of Daily Living (ADL) self-care performance deficit, with an intervention, dated as initiated 01/28/2020 and revised 02/01/2022, of bed mobility requiring extensive assistance times (x) 2 staff for repositioning and turning in bed every (q) 2 hours and as necessary. The Care Plan also revealed Resident #17 had an actual fall with minor injury on 02/05/2026 and one on one education was provided with staff to ensure using two persons assistance with bed mobility and care. Review of a Progress Note dated 02/05/2026 at 4:19 AM, revealed Resident #17 was found lying on the floor on the resident's side after rolling out of bed during briefs change. Review of an Incident and Accident (I&A) Report dated 02/05/2026 revealed Resident #17 was found on the floor lying on Resident #17's side after rolling out of bed while CNA [not named] was trying to smooth out the drawsheet. The incident report indicated Resident #17 did not have any injuries. During a telephone interview on 03/19/2026 at 3:22 AM, Licensed Practical Nurse (LPN) #12 stated knowing how to care for Resident #17 by looking at the resident's care plan and if there are changes the day shift nurse gives her those changes about the resident in report. She stated she was working 02/13/2026 when Resident #17's incident of falling out of the bed occurred and CNA #11 was the CNA working with Resident #17 that night. LPN #12 recalled CNA #11 notifying her that Resident #17 rolled down CNA #11's body to the floor after she noticed the bed moving and the wheels unlocked. LPN #12 stated 2 CNAs were required to turn and reposition Resident #17 while in bed. During a telephone interview on 03/19/2026 at 3:48 AM, CNA #11 stated she was familiar with what care Resident #17 required by reviewing the Closet Care Plan. She stated Resident #17 required two CNAs to turn and reposition the resident and admitted to moving the resident in bed with no help. She stated she did not check the wheels on the resident's bed before reaching under the resident to smooth the drawsheet because the wheels appeared to be locked to her. CNA #11 stated when she let go of the drawsheet that was under Resident #17, the bed moved and Resident #17 rolled out of the bed down her [CNA #11's] body to the floor. CNA #11 stated, because my arm length is long, I thought I could straighten the draw sheet under the resident on my own. She stated she does check the wheels on the resident's beds before providing care, but she was trying to handle many tasks that night and did not check the wheels on Resident #17's bed. During an interview on 03/19/2026 at 2:43 PM, the Director of Nursing (DON) stated she expected staff to follow the resident's Care Plan every time they provided care and if staff had any questions about the Care Plan to reach out to the charge nurse or nurse manager. She stated staff should check the wheels on the residents' bed before providing care and before exiting the room. Review of a facility policy titled Care Plans, Comprehensive Person-Centered revised March 2022, revealed A comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan policy also revealed the comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and reflects currently recognized standards of practice for problem areas and conditions.

Number of residents sampled: Number of residents cited: Based on observation, record review and interviews, the facility failed to ensure the Medical Director (MD) or Nurse Practitioner (NP) were contacted for orders when two medications were unavailable for one resident (Resident #98) during medication pass. Specifically, this surveyor observed 2 of 37 opportunities for medication not administered in accordance with the physician orders by way of omission, resulting in a medication error rate of 5.41%. The findings include: Review of Resident #98's Medical Diagnosis revealed the facility admitted Resident #98 with diagnoses which included dementia, fibromyalgia (widespread chronic pain and fatigue) and polyneuropathy (widespread damage to peripheral nerves causing numbness, burning pain and weakness starting in the hands and feet). Review of an admission Minimum Data Set with an Assessment Reference Date of 12/10/2025, revealed Resident #98 had a Brief Interview for Mental Status score of 5, which indicated the resident had severe cognitive impairment. The MDS also revealed Resident #98 was on a scheduled pain management regimen and the resident used a wheelchair and was not assessed for ambulation due to their physical condition. Review of a Care Plan with initiated date of 12/29/2025, revealed Resident #98 had chronic pain related to arthritis, was at risk for thrombotic event related to a topical nonsteroid anti-inflammatory gel. Interventions included to watch for signs of heart attack, stroke, and gastrointestinal reactions including bleeding and ulcers. Review of Medication Pass Competencies for Licensed Practical Nurse (LPN) #1 revealed competencies were achieved on 02/16/2026 and completed by the Assistant Director of Nursing (ADON). Competencies were not provided for LPN #3. Review of a Progress Note dated 03/17/2026 at 8:13 AM, revealed LPN #1 indicated that an anti-inflammatory gel was on order, no documentation indicated that the Medical Director (MD) or the ADON was made aware. Review of a Progress Note dated 03/18/2026 at 9:11 AM, revealed LPN #1 indicated an oral non-steroidal anti-inflammatory drug (NSAID) was on order, no documentation indicated that the MD or the ADON was made aware. Review of a Progress Note dated 03/18/2026 at 9:21 AM, revealed LPN #1 indicated that an anti-inflammatory gel was on order, no documentation indicated that the Medical Director (MD) or the ADON was made aware. Review of a Progress Note dated 03/18/2026 at 10:23 PM, revealed LPN #3 indicated that the anti-inflammatory gel was not available and an electronic message was sent to the ADON. Review of a receipt from [Named] pharmacy showed the NSAID and the anti-inflammatory gel were delivered to the facility on [DATE] at 11:06 AM. On 03/18/2026 at 9:08 AM, LPN #1 was observed giving medication to Resident #98. LPN #1 revealed the facility was out of a NSAID and an anti-inflammatory gel, and the medication should arrive on 03/18/2026 from a pharmacy. During a telephone interview on 03/18/2026 at 10:34 AM, LPN #1 stated Resident #98's NSAID and an anti-inflammatory gel had arrived from the pharmacy. LPN #1 stated no the doctor was not notified the resident had not received the ordered doses were not administered, and LPN #1 also stated they did not give the missed dose of medication because Resident #98 would get it at the next dose period. During an interview on 03/19/2026 at 10:43 AM, LPN #1 stated that on 03/17/2026 the anti-inflammatory gel was emptied, and a note was made showing it was on order. The anti-inflammatory gel came from a pharmacy in the morning on 03/18/2026. LPN #1 confirmed Resident #98 did not get a dose of the topical gel until the evening of 03/19/2026. LPN #1 confirmed Resident #98's last dose of NSAID was on 03/17/2026, and Resident #98 did not get another dose until the morning of 03/19/2025. LPN #1 revealed the process for ordering medications was to make a list of medications low in stock and notify the ADON. Sometimes the medications were on back order and the ADON would call [Named] Pharmacy, and the facility would pick the medication up. LPN #1 stated the NSAID and the anti-inflammatory gel was now in stock. During an interview on 03/19/2026 at 11:00 AM, the ADON stated that if a medication was not in the facility nursing staff were to notify the pharmacy and make a note about the pharmacy response and then notify the MD or Nurse Practitioner (NP), and document in the nurse progress notes or administration note. The ADON confirmed Resident #98 was out of NSAID and anti-inflammatory gel on 03/18/2026 and [named] pharmacy delivered the medications. The ADON revealed how late the Pharmacy delivered the medication would determine when the next dose was administered. The ADON reviewed the electronic record and stated, It [electronic record] shows that Resident #98 did not get last night's dose of topical anti-inflammatory gel even though it was delivered the morning of 03/18/2026. LPN #3 documented in progress notes that the anti-inflammatory gel was not available. The ADON also confirmed Resident #98 did not get a dose of NSAID on 03/18/2026 according to the Medication Administration Record [MAR.] The ADON stated I do not see a note that the doctor was notified that Resident #98 missed a dosed of NSAID and two doses of anti-inflammatory gel. The ADON indicated that the MD or NP should have been notified. During an interview on 03/19/2026 at 11:15 AM, The MD stated the NP should have been notified that medications for Resident #98 were not available. During an interview on 03/19/2026 at 11:18 AM, The Administrator stated his expectation was that nurses would immediately call the care Physician and call [named] pharmacy and have medications delivered immediately. The Administrator stated the Physician should be notified when a resident does not have medication, because they need to know if the medication was delivered and was in the building. The Administrator also stated the medication should be given at the next dosing period unless the care Physician stated otherwise. The Administrator stated, I would anticipate that the resident would get the ordered medication if it were on the MAR. During an interview on 03/19/2026 at 4:00 PM, Resident #98 stated a nurse put the cream on me [feet and legs] this morning. Resident #98 revealed having some discomfort and pain going to and from the doctor's office on 03/18/2026. I sure think it would have helped if I had gotten my pain cream yesterday. Resident #98 stated staff were not notified about residents' discomfort because there was nothing they could do about it due to not having the resident's prescribed medication. Review of a facility policy titled Administering Medications, revised on 04/2019, revealed medications are administered in accordance to prescriber orders, including any required time frame. The policy also revealed If medication is given at a time other than the scheduled time, the administrator of the medication should initial, and circle the MAR space provided for that drug and dose. Review of a facility in-service titled TX/IP dated 03/26/2025, revealed staff received medication administration training. LPN #1 signed the in-service which indicated LPN #1 attended training.

Number of residents sampled:Number of residents cited:Based on interview and record review the facility failed to ensure one (Resident #14) of one resident reviewed for pain management, received their pain medication when requested. The findings include: Review of an admission Record revealed the facility admitted Resident #14 on 10/18/2024 with diagnoses which included age-related osteoporosis with current pathological fracture. Review of a quarterly Minimum Data Set with an Assessment Reference Date of 1/20/2026, revealed Resident #14 had a Brief Interview of Mental Status score of 15 which indicated Resident #14 was cognitively intact. Review of Resident #14's Order Summary Report with a start date of 10/18/2024, revealed a Physician's Order for an opioid pain medication, to be given every eight hours as needed (PRN) for pain. Review of Resident #14's Care Plan, revised on 10/26/2024, revealed the resident had acute pain related to fracture of the back, and osteoporosis. The Care Plan interventions included to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. During an interview on 03/17/2026 at 10:25 AM, Resident #14 complained of back pain. Resident #14 indicated they had not received their scheduled pain medication. Resident #14 indicated that the nurse should bring the scheduled pain medication between 7:00 AM- 9:00 AM. Resident #14 indicated that they asked Certified Nursing Assistant (CNA) #4 at approximately 9:56 AM to inform Licensed Practical Nurse (LPN) #2 that the residents pain medication was needed. During an interview on 03/17/2026 at 10:31 AM, LPN #2 indicated that she had finished passing all medications for the morning. LPN #2 indicated that Resident #14 received a PRN pain medication every eight hours. LPN #2 indicated that the resident usually requested the medication every morning. LPN #2 indicated that she had a hectic morning and could not remember if any of the staff informed her that Resident #14 wanted the pain medication. LPN #2 indicated that she did not assess Resident #14's pain because Med Tech #5 was assigned to pass medications to Resident #14. LPN #2 indicated that residents were to be assessed for pain every morning. LPN #2 confirmed that Resident #14 was not assessed for pain during the medication pass and the resident did not receive any pain medication. During an interview on 03/17/2026 at 10:38 AM, CNA #4 indicated that Resident #14 informed her that morning of the need for the PRN pain medication. CNA #4 indicated that LPN #2 was informed of Resident #14's request for pain medication. During an interview on 03/17/2026 at 12:57 PM, Resident #14 indicated that the pain medication was received approximately 45 minutes after this surveyor had talked with the resident that morning. Resident #14 indicated that the pain medication helped a little and Resident #14 reported a pain level of eight on a scale of 1-10. During an interview on 03/18/2026 at 9:20 AM, LPN #2 indicated that pain medication should be administered when requested by a resident to ensure the resident was not uncomfortable. During an interview on 03/18/2026 at 9:23 AM, the Nurse Practitioner (NP) indicated that she expected pain medications to be administered within an hour after a resident requested the medication. The NP indicated that she felt pain medication should be administered as soon as possible so that pain could be controlled. During an interview on 03/18/2026 at 10:58 AM, the Director of Nursing (DON) indicated that a nurse should administer a PRN pain medication immediately after receiving the request from a resident. The DON indicated that if the nurse was in the middle of passing another resident their medications that the PRN medication should be administered immediately after. During an interview on 03/18/2026 at 2:08 PM, the Administrator indicated that if a resident requested a PRN medication it should be administered as soon as possible. Review of a facility document titled Inservice Education Report dated 11/2/2025 indicated that PRN (as needed) medications are documented and administered properly. The in-service indicated that a patient must ask for the PRN medication. The in-service indicated to assess pain for location and severity, then follow up and document. Review of a facility policy titled, Administering Medications with a revised date of April 2019 revealed that medication administration times are determined by the resident and need and benefit, and not staff convenience, resident's choices and preferences should be honored. The policy also revealed if a resident is unavailable to receive medication on medication pass the medication record should be flagged and after completing the medication pass the nurse should return the resident to administer the medication.

Number of residents sampled: Number of residents cited: Based on observations, interviews, and record reviews, the facility failed to add oxygen to the Physician Orders for one (Resident #40) of two residents reviewed for oxygen orders. The findings include: Review of Resident #40's admission Record indicated that the facility admitted Resident #40 on 12/11/2025 with diagnoses which included pneumonia, shortness of breath, obstructive sleep apnea, and acute bronchitis. Review of a discharge return anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/28/2026 revealed Resident #40 had modified independence for daily decision according to a Staff Assessment of Mental Status (SAMS). Review of Residents #40's Physician Orders did not indicate that Resident #40 had an order for oxygen administration. Review of a form titled Standing Orders dated 02/08/2021, signed by the Nurse Practitioner (NP), indicated to administer oxygen at 2-4 liters per minute as needed for shortness of breath and/or a pulse oximetry less than 90%. Review of Resident #40's Care Plan did not indicate that Resident #40 was on oxygen. During an interview on 03/16/2026 at 12:45 PM, Resident #40 was sitting in a medical reclining chair in the dining room. Resident #40 indicated that they were supposed to have oxygen. Resident #40 indicated they were having difficulty breathing. During an interview on 03/16/2026 at 12:55 PM, Resident #40 asked this surveyor to raise their medical reclining chair. The surveyor informed Certified Nursing Assistant (CNA) #7 that Resident #40 needed assistance with reclining their chair. During an observation on 03/16/2026 at 12:57 PM, Resident #40 informed Certified Nursing Assistant (CNA) #7 that they needed oxygen. During an observation on 03/16/2026 at 1:02 PM, Resident #40 had their head covered crying. Resident #40 indicated that they were having trouble breathing. During an interview on 03/16/2026 at 1:02 PM, the Housekeeping Supervisor was informed that Resident #40 needed assistance. The housekeeping supervisor paged the nursing staff. During an observation and concurrent interview on 03/16/2026 1:03 PM, CNA #7 checked Resident #40's oxygen saturation. Resident #40's oxygen saturation was 90%. CNA #7 indicated Licensed Practical Nurse (LPN) #2 was informed that Resident #40 needed oxygen. During an observation on 03/16/2026 at 1:27 PM, LPN #2 administered oxygen to Resident #40. The oxygen was set on three liters per minute by nasal cannula. During an observation on 03/18/2026 at 8:40 AM, Resident #40 was in bed with oxygen on three liters per minute by nasal cannula. During an interview on 03/18/2026 at 9:14 AM, LPN #2 indicated that she was not sure how long Resident #40 had been on oxygen. LPN #2 indicated that Resident #40 was on another hall and recently moved to the 300 Hall. LPN #2 indicated that every resident had a standing order for two liters of oxygen as needed. During an interview on 03/18/2026 at 9:36 AM, the NP indicated that Resident #40 had been on oxygen since the resident was admitted to the facility. The NP indicated that if a resident required standing orders, the order must be added to the resident's active Physician Orders. The NP indicated that she had observed Resident #40 with oxygen on but she was not sure how often the resident should be administered oxygen. During an interview on 03/18/2026 at 11:03 AM, the Director of Nursing (DON) indicated that there was a standing order for oxygen, and she was not sure how long Resident #40 had been on oxygen. The DON indicated that if a standing order was used it must be added to the resident's active Physician Orders and Care Plan. The DON indicated that the oxygen dosage should also be added to the orders. During an interview on 03/18/2026 at 1:32 PM, Resident #40 confirmed that she had been on oxygen since admission to the facility. During an interview on 03/18/2026 at 2:11 PM, the Administrator indicated that residents should have an order for oxygen before it was administered. During an interview on 03/18/2026 at 2:28 PM, the MDS Coordinator indicated the nurses, or the CNAs would let her know if oxygen needed to be added to the Care Plan. The MDS Coordinator indicated that she knew Resident #40 was on oxygen because she observed oxygen on the resident. The MDS Coordinator indicated that she had not added oxygen to the Care Plan yet because she was behind on updating the Care Plans. The MDS Coordinator indicated that she had been updating Care Plans for three months independently. The MDS Coordinator indicated that oxygen should be added to the Care Plan as soon as an order was obtained for the resident. Review of a facility policy titled, Oxygen Administration with an effective date of 12/08/2005 revealed that oxygen should be administered under orders of the attending physician, except in the case of an emergency. In an emergency, oxygen may be administered without a physician's order, however, the order should be obtained immediately after the crisis is under control. The policy also revealed that a physician's order should be obtained for the rate of flow and route (tank, concentrator, nasal cannula, mask) of administration.

Number of residents sampled: Number of residents cited: Based on observations, interviews, record reviews and facility policy review, the facility failed to ensure nails were trimmed for one (Resident #4) of three residents reviewed for Activities of Daily Living (ADL) care. The findings include: Review of a facility policy on nail care titled Fingernails/Toenails, Care of revealed the propose of nail care is the clean the nail bed, keep nails trimmed, and prevent infections. The policy revealed that nail care included daily cleaning and regular trimming. The policy revealed that the condition of a resident's nails and nail bed should be documented in the resident's medical record. The policy revealed that proper nail care helps to prevent skin problems around the nail bed. The policy revealed nails should be trimmed and smooth to prevent the resident from accidentally scratching and injuring his skin and the nurse supervisor should be contacted if there is evidence of ingrown nails, or if the nails are too hard or too thick to cut with ease. Review of an admission Record revealed Resident #4 was admitted to the facility on [DATE] with diagnosis of type 2 diabetes with hyperglycemia. Review of a 5-day Minimum Data Set with an Assessment Reference Date of 12/26/2025 revealed Resident #4 had short and long term/memory problems according to a Staff Assessment of Mental Status (SAMS), the SAMS was not scored. Resident #4 was dependent on staff for personal hygiene. Review of an Order Summary Report for Resident #4 revealed an order with a start date of 12/23/2025 for diabetic nail care that should be provided by a Licensed Nurse as needed. Review of Resident #4's Care Plan, initiated on 12/30/2025, revealed the resident had an ADL self-care performance deficit related to dementia. Interventions indicated that the resident was totally dependent on one staff for personal hygiene. On 03/16/2026 at 2:49 PM, this Surveyor observed that Resident #4's toenails were long and curved. During an interview on 03/17/2026 at 9:15 AM, Nurse Aide (NA) #6, indicated that the facility had certain people to do nail care. NA #6 indicated that she does not clip Resident #4's toenails because she was not certified to perform nailcare for diabetic residents. NA #6 stated that she informed the nurse when a resident wanted their nails trimmed. During an observation and concurrent interview on 03/17/2026 at 1:13 PM, the Director of Nursing (DON) looked at Resident #4's toenails and indicated Resident #4's toenails were very long, jagged, and probably had fungus. The DON indicated that Resident #4's right big toenail was overlapping onto the second toe. The DON indicated that the nurse could trim Resident #4's toenails if they were a diabetic and that Resident #4's toenails should be trimmed weekly. The DON indicated that the podiatrist came to the facility at least monthly, and sometimes every 2-3 weeks. [The podiatrist saw residents based off of a list provided by the facility] According to a podiatry list provided by the DON the last time the podiatrist came to the facility was in February 2026. Resident #4 was not on the list to be seen by the podiatrist. During an interview on 03/17/2026 at 1:21 PM, the Treatment Nurse (TN) indicated that the nurses and Certified Nursing Assistants (CNA s) were responsible for cutting Resident #4's toenails. The TN indicated that Resident #4 should be referred to podiatry if the nails were too thick. The TN looked at the treatment record and indicated the resident was a diabetic and the CNAs did not do diabetic nail care. The TN confirmed that she signed Resident #4's treatment record on 03/12/2026 indicating that Resident #4's nail care had been completed. The TN verified that the treatment record was signed after the care had been completed. During an observation on 03/17/2026 at 1:30 PM, the TN raised Resident #4's right foot. The right big toenail was curved overlapping the second toe. Resident #4's toenail on the third toe was severely curved, extending halfway under the toe. Doing an interview on 03/18/2026 at 9:36 AM, the Nurse Practitioner indicated that she was not sure who was responsible for cutting Resident #4's nails. She indicated that a Podiatrist could come if Resident #4's nails were thick. During an interview on 03/18/2026 at 3:47 PM, CNA #4 indicated that the nurses were responsible for cutting Resident #4's toenails since the resident was a diabetic. Review of a Podiatry Referral List for September 2025, October 2025, and February 2026 did not indicate that Resident #4 had been referred to see the Podiatrist.

Number of residents sampled: Number of residents cited: Based on observation, record review, interviews and facility policy review, the facility failed to ensure required nurse staffing information (staff, census, date and location) was consistently provided on the Daily Staffing Log, to ensure nurse staffing information was documented in a readable format for visitors and staff. The findings include: During observation and concurrent interview on 03/17/2026 at 3:07 PM, Human Resources [HR] provided Daily Staffing Logs from 02/15/2026-03/15/2026. This Surveyor observed the Daily Staffing Logs were missing dates, resident census, staff names and work locations on some of the logs. HR stated, The Daily Staffing Logs are hanging on a whiteboard opposite the time clock and facing the common entry area for visitors. HR stated that they were responsible for dating the staffing log, hanging it up, recording the census, and writing down the total work hours and that staff were responsible for writing their names and their location worked on the Daily Staffing Log. If anything gets left off, I try to find the information and correct it the next morning. HR stated that they had gotten behind on completing the staffing logs and had not caught up. HR stated that she also printed out the time clock information and attached it to the Daily Staffing Log. Review of Daily Staffing Logs dated 02/15/2026-03/15/2026 and concurrent interview with HR on 03/17/2026 revealed the following:-02/15/2026 Day Shift had no resident census and specific units worked were not filled out for 3 CNAs.-02/15/2026 Evening Shift was not dated, had no resident census and Certified Nursing Assistants [CNAs] specific units worked were not filled out.-02/15/2026 Night Shift was undated, had no resident census, no Licensed Practical Nurse [LPN]/Registered Nurse [RN] staff and hours were documented, no specific units worked for any staff were documented.-02/16/2026 unknown shift documented a resident census of 77, 2 RN/2 LPN/2 MA-C and 7 CNA without a specific unit worked.-Unknown date, shift and resident census, with one LPN and 2 CNA with locations worked documented and 3 CNAs without a specific unit work location.-Unknown date, shift and resident census, with one LPN documented and 3of 4 CNAs not showing a specific unit worked.-02/17/2026 Day Shift documented a resident census of 78, 1 of 2 RN, 1 LPN, 2 Medication Administration Certified [MA-C], 1 Restorative CNA, and 8 of 9 CNAs without a specific unit worked.-02/17/2026 Evening Shift had no resident census, 1 LPN without a specific unit worked and one CNA documented on the log as having worked that shift.-02/17/2026 Night Shift had no resident census, 1 LPN and 3 of 4 CNAs documented on the log without a specific unit worked.HR confirmed that all the Daily Staffing Log sheets from 02/15/2026-03/15/2026 were missing required nurse staffing information. During an interview on 03/19/2026 at 12:01 PM, the Administrator confirmed that HR made sure the Daily Staffing Logs were filled out with nurse staffing information, and that the Daily Staffing Logs were put on the wall opposite the time clock to make sure staff filled in their name and location worked. The Administrator stated, The Director of Nursing should check the daily log sheet and make sure the staff names, resident census, shift and date were filled out. I also think that staff need to be in-serviced on how to fill this daily log sheet out because it is putting a lot of work on HR. The Administrator revealed the purpose of nurse staffing information being documented on the Daily Staffing Log were for visitors and families to know who was working in their family's area, and to know how many residents were in the building. Review of a facility policy titled Staffing, Sufficient and Competent Nursing, revised 08/2022, revealed the facility provides enough staffing with appropriate skills and competency. Staffing rations include an evaluation of disease, condition, physical or cognitive limitations of the population. Direct care daily staffing numbers are posted in the facility for every shift and include the number of nursing personnel responsible for providing direct care.

Based on observation, record review, and interviews, the facility failed to ensure that the environment was clean and sanitary to provide a homelike environment on the secured unit. This failed practice had the potential to affect all 20 residents who resided in the secure unit. The findings are: A review of the facility policy Housekeeping Cleaning Guidelines indicated: a. Corridors and Public Areas: (including dining rooms, day rooms, lobby, activity areas, therapy areas etc.) Dust mopping, (including corners and edges) daily, damp/wet mop daily, scrubbing of resilient tile as scheduled. b. Corridors and Public Areas: (including dining rooms, day rooms, lobby, activity areas, therapy areas etc.) 3. Check/dust horizontal areas daily, 4. check/dust/clean vertical services daily, 16. Public area deep clean (light fixtures, vents, cubicle curtains/tracks, air/heat units, fire alarms, extinguishers, call lights/devices, baseboards, room corners, edges, ceiling corners etc.) monthly. c. Patient Room Cleaning: 3. Check/dust horizontal surfaces daily, 4. Check/dust/clean vertical surfaces daily, 15. Patient room deep cleaning (light fixtures, vents, cubicle curtains/tracks, air/heat units, room corners, edges, ceiling corners, etc.) monthly. d. Corridors/Public area dust all surfaces and furnishings. Patient Rooms dust all surfaces and furniture and furnishings. A review of the [Facility Name] Floor Tech Job Description indicated, Job Summary: Under general direction, clean and maintain all carpeted and hard surfaces in the facility, perform preventative maintenance on special floor equipment. On 01/21/2025 at 11:50 AM, this surveyor observed in room [ROOM NUMBER], cobwebs behind the television on top of the closet unit, and above the air conditioner unit, and the paint was peeling and bubbling, exposing the dry wall under the window. On 01/21/2025 at 12:00 PM, this surveyor observed that a light in the hallway on the secure unit was out, making the area around the nurse's station dim. This surveyor observed that two light covers in the dining room, closest to the television, were covered in brown splatters, and the inside contained dead insects and debris. On 01/21/2025 at 12:30 PM, this surveyor observed the inside area of the handrails in the hallway of the secure unit contained debris, dried matter, and dead insects. This surveyor observed, at the end of the hallway, was a light cover with what appears to be webs on the left side of the light cover, the inside of the light cover contained debris and dead insects. The vents in the hallway were covered in a thick layer of fine brown particles. This surveyor observed that along the edges of the hallway the tiles were discolored in a gray, black matter with debris on top of them. This surveyor observed that this same discoloration of tiles was located in the rooms around the edge of closets. On 01/21/2025 at 12:40 PM, this surveyor observed residents wandering up and down the hallway touching the handrails. On 01/22/2025 at 9:00 AM, this surveyor observed that the light covers, the handrails, the vents, the floors, and the observations in room [ROOM NUMBER] had not changed. On 01/22/2025 at 9:30 AM, this surveyor observed residents wandering up and down the hallway touching the handrails. On 01/22/2025 at 1:00 PM, this surveyor observed a brown, wet splatter on the floor of the hallway. On 01/22/2025 at 3:00 PM, this surveyor observed that the previous brown splatter on the floor of the hallway had dried and become sticky. On 01/23/2025 at 9:00 AM, this surveyor observed the brown, sticky splatter remained on the floor. On 01/23/2025 at 9:15 AM, this surveyor observed that the light covers, the handrails, the vents, the floors, and the observations in room [ROOM NUMBER] had not changed. On 01/23/2025 at 9:20 AM, this surveyor observed Housekeeper (HK) #2 cleaning the dining room. HK #2 changed gloves without washing hands when wiping down tables. When mopping the floors HK #2 stopped at the edge of the dining room, and did not mop in front of the nurse's station. HK #2 moved to room [ROOM NUMBER] on the hall, rolled the cart right next to the splatter in the hallway and did not clean it up. HK #2 switched gloves between sweeping and wiping hard surfaces without washing hands. HK #2 then proceeded to clean room [ROOM NUMBER], but did not mop the floor in the bathroom. On 01/23/2025 at 10:00 AM, during an interview HK #2 stated that they have worked in the facility for two months and usually only have two housekeepers for the building. HK #2 stated that they do not have a floor tech currently and when they have time, they buff the hallways when there is less traffic. HK #2 stated that they do two deep cleans a week, and they usually work together with other housekeepers on them. HK#2 grimaced when asked if they felt short staff then nodded and stated, it can be difficult some days to get it done but I do the best I can and clean how I was taught to. HK#2 then stated if I do not finish, I will pick up where I left off the next day. On 01/23/2025 at 11:50 AM, during an interview, HK#3 stated they had worked here three years and that they cannot always do the floor tech duties, but they are used to the amount of work. HK #3 stated they only have two housekeepers on duty, but did have three scheduled to keep up with floor tech duties. With budget constraints they were told only two people could be scheduled at a time. HK #3 stated they would like to get the hallway floors clean again. HK#3 stated they were not sure if the facility was still hiring for a floor tech then stated that they sometimes feel like they are short staffed depending on what they come into when cleaning the rooms. On 01/23/2025 at 2:00 PM, this surveyor observed the shower room on the unit, in the upper left-hand corner black, gray circular spots are observed on the ceiling. The vent was covered in a thick layer of fine brown particles. The walls of the shower were observed to be covered in brown matter, on the floor in the right-hand corner the grout and tiles are covered in a layer of brown matter. On 01/23/2025 at 2:47 PM, during an interview the Infection Preventionist (IP) stated the importance of a clean environment was infection control, the residents deserved a clean environment to live in. Then stated they were looking for a floor tech but with it being a temporary position, as they will not need one at the new facility, the position had not been filled. On 01/23/2025 at 3:18 PM, Maintenance stated the procedure for reporting maintenance issues was with the logbook. Maintenance then stated that the shower room had not been reported to him and that it looked like mold was in the corner of the shower room. Then stated that they needed to check that out immediately.

Based on record review, observations, and interviews, the facility failed to ensure infection control measures, including the storage of resident equipment, were implemented during residents smoking for 1 (Resident #1) of 1 sampled resident observed for prevention of potential infection and/or the spread of infections. The findings include: Review of a facility policy titled, Cleaning and Disinfection of Resident-Care items and Equipment dated September 2022, indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. A review of an Admission Record indicated the facility admitted Resident #1 with diagnoses that included cerebral palsy and Parkinson's disease. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/07/2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 9 (08-12 indicates moderately impaired). Review of Resident #1's Care Plan initiated: 06/15/2015, with a revision date of 01/02/2024, revealed Resident #1was a smoker and was at risk for injury. The Care Plan indicated Resident #1 was to use a special ashtray that holds their cigarette and that if the resident does not use it, the cigarette will break. On 01/22/2025 at 3:30 PM, this surveyor observed the smoking area for the residents. This surveyor observed an assistive device called clip on ash tray with a remote tube which was used to extend amount of space between the resident and cigarette. The device was exposed and left unattended on a table in the smoking area. On 01/23/2025 at 9:30 AM, this surveyor observed the smoking area for the residents. This surveyor observed the assistive device exposed and left unattended. On 01/23/2025 at 11:45 AM, this surveyor observed residents smoking in the designated area. The Restorative Certified Nursing Assistant, (RCNA) picked the device up off the table and without cleaning it, handed it to Resident #1. Resident #1 placed the device in their mouth and used it. On 01/23/2025 at 11:44 AM, the RNCA was asked if the smoking device had been cleaned before it was handed to Resident #1. She stated it had not been but that she should have cleaned it since it had been left lying on the table and anyone could touch it. On 01/23/2025 at 12:10 PM, during an interview, the Director of Nursing (DON) was asked if the smoking device that belonged to Resident #1 should have been left outside unattended and if it should have been cleaned before it was handed to Resident #1. The DON stated that the device should be stored in a plastic bag and kept at the nurse's station and that it should be cleaned before and after Resident #1 used it.

Surveyor: Young, [NAME] Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program [QAPI] Committee developed and implemented appropriate plans of action to prevent repeated deficiencies with a maintenance program in place to prevent broken, exposed wall plug outlets, broken wall trim, holes in sheet rock, wall nail holes and leaky toilets in resident's rooms to maintain a safe, clean, and homelike environment. These failed practices had the potential to affect 51 residents who reside in the facility. The findings are: 1. A Recertification survey was conducted on 01/05/2024 at the facility. During this survey, the team identified concerns with food services, food storage, and hand hygiene when preparing and serving food in a sanitary manner and concerns with infection control. A. The Plan of Correction with a completion date of 10/22/2022 documented: This Plan of Correction is to be considered as an allegation of Compliance. Step #1: Corrective Action: On 10/6/22, upon notification of deficient practice, Administrator/designee and Maintenance Director observed bathroom of Resident #3 and #16. The Maintenance Director immediately began repairs of bathroom of Resident #3 and #16 to ensure proper usage of bathrooms. Step #2: Identification of others with the potential of being affected: On 10/6/22, Administrator/designee instructed Maintenance Director to inspect each bathroom of all residents to ensure each bathroom was in good repair and proper usage to ensure no other residents had the potential to be affected. Any negative findings were corrected immediately. Step #3: To ensure deficient practice does not recur: On 10/6/22, Administrator/designee in-serviced Maintenance Director on ensuring that all areas of the facility were in good repair by visual observations and reviewing of submitted maintenance work orders during daily rounds and that all repairs are completed immediately. Step #4: Monitoring: Administrator/designee, will review and sign off on all Maintenance Director work orders and maintenance log sheet to ensure all reported repairs have been completed in a timely manner. The Maintenance Director will conduct daily visual observations of building 5 x weekly x 4 weeks or until substantial compliance is achieved. Work orders, location and completion dates will be documented on the Maintenance Log Sheet. Any negative findings will be corrected immediately with verification by the Administrator/designee. Step #5: QA: Maintenance Director/designee will present all findings to monthly QA committee for further review and recommendations. On 01/05/24 at 10:34 AM, the Administrator was interviewed. The Surveyor asked, how does the QAPI team obtain and use feedback from residents, their representatives, or staff to identify high-risk, high-volume, or problem prone issues as well as opportunities for improvement? The Administrator stated, We use our startup 9 AM meeting. Problems are discussed during that time. I&A, weights, IP situations, etc. track through monthly QA (Quality Assurance) meetings. Falls are our QAPI focus this year. A QAPI Plan provided by the Administrator during entrance conference on 01/02/24 at 10:15 am documented .II. Purpose Statement: The purpose of QAPI in our facility .Continuous quality improvement involves a review of the processes involved in delivering various components of care and service, analyzing ways in which these processes can be improved . The Facility Assessment Tool provided by the Administrator during entrance conference on 01/02/24 at 10:15 am documented .483.75 (c) QAPI Program Feedback, data systems, and monitoring .483.75 (e) QAPI Program activities .

Based on observation, record review and interview, the facility failed to ensure medications were given within a timely manner to avoid adverse effects on resident's condition and ensure that medications were administrated without unnecessary interruptions, for 2 (Resident #7 and #44) sampled residents. This failed practice had the potential to affect 51 residents who were dependent on the nurses for medication administration. The findings are: 1. Resident #7 [R#7] had diagnosis Hemiplegia ( weakness or paralysis on one side of the body) and Hemiparesis ( weakness of one side of the body) following unspecified Cerebrovascular Disease affecting Left Non-Dominant side. a. On 01/02/24 at 12:11 p. m., R #7 stated, My night medications [meds] are always late, I get them around 11 p. m. I have filed a grievance because on 12/19/23 I didn't get them until 2:00 a.m. I don't think they are short-staffed; I think the nurses just don't do their jobs. b. Review of the grievance filed by R#7 on 12/19/23 documented .Nature of Grievance: didn't get her night times meds until 2 am . Resolution: Verified medications were not administered on time. Nurse received written warning and educated on med pass administration . c. On 01/04/24 at 3:34 p.m., the Director of Nurses [DON] was asked about the grievance involving Resident #7. The DON said I did an investigation and resident's meds were late. I asked the nurse that worked that night why the resident ' s meds were late. The nurse said they were busy, and meds were given late. That nurse was written up and educated. d. On 01/04/24 at 3:34 p.m., the DON was asked, what is the importance of giving medications at the time that are prescribed? The DON said, It can back everything up. Like if morning meds are given late then the other meds will either be late or given to close together. 2. Resident #44 (R#44) had Diagnoses of Diabetes Mellitus Type 2 and End Stage Renal Disease. a. A Physicians Order dated 12/13/23 documented, Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 15 unit subcutaneously with meals related to Type 2 Diabetes Mellitus with complications. Hold if BS [blood sugar] is less than 200 b. A Physicians Order dated 12/14/23 documented, Inject 70 unit subcutaneously in the morning related to Type 2 Diabetes Mellitus with complications. c. A Care Plan initiated 8/29/22 documented, .Diabetes medication as ordered by doctor . d. On 1/3/24 at 9:30 AM, the Surveyor observed the Licensed Practical Nurse (LPN) #1 administer 7 units of Lispro injection [named]pen, and 15 units of Humalog Regular Insulin injection to R #44 during morning medication pass. e. On 1/3/23 at 09:36 AM The Surveyor observed the LPN #1 administer 70 units of Toujeo Max solo start injection insulin to R #44 f. The Survey readiness book provided by the Administrator on 1/2/23 at 11:00 AM documented under Medication Times, 0800 for morning medications. g. On 1/3/23 during morning medication pass between 0836 - 0945 AM, the Surveyor observed LPN #3 doing glucose checks, blood pressure checks, and lung assessments to address needs reported to her during medication pass by staff. h. On 1/3/23 at 9:37 AM The Surveyor asked the LPN#1 why the Humalog insulin was late and why it wasn't given with R #44 breakfast. The LPN #1 stated, We've been having a little trouble getting his insulin schedule right. It sometimes upsets his stomach, so we don't give it until later. The Surveyor asked if medications were always running this late in the mornings. LPN#1 answered, You've seen the interruptions this morning. We normally have 3 nurses. Today we only have 2. It's just hard to get it all done with all of the interruptions. If there are 2 nurses, we have a med tech on each side. Today there are no med techs. The Surveyor asked if they were often short-staffed. The LPN answered, Today we are. 47912

48808 Based on observation, interview and record review, the facility failed to ensure maintenance was in place to maintain and prevent broken and exposed wall plug outlets, broken trim on walls, holes in sheet rock, wall nail holes, and leaky toilet rims in resident rooms to maintain a safe, clean, and homelike environment in Hall 1 of eleven (11) Resident rooms. The findings are: On 01/02/2023, at 12:20 PM, environmental rounds were made in the facility rooms, the following were observed: a. Standing in the entrance of room eight (8), wall trim behind the headboard on the left, is located on the floor. In addition, the 4-plug wall outlet is separated from the sheetrock, exposing 1/2 inch across the top of the wall plate. A 2-plug wall outlet on the right side of the wall, is separated from the sheetrock exposing 1/2 inch across the top of the wall plate. b. Standing in the entrance of room ten (10), behind the entrance door, is a hole in the sheetrock approximately (12 x 12 cm [centimeters]). In addition, the bathroom toilet has black-gray colored residue against the base rim. The standalone double closet doors against the right side will not safely close. c. Standing at the entrance of room sixteen (16), the left side of the upper wall, had ten (10) wall nails holes, approximately (1 x 1 cm). The right side of the room had two (2) 2-plug wall outlets, separated from the sheetrock, exposing 1/2 in across the top of the wall plate. d. On 01/02/24 at 12:37 PM, Resident #8 stated My toilet is leaking and has been for ages now. The Surveyor asked Resident #8 if she had told someone. Resident #8 answered, Yes, they just wrap a towel around it, but it still leaks. It is a slipping hazard for me. I've also seen roaches in the facility, but I don't have any now. e. On 01/04/24 at 9:26 AM, the Surveyor accompanied the Maintenance Supervisor to to observe Resident #8's toilet in bathroom. The Surveyor asked if Maintenance was aware the toilet was leaking. The Maintenance Supervisor answered, I replaced the flange yesterday. The Surveyor asked the Maintenance Supervisor how long the toilet had been leaking. The Maintenance Supervisor stated, I don't know. f. On 01/02/24 at 05:25 PM, the Surveyor observed the faucet continuously dripping in the sink in room [ROOM NUMBER]-A. The faucet would not turn off. g. On 01/04/24 at 9:20 AM, the Surveyor accompanied Maintenance to room [ROOM NUMBER]-A and asked if he knew about the leaky faucet. Maintenance stated, I've ordered two of those. This is an old building. The Surveyor asked how long these faucets last. Maintenance stated, This building is very old. Everything here is old and needs to be repaired. The Surveyor asked how does Maintenance know when repairs are needed to be done. Maintenance stated, They let me know. I have a book that I write everything down in. The Surveyor observed that the sink continued to drip a continuous, steady stream of water. During an interview and tour of Hall 1 on 01/04/2023, at 11:10 am, with the Maintenance Supervisor (MS) #1, in response to the question, are you aware of the residents wall trim that fell in room [ROOM NUMBER], and the left and right separated electrical wall covers, [and] in room [ROOM NUMBER], the wall hole behind the door, black-gray residue on the toilet rim base and the non-closing double door closet ? The MS #1, stated I was not aware of the fallen wall trim, separated electrical wall covers, black-gray toilet rim base, and closet broken doors and I was not aware of the hole behind the door, and will repair this as soon as possible. In response to the question, are you aware of the holes in the wall and the separated and exposed wall covers? MS #1 stated, I have not been back in this Hall, as they have been in quarantine. The policy Maintenance Service (Revised December 2009) received on 1/04/2024, at 10:08 PM, from the Administrator, read in part . The Maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times, maintaining a schedule of maintenance service [and] a copy will be provided to each department director so that appropriate scheduling can be made without interruption of services to the residents. In addition, the Maintenance Director is responsible for maintaining the following reports: Inspection of building, work order requests, maintenance schedules.

Based on observation, interview and record review, the facility failed to ensure staff did not leave medications unattended on a secured unit. The findings are: During observation on 10/4/23 at 11:16 AM, a resident was sitting in the day room at a table with two other residents on the secured unit. The resident had a cup of water and a medication cup with four pills on a table in front of her. There was a total of four residents in the day room. During interview on 10/4/23 at 11:27 AM, Licensed Practical Nurse (LPN) #1 came into the day room. The Surveyor asked LPN #1 should a cup of medications be on a table unsupervised with residents in the day room? LPN #1 said she gave the resident her morning medications and she does not how the medications got on the table. During interview on 10/4/23 at 11:32 AM, the Director of Nursing (DON) confirmed a cup of medications should not have been left on a table in a secured unit unsupervised. Review on 10/4/23 at 3:18 PM of facility policy titled Administering Medications showed, medications shall be administered in a safe and timely manner and as prescribed. Review on 10/5/23 at 9:30 AM of facility policy titled Storage of Medications showed, the facility shall store all drugs and biologicals in a safe, secure, and orderly manner.

Based on observation, record review, and interview, the facility to ensure food was prepared by methods that maintained the flavor and encourage good nutritional intake for the residents who received regular diets and mechanical soft diets and pureed diets 1 of 1 meal observed These failed practice had the potential to affect 46 residents who received regular diets, 14 residents who required mechanical soft diets and 6 residents on pureed diets, according to lists provided by the Dietary Supervisor on 1/10/23. The findings are: 1. The grievance log for 11/28/22 documented, Food not appetizing nor taste good but notify just on weekends. 11/28/22 Inservice education report documented, Encourage dietary staff to season food according to recipe. 2. The facility recipe for baked ziti with meat sauce documented for 60 servings, use 1/2 (half) cup of pure vegetable oil, 3/8 cup of herb fresh rosemary, 20 cloved chopped garlic, 3/8 cup of Italian seasoning with no Msg (Monosodium Glutamate), 2 1/8 lb (pounds) of [named] whole milk. a. On 1/09/23 at 9:08 AM, a pot that contained 2 logs of hamburger meat was on the stove. There were no seasonings on the meat. Dietary Employee #1 flipped the meat items with a spatula. She added parsley flakes on the meat. She peeled 7 onions, chopped, and placed them on ground beef. There were no other spices added to the ground beef. b. On 1/09/23 at 9:35 AM, Dietary Employee #1 poured pasta in a pot water on the stove. There was no seasoning added in the water. Dietary Employee #1 drained the unseasoned pasta and poured it into 2 pans. She added ground beef that was cooked with parsley flasks and onions. She added a can and half of marinara sauce on each pan of pasta and meat. She mixed the content, sprinkled the top of each food content with shredded cheese. She placed the two pans of pasta with sauce in the oven to be baked and served to the residents for lunch. The above ingredients listed were not added in the baked ziti. 3. The facility recipe for Italian vegetable blend documented for 60 servings. Add 3/8 cup of solids pure vegetable margarine and 1 1/4 tablespoon of salt. Dietary Employee #1 poured a 25 pound of vegetable blend in a pot. She added water and placed it on the stove. She poured the pureed unseasoned Italian vegetable blend in a pan that was on the steam table to be served to the residents for lunch. There was no seasoning added to the vegetable blend. a. On 1/09/23 at 10:38 AM, Dietary Employee #1 poured squash in a pot, added water, and placed it on the stove to cook. She poured the unseasoned squash in a pan and placed on the steam table to be served to the residents who do not like Italian vegetable blend. b. On 1/09/23 at 11:38 AM, Dietary Employee #2 placed a pot of water on the stove and boiled. She added potato flakes, stirred, and poured the content in a pan. She covered the pan with foil and placed it in the oven. No seasoning was added to the mashed potatoes. c. On 9/09/23 at 1:03 PM, a taste tray that consisted of regular Italian vegetable blend, pureed Italian vegetable blend, squash, mashed potatoes and pureed pasta was obtained. The Dietary Supervisor tasted the food items and stated, pasta without sauce was bland, regular Italian vegetable blend had no seasoning. It needs some seasoning. Pureed pasta was gross, no seasoning, squash was tasteless and pureed Italian vegetable blend was bland. d. On 1/09/23 at 1:45 PM, Resident #5 was sitting in a Geri-chair in the dining room. PRD in chair. She wears a hand roll on her left hand. She was well-groomed. She was served regular pasta, regular Italian vegetable blend, salt 1, pepper 2 packets, and an 8 oz (ounce) cup of coffee. The Surveyor asked, How was your meal? She stated, It was good. The Surveyor asked, Is the food cooked and how does it taste? Do you serve a variety of foods? She stated, The vegetables were unflavored. e. On 1/09/23 at 1:53 PM, the Surveyor asked Dietary Employee #1, what was the reason that the food items prepared and served to the residents for lunch were not seasoned? She stated, I didn't know we could add some salt and pepper, because we have residents who are on no added salt diets. But I used parsley flakes and onions on ground beef. f. On 1/09/23 at 1:58 PM, the Surveyor asked Dietary Employee #2, what was the reason why she prepared the mashed potatoes with no seasoning? She stated, we were behind, and I was in a hurry.

Based on observation, interview, and record review the facility failed to ensure Physician's orders for wound care treatment were processed and implemented to prevent complications and infection for 1 resident (Resident #1) of 3 sampled residents (R #1, R #2, R #3). The findings are: 1. Resident #1 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) with an Assessment Reference Date of 8/27/22 documented the resident scored 15(13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required extensive assistance with transfers, toileting, and personal hygiene. a. A 7/1/22 the revised care plan documented, .The resident had an arterial/ischemic ulcer of bilat feet and toes r/t [related to] poor circulation . The resident will be free from infection or complications related to arterial ulcer through review date . Keep the feet clean and dry . b. A 11/1/22 The Physician's Orders documented, .Cleanse vascular ulcers to bilateral feet with wound cleanser and 4x4s, pat dry with 4x4s. Apply wound gel daily. Every day shift c. On 11/10/22 at 8:52 am, Resident #1 was seen by [named] facility. In the HPI [History of Present Illness] section of the visit it documented, [Resident #1] seen today for f/u [follow up] wound care visit. She has no complaints today. She is non-compliant w[with]/treatment but understands her wounds should be dry . In the Assessment/Plan section of the visit it documented, .encouraged compliance with wound care today. Start [MEDICATION(S)] to all wounds. Discussed importance of keeping her wounds clean and dry to prevent infection . d. On 11/16/22 The Physician's Orders documented, Cleanse vascular ulcer to right medial foot with wound cleanser and 4x4s, pat dry with 4x4s. Paint with [MEDICATION(S)] daily. Every day shift and as needed; Cleanse vascular ulcer to right 4th [fourth] toe with wound cleanser and 4x4s, pat dry with 4x4s. Paint with [MEDICATION(S)] daily. Every day shift and as needed; Cleanse vascular ulcer to left great toe with wound cleanser and 4x4s, pat dry with 4x4s. Paint with [MEDICATION(S)] daily. Every day shift and as needed; Cleanse vascular ulcer to left dorsal foot with wound cleanser and 4x4s, pat dry with 4x4s. Paint with [MEDICATION(S)] daily. Every day shift and as needed . e. On 11/16/22 at 09:40 am, Resident #1 was in the bathroom cleaning herself up after toileting. She transferred herself to her wheelchair and wheeled into her room. She was clean and well groomed. She had wounds on both feet. The 4th [fourth] toe on her right foot had an ulcer on the top of the toe that had a small amount of clear drainage with a light yellow/white appearance in the wound bed. She had another wound on her right foot that was dry. She had 2 wounds on her left foot, one on the top of her foot that had scabbed around the edges with a white center that appeared dry, and one on her left great toe that was scabbed. None were covered by dressings. She reported that she went to [named] clinic and was told by the doctor that was looking at her hip that he would not operate on her hip until she had a skin graft on the wound on the top of her left foot. She reported that the white center of the wound is a tendon. She stated, I've been trying to get Licensed Practical Nurse (LPN #1) down here to do something about them and she says that she will, but she doesn't come. The Surveyor asked, Do you see wound care doctors for your wounds? She replied, Yes, about every 3 weeks. f. On 11/17/22 at 09:10 am, The Surveyor asked the [named] Physician to look at the progress notes from the 11/10/22 on-site visit and asked, Is there an order associated with this visit? She replied, Yes, it is here in the plan. The Surveyor asked, Is it the start [MEDICATION(S)] to all wounds? She replied, Yes. The Surveyor asked, When was this order for [MEDICATION(S)] intended to be started? The Physician replied, The day it was written. The Surveyor asked, So on the tenth of November? She replied, Yes. The Surveyor asked, What is the process in which your orders are processed and implemented? She replied, Well, the nursing home keeps the original, I make a copy and turn it into the clinic, and it is put into the medical record there. The original goes to (LPN #1). I don't have anything to do with getting it into EHR [Electronic Health Record]. The Surveyor asked, Who is supposed to put it into EHR? She replied, I give it to (LPN #1). The Surveyor asked if she was aware that the order for [MEDICATION(S)] written on 11/10/22 had not been implemented until 11/16. She stated, I found out today. g. On 11/17/22 at 09:43 am, The Surveyor asked Licensed Practical Nurse (LPN) #1, On 11/10/22 when the [named] Physician was here and saw [Resident #1], Did she round by herself or did you round with her? LPN #1 replied, I rounded with her. The Surveyor asked to look at the visit notes and asked, What orders were written for [Resident #1] on 11/10/22? LPN #1 replied, Start [MEDICATION(S)] to all wounds. The Surveyor asked LPN #1, Who's responsibility is it to process the orders? LPN #1 replied, Mine. The Surveyor asked LPN #1, Why wasn't the order processed? She replied, It should have been. The Surveyor asked, Why wasn't it? She replied, [Resident #1] has been non-compliant in the past with [MEDICATION(S)]. She says it makes her wounds too dry. The Surveyor asked LPN #1, What does it say the purpose for the [MEDICATION(S)] is in the physician's visit notes? She replied, To keep wounds clean and dry and prevent infection. The Surveyor asked, Does [Resident #1] have a history of [CONDITION(S)]? LPN #1 replied, Yes. The Surveyor asked, Was she hospitalized in September and received IV (intravenous) Antibiotics? She replied, Yes. The Surveyor asked, What could happen if Physician's Orders aren't processed and implemented? She replied, A delay in treatment and potential infection. h. On 11/18/22 at 10:40 am, The Director of Nursing (DON) was asked to look at the [named Medical Facility] visit from 11/10/22. The Surveyor asked the Director of Nursing (DON), If you were given this from the doctor, would you interpret that as an order? She replied, Yes, I would have probably clarified the order but yes. The Surveyor asked, What would you do next? She replied, I would have updated the order in the resident's chart. The Surveyor asked, What could happen by not processing and implementing the order? She replied, She could get an infection and even become septic. i. On 11/18/22 at 09:10 am, The Minimum Data Set Coordinator (MDSC) provided a document titled, Wound Care that documented, .Preparation 1. Verify that there is a physician's order for this procedure .

Based on observation, record review, and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment. This failed practice had the potential to affect residents who received meals from the kitchen (total census:) as documented on a list provided by Dietary Supervisor on 9/8/22. The findings are: 1. On 10/03/22 at 11:24 AM, Dietary Employee #1 opened the entrance door to the kitchen and spoke to the residents and without washing her hands, she removed gloves from the glove box, placed them on her hands, contaminated the gloves. She used the gloved hands to separate the meat to be served to the residents for the lunch meal. 2. On 10/03/22 at 11:32 AM, Dietary Employee #1 opened the refrigerator and took a glass of juice by the rim and placed it on the counter. She picked up a cup of coffee and placed it on the counter. She unwrapped 2 straws, picked them up by their tips. She placed one in a glass of juice and placed the other in a cup of coffee to be served to the residents who requested coffee and or juice. 3. On 10/03/22 at 11:38 AM, Dietary Employee #2 placed a scale on the counter. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in preparing foods to be served to the residents. 4. On 10/03/22 at 11:47 AM, Dietary Employee #1 took out a box of broccoli cuts from the freezer and placed it on the counter. She turned on the sink faucet and ran water on the rag. She then turned off the faucet. She used the rag to wipe off spilled food from the counter and contaminated her hands. Without washing her hands, she picked up a pan, placed it on the counter with her fingers inside the pan. The pan was used for meat to be served to the residents for the lunch meal. 5. On 10/03/22 at 12:01 PM, Dietary Employee #1 removed all the pans that contained food items to be served for lunch from the oven and placed them on the steam table. Without washing her hands, she used her bare hands to pick up a piece of foil that was on the meat with her thumb touching the meat. 6. On 10/03/22 at 12:26 PM, Dietary Employee #1 turned on the sink faucet and washed her hands, she turned the facet off. Without washing her hands, she picked up glasses by their rims and placed them in a rubber container. The Surveyor asked, what should you have done after touching dirty objects ad before handling clean equipment? She stated, I should have washed my hands. 7. The facility's policy for hand washing provided by the Dietary Supervisor on 10/04/22, documented, Any other time deemed necessary.

Based on record review and interview the facility failed to inform the residents and/or their representatives of a change in the COVID-19 status of the building by 5:00 PM on the next calendar day after positive test results. The failed practice had the potential to affect 63 residents according to the room/bed list provided by the Administrator on 10/03/22 at 11:10 AM. The findings are: 1. According to a list provided by the Administrator on 10/04/22 at 9:00 AM, the facility had a resident test positive for COVID-19 on 07/8/22 and 07/16/22. a. According to a review of the Electronic Medical Records, there were no family or resident notifications of a change in the COVID-19 status of the building made on 07/9/22 or 07/16/22 by 5:00 PM the next calendar day. 2. According to a list provided by the administrator on 10/04/22 at 9:00 AM the facility had an employee test positive for COVID-19 on 08/31/22, and 09/12/22. a. According to a review of the electronic medical records there were no family or resident notifications of a change in the COVID-19 status of the building made on 09/01/22 or 09/13/22 by 5:00 PM the next calendar day. 3. On 10/06/22 at 10:10 AM, the Surveyor asked the Director of Nursing (DON), who is responsible for notifying the resident and their representatives of a change in COVID-19 status in the building? She stated, it's really a team effort. Our Infection Preventionist takes a list of all the residents and divides it up between all the department heads and we each make the calls. 4. On 10/06/22 at 10:12 AM, the Nursing Consultant provided a policy entitled, Coronavirus Disease (COVID-19) Testing Residents . 4. The Management of Testing & and Reporting: the Facility resident/responsible party/family will be notified of positive tests within the building by 5 PM the following day.

Based on observation, record review and interview, the facility failed to ensure all areas of the building were in good repair for the bathroom of 2 (Resident #3, #16) of 2 sampled residents whose bathrooms were inspected. The findings are: 1. On 10/03/22 at 12:07 PM, Resident #3 reported that her bathroom continuously had water in the floor. Resident stated that since the water is so close to the toilet, she wasn't certain what the liquid was and that was distressing to her. A puddle of water was in the floor 6 inches from the base of the toilet. The area of liquid extended back toward the wall 2 feet and was 6 - 8 inches wide. There was an area along the left wall of the bathroom that was discolored approximately 4 feet long. On each end of the discoloration were areas where the plaster was missing from the wall. 2. On 10/03/22 at 12:30 PM, Resident #16 approached the Surveyor and stated, have you looked at my bathroom yet? Please check the bathroom. It's bad. The tile was coming up off the floor in front of the toilet. The brown plastic base board was missing from the edge of the wall to the floor and near the doorway. There was a very strong odor of urine in the bathroom. 3. A Policy titled, Maintenance Service which was provided by the Nurse Consultant on 10/5/22 at 10:32 AM documented, . Maintenance Service shall be provided to all areas of the building, grounds, and equipment . the Maintenance Director is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times . 4. On 10/04/22 at 02:38 PM, The Surveyor asked the Maintenance Director, tell me the process for making environmental rounds. He answered, When I come in every day, I check all the lights and change bulbs and ballasts. I check the bathrooms about once a week and fix toilets, etc. If there is a problem that needs fixed, they log it in my log, and I fix it. The Surveyor asked, are you aware of any issues in the bathroom in room 27? He answered, Yes. There are 4 men who share that bathroom. There is one man who urinates on the floor in there. I'm working on that smell. I got some chemicals to get the smell out of the concrete. That tile is chipped and not a tripping hazard. The Surveyor asked, would you want to use that bathroom? He answered, No ma'am. But the housekeepers are working on the smell. The Surveyor asked, how often are the housekeepers applying the chemical? He answered, I'm not sure but I think twice a week. The Surveyor asked, how long have they been using it? He answered, About a month. The Surveyor asked, would you say the chemical is working? He answered, I'm not sure. Maybe not. 5. On 10/05/22 at 08:15 AM, The Surveyor asked Certified Nursing Assistant CNA #2, tell me about the bathroom in room 27. She answered, It needs to be fixed. The tile. And it smells like urine. The Surveyor asked, would you want to use this bathroom? She answered, You are putting me on the spot, but no. 6. On 10/05/22 at 08:24 AM, The Surveyor asked Resident #16, has the facility done anything to get rid of the smell in your bathroom? He answered, They put shaving cream on it and something else. The Surveyor asked, has that helped the smell? He answered, No. As long as he keeps peeing on the floor it's never going to get any better. The Surveyor asked, does the condition of the bathroom bother you? He answered, Yes.

Based on observation, record review, and interview the facility failed to inform the residents and/or their representatives of a change in the COVID-19 status of the building by 5:00 PM on the next calendar day after positive test results. The failed practice had the potential to affect 63 residents according to the room/bed list provided by the Administrator on 10/03/22 at 11:10 AM. The findings are: According to a list provided by the Administrator on 10/04/22 at 9:00 AM the facility had an employee test positive for COVID-19 on 8/31/22 and 9/12/22. According to a review of the electronic medical records there were no family or resident notifications of a change in the COVID-19 status of the building which were made on 09/01/22 or 9/13/22 which would have met the requirement of resident/family notification by 5:00 PM of the next calendar day after positive results. a. On 10/06/22 at 10:10 AM, The Surveyor asked the Director of Nursing (DON) who was responsible for notifying the resident and their representatives of a change in COVID-19 status in the building. She stated .it's really a team effort. Our Infection Preventionist takes a list of all the residents and divides it up between all the department heads and we each make the calls . b. On 10/06/22 at 10:12 AM, The Nursing Consultant provided a policy entitled, Coronavirus Disease (COVID-19) - Testing Residents. The Management of Testing and Reporting #4 stated, Facility resident/responsible party/family will be notified of positive tests within the building by 5 PM the following day.