Every finding on record at Maple Manor Rehab Center

Based on interview and record review the facility failed to maintain a continuous Antibiotic Stewardship Program that includes monitoring antibiotic usage, tracking resistance, preventing emergence of resistance, and following protocols for antibiotic use, which has the potential to affect all residents residing in the facility. Findings include: On 5/29/26 at 10:40 AM, a meeting was held with Director of Nursing (DON) D and Licensed Practical Nurse/Infection Preventionist (LPN/IP) H, both of whom were employed at a sister facility. DON D said that the facility's regular Infection Preventionist was currently out of the country. When asked for documentation regarding the facility's antibiotic stewardship program, DON D and LPN/IP H indicated that this information was not available for May 2025 to December 2025. On 5/29/26 at 1:30 PM, the facility's DON indicated that part of an effective infection control program included consistent proactive attention to prevent the spread of infections. A review of the facility policy titled, Antibiotic Stewardship Program, reviewed January 2026, documented in part the following: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. On 5/29/26 at 2:30 PM during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.

Based on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Based on interview and record review, the facility failed to consistently implement a comprehensive infection control program that conducted proper facility surveillance and utilized maps or other processes to readily identify trends of infections, resulting in missed opportunities for corrective actions and the potential for spread of infectious organisms throughout the facility affecting the entire census of 36 residents. Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices were followed for one resident (R1) out of 4 residents reviewed for infection control and prevention, resulting in the potential for spread of infection among residents in the facility. Findings Include:On 05/27/2026 at 9:45 AM observed a hand sink with a plastic board covering the basin and the hot and cold water off in the emergency food and water storage room. On 05/27/2026 at 10:28 AM observed a residential washing machine with water lines intact and an out of order sign on the machine in the laundry room. In an interview at this time with Laundry Aid (LA) G when asked how long the washer had been out of order, LA G indicated one or two months. Further observation found a residential washing machine with a towel covering the surface. When asked if this machine was broken, LA G indicated it works, however, they do not like to use it. On 05/27/2026 at 10:35 AM observed a hopper with the hot water faucet off in the south hall soiled linin room indicating possible stagnant water in the line. A sign on the hopper stated do not use. Further observation found a nonfunctional hand sink with foot pedal attachments to control the flow of water, indicating possible stagnant water in the line. On 05/27/2026 at 10:40 AM observed the cold water off at the hand sink faucet in the south hall supply room. On 05/27/2026 at 10:46 AM observed discolored water coming from the hopper cold water faucet for a few seconds before running clear in the north hall soiled utility room. The spray hose attachment was observed off, when turned upside down some discolored water dripped from the hose. On 05/27/2026 at 10:49 AM observed a nonfunctional hand sink with an out of order sign in the north hall supply room. An interview with LA G at this time found they were unsure why the faucet was off. On 05/27/2026 at 1:34 PM an interview with Maintenance Supervisor (MS) F found they are on the water management team, and meet quarterly to discuss with the team. When asked about control measures to prevent the growth of legionella, MS F indicated they keep the boilers above 140 degrees F and test for legionella yearly. MS F indicated they ordered chlorine tests and will begin using those to test the chlorine residual. When asked about empty rooms, MS F indicated they flush rooms quarterly that are not in use. When asked if the hoppers on the floor are a part of flushing schedule, MD F indicated no. On 05/27/2026 beginning at 1:45 PM a facility tour was conducted with MS F. On 05/27/2026 at 1:47 PM observed a nonfunctional hand sink in the north hall soiled linen room. An interview with MS F at this time found it was clogged and needed to be snaked out. When asked how long it had been out of order MS F indicated two weeks. On 05/27/2026 at 1:51 PM observed a tub with supplies in the basin in the north hall shower room. Further observation found a second tub near the back of the room. In an interview at this time, when asked if the tubs are used, MS F indicated the tubs are not used. On 05/27/2026 at 1:58 PM observed a nonfunctional hand sink in the emergency food and water room. An interview with MS F at this time found they turned the hand sink off and the room is used as storage. On 05/27/2026 at 2:49 PM observed discolored water discharging for a few seconds before running clear from the bathroom hand sink in unoccupied room [ROOM NUMBER]. On 05/27/2026 at 2:51 PM observed the hand sink with an out of order sign dated 2/7/21 in unoccupied room [ROOM NUMBER]. The hand sink was observed to be nonfunctional when turned on indicating possible stagnant water. On 05/27/2026 at 3:00 PM an interview with MS F regarding flushing of unoccupied rooms found they flush the sink faucet, toilet and shower. When asked about the nonfunctional hand sink in room [ROOM NUMBER], MS F indicated they turned the water off to the sink because it was not being used. Record review of the facility provided document titled WATER MANAGEMENT PROGRAM lists the scope of the program, 3. Identification of potentially hazardous areas or devices where Legionella could grow and spread. 4. Establishment of control point, measures and limits for identified potentially hazardous areas or devices. A risk assessment of the building was completed on January 27, 2026. The risk assessment did not include hoppers and nonfunctional fixtures still connected to the water line. A flow diagram of the facility, controls and control limits were not identified in the program. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. Eliminate dead legs, which are sections of no- or low-water flow. On 5/29/26 at 10:40 AM, a meeting was held with Director of Nursing (DON) D and Licensed Practical Nurse/Infection Preventionist (LPN/IP) H, both of whom were employed at a sister facility. DON D said that the facility's regular Infection Preventionist was currently out of the country. When asked for documentation regarding infection identification, tracking, monitoring, analysis of surveillance data, and responding follow-up activity, DON D and IP H indicated this information was not available for May 2025 to December 2025. On 5/29/26 at 1:30 PM, the facility's DON said it was important to have a consistently implemented and comprehensive infection program for the facility to be aware of the state of infections in the facility, preempt outbreaks, detect any patterns, and proactively address outbreak of infections. A review of the facility policy titled, Infection Prevention and Control Program, reviewed January 2026, documented in part the following: - This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. - A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. - An antibiotic stewardship program will be implemented as part of the overall infection prevention and control program. On 5/29/26 at 2:30 PM during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not. On 5/27/2026 at approximately 10:10 AM, R1's room door was observed to be closed. On the door was a sign indicating that R1 was on enhanced barrier precautions (the use of infection control interventions designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high-contact resident care activities). Outside the door was a cart which contained personal protective equipment (PPE) such as gloves, gowns, and hand sanitizer. Certified Nursing Assistant (CNA) A was observed to enter the room holding linens and a pack of cleaning wipes. CNA A did not perform hand hygiene or don PPE prior to entering the room. At approximately 10:22 AM, CNA A exited the room wearing only a face mask and proceeded to a metal cabinet in the hallway and retrieved gloves and what appeared to be packs of gauze. CNA A then re-entered R1's room. At approximately 10:30 AM, CNA A was observed to exit R1's room wearing a face mask and carrying a clear bag of soiled linen and a pack of cleaning wipes. At approximately 10:31 AM, an interview was conducted with R1. When queried as to what care was just provided to them, R1 responded that they had a bowel movement and the CNA was providing care to them. When asked if the CNA wore a gown, they said no. At approximately 11:17 AM, an interview was conducted with CNA A. When asked what care he provided to R1, CNA A replied that R1 had a bowel movement and so he went in to change their brief. When asked if he wore PPE during the care provided, CNA A said no, that he did not wear a gown but that he knew he should have worn one. When asked how he knows if PPE should be donned prior to providing care to a resident, CNA A pointed to the sign on R1's door and said he would look for the PPE signage. A record review was completed which revealed R1 admitted to the facility on [DATE] with diagnoses that included paraplegia, muscle weakness, neuromuscular dysfunction of bladder, retention of urine, urinary tract infection, pressure ulcer of the sacral region, and hypertension. Physician orders included the use of Enhanced Barrier Precautions initiated on 1/23/2026. Section C of the Minimum Data Set (MDS) with an Assessment Reference Date of 3/5/2026 indicated R1 scored a 13/15 on the Brief Interview for Mental Status questionnaire - indicative of no cognitive impairment. Section GG of the same MDS indicated the resident was dependent on staff for all activities of daily living. A review of R1's care plan did not indicate any interventions for the use of Enhanced Barrier Precautions. On 5/28/2026, at approximately 12:00 PM, an interview was requested with the facility Infection Preventionist, but they were not available. An interview was then conducted with the Director of Nursing. When queried as to their expectation of staff following infection control and prevention interventions such as Enhanced Barrier Precautions, they said it was their expectation that staff follow the signage so that they can stop the spread of infection among residents. A policy titled Enhanced Barrier Precautions last reviewed/revised January 2026 was provided by the facility and read in part, PPE for enhanced barrier precautions is only necessary when performing high-contact care activities., and high contact care activities include.changing briefs or assisting with toileting.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 05/27/2026 at 8:49 AM in an interview regarding date marking, Dietary Manager (DM) E indicated every food item is dated the day opened, and is discarded within three days.On 05/27/2026 at 8:50 AM observed sliced cheese wrapped in plastic with a facility marked date of 5/18 in the walk in cooler. On 05/27/2026 at 9:05 AM observed the three compartment sink drain lines for the wash, rinse, and sanitize basins all connect to a common drain line and discharge to the floor with no air gap.On 05/27/2026 at 9:08 AM observed a piece of cloth wrapped around the rinse and sanitizer faucet base. An interview with DM E at this time found that the sink drips sometimes and they had reminded maintenance about it. On 05/27/2026 at 9:20 AM an interview with DM E found the ice scoop and ice scoop bucket are cleaned weekly. Observation found water pooled at the bottom of the ice scoop bucket and brown debris floating in the water. DM E indicated they would have someone clean it.On 05/27/2026 at 9:24 AM observed an opened two liter of diet coke in the 215 kitchenette refrigerator with a sticker and no date or label on the bottle.On 05/27/2026 at 9:29 AM observed orange juice with a manufacturer in date of 4/6 in the 315 kitchenette refrigerator. DM E indicated they did not know an expiration date was not on the container. Further observation found a container of sliced meats with a facility marked date of 5/22. DM E indicated they had not seen it before.Record review of the facility provided document titled Maple Manor Rehab and Neuro Center Use and Storage of Food Brought in by Family or Visitors last revised January 2026, states: All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. The policy continues, The prepared food must be consumed by the resident within 3 days. If not consumed within 3 days, food will be thrown away by the facility staff.According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention, (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed.According to the 2022 FDA Food Code section 5-205.15 System Maintained in Good Repair, A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on interview and record review, the facility failed to ensure a registered nurse was designated to serve full-time as the Director of Nursing. Findings include:Upon entrance to the facility on 5/27/2026, the Director of Nursing (DON) said they had started in their role on 5/19/2026. On 5/28/2026 at approximately 12:00 PM, the DON and Registered Nurse (RN) D were interviewed regarding nurse staffing within the facility. RN D identified themselves as a Director of Nursing at another facility owned by the same company and was assisting the facility DON learn their new role. When asked who the DON prior to the current DON was, they responded that the prior DON was terminated from employment on May 1, 2026. When asked who the acting DON between 5/1/2026 and 5/19/2026 was, RN D said they were acting as the interim. RN D then confirmed that their nursing license was designated as the Director of Nursing at another facility. No response was provided when asked whose name and license number was communicated to the state agency notifying them of the change in Director of Nursing. On 5/28/2026 at approximately 12:40 PM, Registered Nurse C was queried as to who the DON was at the facility. RN C confirmed the correct name of the current DON. When asked who the DON was between 5/1/2026 and 5/19/2026, RN C said they were not sure - that sometimes it was RN D and sometimes it was another nurse in the facility. When asked who they would contact regarding clinical concerns, RN C said they would contact RN D (the Director of Nursing at another facility). At approximately 12:57 PM, the Nursing Home Administrator (NHA) and RN D returned to the surveyor. The NHA reported that a charge nurse in the facility was assigned as the interim DON. When asked if the required notification to the state agency regarding the change in the Director of Nursing was completed, the NHA said no. The NHA further said that he was the person responsible for notifying the state agency of any DON changes within the facility but did not do so. A policy titled, Nursing Services - Registered Nurse and Full Time Director of Nursing dated reviewed/revised 5/28/2026 was received and read in part, The facility will designate a Registered Nurse to serve as the Director of Nursing on a full-time basis.

Based on interview and record review the facility failed to provide the Covid-19 vaccine for one (R4) of five residents resulting in R4 not receiving the Covid-19 vaccine that was consented to in January 2025. On 7/17/2025 at approximately 11:00 AM the facility's Infection Prevention Control Program was reviewed with Registered Nurse and Infection Preventionist (RN) G. Immunizations/vaccines were reviewed for R4.According to R4's Electronic Health Record, the resident admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. On 1/7/2025 the resident and the resident's Legal Guardian (LG) signed a consent for the resident to receive the Covid-19 vaccine. There was no documentation to support the resident had received the Covid-19 vaccine.RN G was queried and said, The resident was screened and determined to be eligible for Covid-19 vaccine. It was missed. They should have received the Covid vaccine. I have no excuse. RN G confirmed it was the facility's policy to screen, educate, and provide residents with the covid vaccine upon admission. According to the facility's Covid-19 Vaccination policy last revised in June 2024 in part reads: It is the policy of the facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the Covid-19 vaccine.2. Covid-19 vaccinations currently in use include the updated 2023-2024 formula MRNA COVID-19 vaccine .5. People who are 65 years and older should receive 1 additional dose of any updated COVID-19 vaccine

Based on interview and record review the facility failed to provide the influenza and pneumococcal immunizations/vaccines for one (R4) of five residents resulting in R4 not receiving these immunizations/vaccines that were consented to in January 2025. On 7/17/2025 at 11:00 AM the facility's Infection Prevention Control Program was reviewed with Registered Nurse and Infection Preventionist (RN) G. Immunizations/vaccines were reviewed for R4.According to R4's Electronic Health Record the resident admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. On 1/7/2025 the resident and the resident's Legal Guardian (LG) signed consents for the resident to receive the pneumococcal and influenza vaccines. There was no documentation to support the resident received those vaccines.RN G was queried and said, The resident was screened and determined to be eligible for both the pneumococcal and influenza vaccine but did not receive either one of those vaccines. It was missed. They should have received them. I have no excuse. RN G confirmed the facility administers the influenza vaccine between October 1st and March 31st.According to the facility's Influenza Vaccination policy last revised June 2024 reads in part: 2. Influenza vaccinations will be routinely offered annualy from October 1st through March 31 st. 7. The completed, signed, and dated record will be filed in the individual's medical record.According to the facility's Pneumococcal Vaccine policy last revised January 2025 reads in part: 1. Each resident will be offered the pneumococcal immunization unless it is medically contraindicated of the resident has already been immunized.

Based on interview and record review the facility failed to accurately record the use of an antibiotics for 1 of 1 resident (R1) on the facility's antibiotic surveillance log resulting in R1's use of antibiotics from 3/26/25 - 5/23/25 not recorded on the facility log and an incorrect facility infection rate for the months April, May, and June of 2025. On 7/17/25 at 10:01 AM the facility's Infection Prevention Control Program was reviewed with Registered Nurse and Infection Preventionist (RN) G. Antibiotic Stewardship was reviewed for R1.According to R1's Electronic Health Record (EHR), R1 admitted to the facility with diagnoses that included Urinary Retention and required a supra-pubic catheter (flexible tube surgically inserted through the lower abdomen into the bladder to drain urine). On 3/18/25 R1 was diagnosed with a UTI (urinary tract infection). A Urologist prescribed the following antibiotic: Macrobid 100 mg (milligrams) twice a day for 7 days and then Macrobid 50 mg once a day for 90 days. A review of R1's Medication Administration Record (MAR) from 3/18/25 through 6/25/25 revealed R1 received the Macrobid as prescribed.A review of the facility's Infection Control Log from 3/26/25 through 6/25/25 did not include R1's use of the Macrobid 50 mg once a day.RN G was queried and said, I overlooked that. No, that resident was not included in the facility's antibiotic surveillance log or in the infection rate. Yes, I should have carried that over for that resident in April, May, and June. The Infection rate is incorrect because of that.According to the facility's Infection Surveillance policy last revised January 2025 reads in part: 9. All resident infections will be tracked.According to the facility's Infection Prevention and Control Program last revised February 2025 reads in part: 6. Antibiotic Stewardship: An Antibiotic Stewardship program will be implemented as part of the overall infection prevention and control program.

Based on observation, interview, and record review the facility failed to implement pressure ulcer care for one (R4) of one resident reviewed for pressure ulcers resulting in R4 developing a stage two pressure ulcer (open sore, partial thickness loss of skin, presents as shallow crater) on the coccyx when prescribed pressure ulcer skin treatments that included a Low-Air-Loss (LAL) mattress were not implemented.On 7/16/2025 at 9:03 AM, R4 was observed sitting up in bed awake and alert with some confusion. There was no pressure relieving mattress in place or other pressure relieving measures observed. R4 consented to receiving incontinence care from CNA (certified nursing assistant) C. During care, a dime-sized shallow crater-like opened area was observed on the resident's coccyx area. There was dried white cream observed to be covering the surrounding area. CNA C reported the resident developed the pressure ulcer a couple weeks ago and a cream was being applied to the area. Registered Nurse (RN) D entered the resident's room and confirmed the resident's pressure ulcer developed in the facility. RN D reviewed R4's Electronic Health Record (EHR) but could not provide any documentation to support R4 had been prescribed or was receiving skin treatments for the pressure ulcer. R4 did not have a care plan addressing the pressure ulcer on the coccyx. According to the EHR, R4 admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. The quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had moderately impaired cognition and no pressure ulcers. A care plan for skin integrity initiated on 1/8/25 and last reviewed on 4/23/25 had a goal for skin to remain free from breakdown. Interventions included the following: pressure relieving device on bed and reposition every 2 hours when in bed and every 1 hour while in chair. There was no documentation to support there were pressure relieving devices provided to the resident.A review of R4's Medication Administration Records (MAR) revealed there were no current orders for skin treatments for the resident's coccyx area. A previous skin treatment order for Zinc Oxide cream had been discontinued on 7/5/25.Progress notes from the Wound Care Practitioner (WCP) F dated 7/9/25 indicated the resident had MASD (moisture associated skin damage) and a small, opened area at the coccyx that measured 0.79 cm (centimeter) Length and 0.36 cm Width. Recommended the following: Zinc Oxide cream followed by a dry bulky dressing changed daily and as needed if soiled, incorporate aggressive off-loading (pressure relieving measures), add foam wedge to assist with off-loading position changes every 2 hours, Low-Air-Loss (LAL) Mattress, and off-loading heel boots bilaterally while in bed. Recommend Dietitian consultation to assist with augmenting protein, add a multi-vitamin with vitamin C and calorie intake for wound healing. There was no documentation to indicate any of WCP F ‘s recommendations were addressed or followed.Progress notes from Registered Dietitian (RD) E dated 7/15/25 documented the resident's skin was intact. There were no further recommendations for supplementation provided by the RD.On 7/16/2025 at 9:39 AM during an interview with RD E they said they were unaware of the most recent wound care team's findings or recommendations and thought the resident's skin was intact. RD E said they would immediately update their progress note, add a multivitamin, and protein supplement for the resident.On 07/16/2025 at 10:34 AM during an interview with Director of Nursing (DON) B they said the orders and recommendations from WCP F were missed and could not explain why the Zinc oxide treatments had been discontinued on 7/5/25. DON B reviewed R4's EHR and confirmed there were no current orders for the Zinc oxide, the LAL mattress, or the off-loading heel boots. At this time WCP F was interviewed via speaker phone and confirmed that all these orders should be in place. WCP F said they expected those treatment orders to be in place. The Zinc Oxide treatment had never been discontinued. According to the facility's Pressure Injury Prevention and Management policy last revised on 1/2024 in part read: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries.4. a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions.b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics).c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.)d. Minimize exposure to moisture and keep skin clean, especially of fecal contamination; Provide appropriate, pressure-redistributing, support surfaces; Provide non-irritating surfaces; and Maintain or improve nutrition and hydration status, where feasible.5. Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present.

Based on observation, interview and record review the facility failed to ensure adequate delivery of activity of daily living (ADL) care for two residents (R9 and R23) out of three residents reviewed for hygiene resulting in unkempt facial hair and overgrown fingernails.R9 On 7/15/2025 at 11:50 a.m., R9 was observed in the therapy room with long facial hair and long dirty untrimmed fingernails. R9 was not available for interview. On 7/16/2025 at 10:24 a.m., R9 was observed with long facial hair and long dirty untrimmed fingernails. During the interview the resident confirmed not being asked to get shaved not even on scheduled shower days and been wanting to be shaved and to have nail care provided. The resident said before coming to the facility his beard and mustache were trimmed neat. R9 stated, I was waiting for someone to cut my facial hairs.” According to the electronic medical record, R9 was admitted to the facility on [DATE] with diagnoses of hypertension, idiopathic peripheral autonomic neuropathy (a condition where damage to the peripheral autonomic nerves occurs for an unknown reason), asthma, and age-related physical debility. According to the admission Minimum Data Set (MDS) assessment dated [DATE], R9 had intact cognition with a BIMS (brief interview for mental status) score of 15/15. A care plan with a review date of 5/29/2025 for “Activity Daily Living (ADL)” documented, “I have decreased ADL ability related to generalize weakness assistance needed with all ADLS. On 7/17/2025 at 1:34 p.m., during an interview, Registered Nurse/Unit Manager (UM) D stated, “the Certified Nursing Assistance (CNA) are supposed to provide nail care and shaves on shower days. The nurses go into the shower room to make sure the showers, shaves and nail care are complete. The resident scheduled shower days are Monday’s and Thursdays, and the barber comes into the facility every Thursday’s.” UM “D” confirms the resident was admitted into the facility with long facial hair and long fingernails and did not add resident to the barber list or assist the resident with nail care. During an interview on 7/17/2025 at 3:30 p.m. the Director of Nursing (DON) confirmed the CNA should provide shaves and nail care on the resident’s scheduled shower days and the nurses should have made sure the ADL care was completed. According to the facility's January 2025 Activity Daily Living (ADL) policy: “The facility will base (care) on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's ability in ADLs do not deteriorate…” R23 Observations conducted on 7/15/25 at 9:25 AM and 12:51 PM, and on 7/16/25 at 9:30 AM and 3:02 PM, revealed that R23 had long fingernails with visible debris underneath nails. On 7/16/25 at 3:02 PM, R23 reported being unable to cut fingernails independently and had a preference of short nails. Record review of R23’s electronic medical record (EMR) revealed admission into the facility on 6/27/18 with a pertinent diagnosis of cerebral palsy (congenital disorder). Further review revealed R23 had scored 15 out of 15 (intact cognition) on a Brief Interview for Mental Status (BIMS) on 4/16/25 and required substantial/maximal assistance with ADLs. Additionally, review of R23’s EMR revealed care plans documented no specific interventions for nail care and progress notes contained no documentation of refusals to allow staff to provide ADL assistance during the prior three-week period. On 7/16/25 at 3:05 PM after an observation with Registered Nurse (RN) “A” of R23’s fingernails, it was reported by RN “A” that residents’ fingernails should not be long and unkempt. On 7/17/25 at 12:30 PM, the Director of Nursing (DON) reported during an interview that all residents’ nails should be trimmed and cleaned in accordance with their preferences. On 7/17/25 at 12:35 PM, during an interview with the Nursing Home Director (NHA), it was reported that residents should receive routine nail care and should not have long nails if they are unable to perform care independently. Record review of facility’s policy “Providing Nail Care” dated January 2018, it was documented, “3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis.”

Based on observation, interview, and record review, the facility failed to update the care plan for one (R4) of one resident reviewed for care plans to include R4's pressure ulcer or prescribed interventions. On 7/16/2025 at 9:03 AM, R4 was observed sitting up in bed awake and alert with some confusion. There was no pressure relieving mattress in place or other pressure relieving measures observed. R4 consented to receiving incontinence care from CNA (certified nursing assistant) C. During care, a dime-sized shallow crater-like opened area was observed on the resident's coccyx area. There was dried white cream observed to be covering the surrounding area. CNA C reported the resident developed the pressure ulcer a couple weeks ago and a cream was being applied to the area. Registered Nurse (RN) D entered the resident's room and confirmed the resident's pressure ulcer developed in the facility. RN D reviewed R4's Electronic Health Record (EHR) but could not provide any documentation to support R4 had a care plan addressing the pressure ulcer on the coccyx. According to the EHR, R4 admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. The quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had moderately impaired cognition and no pressure ulcers. A care plan for skin integrity initiated on 1/8/25 and last reviewed on 4/23/25 had a goal for skin to remain free from breakdown. On 7/9/2025, progress notes from the Wound Care Practitioner (WCP) F indicated the resident had MASD (moisture associated skin damage) and a small, opened area at the coccyx that measured 0.79 cm (centimeter) Length and 0.36 cm Width. WCP F Recommended the following: Zinc Oxide cream followed by a dry bulky dressing changed daily and as needed if soiled, incorporate aggressive off-loading (pressure relieving measures), add foam wedge to assist with off-loading position changes every 2 hours, Low-Air-Loss (LAL) Mattress, and off-loading heel boots bilaterally while in bed. Recommend Dietitian consultation to assist with augmenting protein, add a multi-vitamin with vitamin C and calorie intake for wound healing. The resident's care plan was not updated to reflect actual skin impairment or include the current interventions. On 07/16/2025 at 10:34 AM during an interview with Director of Nursing (DON) B they said the orders and recommendations from WCP F were missed and the care plan was not updated. According to the facility's Pressure Injury Prevention and Management policy last revised on 1/2024 in part reads:4. Interventions for Prevention and to Promote Healinga. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions.

This citation pertains to intake MI00149794. Based on interview and record review, the facility failed to ensure adequate discharge planning was in place for one resident (R400) of three residents reviewed for discharge planning, resulting in R400/representative not educated on the administration of an injectable anticoagulant (a highest-risk medications used thin blood and prevent blood clots), the potential for medical complications (bleeding) and hospitalization . Findings include: Review of the intake complaint, Hospital Social Worker A revealed the following: Complaint states (they are) a social worker at (Hospital) where resident (R400) is currently at. (Hospital Social Worker A) states resident (R400) was discharged from facility on 1/25/25 with a bottle of heparin (anti-coagulant, believed to prevent blood clots) and syringes without any explanation as to how to use the medication. (Hospital Social Worker A) states this medication is usually administered by a nurse. (Hospital Social Worker A) states resident had not been on this medication previously. (Hospital Social Worker A) states resident has a history of traumatic brain injury. (Hospital Social Worker A) states the residents home health agency nurse was surprised (R400) had this bottle of medication with syringe with no explanation. A review of R400's electronic medical record revealed an admission on 12/30/2024 with the diagnosis of the following: Fracture of the right Humerus, Muscle Protein-calorie malnutrition, Chronic obstructive pulmonary disease, Bipolar Disorder, Anxiety Disorder, Traumatic Brain Injury, Attention-Deficit Hyperactivity Disorder, and Spinal Stenosis. R400 had a Brief Interview for Mental Status (BIMS) of 15/15 meaning cognition is intact. A review of R400's Care Plan reveled the following: Problem Start Date: 01/10/2025, Category: ADLs Functional Status/Rehabilitation Potential: I am at risk for complications related to anticoagulant therapy. Approach Start Date: 01/10/2025, Observe for signs of active bleeding (Nosebleeds, bleeding gums, petechiae, purpura, ecchymotic areas, hematoma, blood in urine, blood in stools, hemoptysis, elevated temp, pain in joints, abdominal pain, epistaxis). Approach Start Date: 01/02/2025, Establish a pre-discharge plan with the resident/family/caregivers and evaluate progress and revise plan as needed. A review of R400's progress notes dated 1/25/25 at 10:45 am revealed the following: Received patient A/Ox3-4 (alert and oriented to person, place, time and event), [NAME] but happy and excited to be going home. V/S, WNL (vital signs within normal limits) With O2@3.5LPM via NC (Nasal Canula). Not in distress. Denies pain. All due scheduled meds given as ordered, well tolerated. All safety measures maintained at all times. Turned and repositioned. Kept clean dry and comfortable thereafter. On fall precaution. NP (Nurse Practitioner) was notified regarding patient's order for discharge and agreeable to take home scheduled medications, Acetaminophen codeine 300-30mg and patient's supply of controlled substances -That was brought in by patient (R400) was returned to patient. Co-signed- 2 RN's (Registered Nurse) and patient was informed to schedule a follow up with PCP (Primary Care Physician) within a week after discharge. RN discussed discharge with care manager printed discharge paper and provided patient with a copy, and obtained care manager signature on discharge paperwork. Patient discharged via Wheelchair at approximately 10:45 AM with instructions and all belongings. Skin assessment: Refused. A review of R400's progress note that was updated 1/27/25 at 10:45 am revealed the following: Edited By: Nurse B on 01/27/2025 08:34 AM Reason: More data available Received patient A/Ox3-4 (alert and oriented to person, place, time and event), [NAME] but happy and excited to be going home. V/S, WNL (vital signs within normal limits) With O2@3.5 LPM via NC (Nasal Canula).Not in distress. Denies pain. All due scheduled meds given as ordered, well tolerated. All safety measures maintained at all times. Turned and repositioned. Kept clean dry and comfortable thereafter. On fall precaution. NP was notified regarding patient's order for discharge and agreeable to take home scheduled medications, Acetaminophen codeine 300-30 mg and patient's supply of controlled substances -That was brought in by Patient was returned to patient. Co-signed- 2 RN's and patient was informed to schedule a follow up with PCP within a week after discharge. RN discussed discharge with care manager printed discharge paper and provided patient with a copy and obtained care manager signature on discharge paperwork. Patient discharged via Wheelchair at approximately 10:45 AM with instructions and all belongings. Skin assessment: Refused. Heparin (Anticoagulant) was discontinued per NP. Order was carried out. (This was the updated information added to Nurse B progress note, updated on 1/27/2025) Edited By: Nurse B on 01/27/2025 08:34 AM Reason: More data available On 2/5/25 at 1:21 PM, an interview was conducted with Nurse B about R400. Nurse B was asked why they updated their 1/25/25 progress note on 1/27/25. Nurse B said they asked the Nurse Practitioner if they should send R400 home with the anticoagulant. Nurse B said that the NP said that if the resident (R400) was not walking, that they should send the resident home with the anticoagulant. Nurse B said, I'm supposed to follow the NP orders .I never sent anyone home on (anticoagulant) .I did not feel comfortable. Nurse B was asked if they provided training to R400 on how to administer the anticoagulant and the dosage. Nurse B said, No because the resident wanted to hurry-up and leave. (R400) gets excited and yells . I gave (R400) the (anticoagulant) and the syringes to go home .I changed the note on January 27 th because I didn't want to get in trouble. Nurse B was queried about why they did not feel comfortable with sending R400 home with the anticoagulant. Nurse B said, (R400) could start bleeding .am I in trouble .I was only following the NP order. On 2/5/25 at 1:37 PM, Social Worker A was interviewed and asked about R400 admission to the hospital. Social Worker A said that the resident was admitted to the hospital. Social Worker A said that the R400's case manager (Case Manager C) said the resident was discharged from the nursing home on 1/25/2025 with a vial of heparin and 4 syringes. Social Worker A said that they were concerned about the resident receiving the medication without directions. The Social Worker A said, It wasn't safe to send (R400) home with such a dangerous medication. On 2/5/25 at 2:09 PM, Case Manager C was interviewed and queried about R400's discharge and home care services. Case Manager C said they provide in home care for R400 and added that the resident lived alone. Case Manager C said that they were concerned after the chore worker stated that the facility sent R400 home with the anticoagulant and syringes. Case Manager C asked Nurse B why they sent R400 home with the anticoagulant, and Nurse B said it was a mistake. On 2/5/25 at 4:10 PM, the Director of Nursing (DON) was queried about Nurse B sending the anticoagulant and syringes home with R400. The DON stated, (Nurse B) was following the order of the Nurse Practitioner. A review of the discharge instructions did not include the anticoagulant and syringes nor any instructions on how to administer the medications provided to the resident/resident representative. A review of the facility's policy Discharge Summary revised on [DATE], revealed the following: a. Reconciliation of all pre-discharge medications with the resident's post discharge medication to include prescription and over the counter medications. 2. For residents discharged to their home, the medical record should contain documentation that written discharge instructions were given to the resident and if applicable, the resident representative. These instructions must be discussed with the resident and resident representative and conveyed in a language and manner they will understand.

Based on interview and record review, the facility failed to establish a comprehensive Infection Control Program that conducted proper facility-wide surveillance and consistently reviewed microbiology summary reports. Findings include: On 9/27/24 beginning at 11:35 AM, the facility's infection control program was reviewed with Infection Preventionist (IP) F and the Interim Director of Nursing (I-DON) and the following was noted: 1. When queried about a list of diseases that may occur that are to be reported to state and local health departments, IP F stated, I don't have a list. 2. When queried about a staff call-in log that documents staff's reasons for calling in, IP F stated, I don't look at the nurse call-in log. IP F added that sometimes the nurse will inform her if the employee calls in sick with symptoms, but this information is not documented or tracked. The I-DON said staff call-ins should be tracked so we know if there is an infection brewing or starting. This information can be used to monitor the residents that the staff have taken care of. 3. The microbiology summary report from the laboratory was requested but was not available. The Incoming Director of Nursing was present and stated the summary report included the results of the cultures completed for the month with cross references of the antibiotic usage for the month. The report helps to prevent overuse or inappropriate use of antibiotics. A review of the policy titled, Antibiotic Stewardship Program, dated June 2024, documented in part the following: - The consultant laboratory will create a summary report of antibiotic susceptibility patterns from organisms isolated in cultures. A review of the policy titled, Infection Surveillance, dated June 2024, documented in part the following: - Employee, volunteer, and contract employee infections will be tracked, as appropriate, such as influenza or gastrointestinal infection outbreaks. - Data to be used in the surveillance activities may include, but are not limited to: Staff reports of signs and symptoms and other relevant documentation, if indicated. On 9/27/24 at 3:30 PM during the exit conference, Medical Director G was unable to provide documentation to support that the laboratory microbiology summary report was received and discussed during the infection control meetings.

Based on observation, interview, and record review, the facility failed to remove expired, undated, unlabeled food from the kitchen walk-in cooler, freezer, pantry and resident refrigerators. This deficient practice had the potential to affect all the residents who consumed food from the kitchen and resident refridgerators, resulting in the increased potential for food borne illness. Findings include: On [DATE] beginning at 8:45 AM, the initial tour of the kitchen was conducted with Dietary Manager (DM) A. During the tour, the following items were observed in the walk-in cooler: - a box of opened moldy bell peppers undated - two bags of mixed salad rotten undated. - a tub of white onions undated - a box of single serving sour cream undated no expiration date The following item was observed in the kitchen freezer: -a frozen 20-ounce bottle of red pop. DM A said staff items do not belong in this fridge/freezer. The following was observed in the pantry: - an opened 26-ounce bottle of honey with expiration date of [DATE]. DM A agreed all items should be labeled, dated and expired items thrown away. On [DATE] at 9:55 AM the North unit resident refrigerator/freezer was observed with Certified Nursing Assistant (CNA) B. The following items were observed: - one 'to go' container unlabeled undated. CNA B stated That's' my lunch. I know it doesn't belong in the resident fridge. -one opened bottle of tea unlabeled, no open date. -one container of cream cheese, unlabeled. -one opened bottle labeled ginger no open date, no expiration date. -one opened bottle of chili sauce unlabeled, no open date. -one opened bottle of banana sauce unlabeled, no open date. -one opened 16-ounce bottle of water unlabeled, no open date. -one opened bottle of spring roll sauce unlabeled no open date. -one opened bottle of flavored water unlabeled, no open date. -one 66 ounce opened bottle of coffee mate unlabeled no open date. -one box of pizza unlabeled, no open date. Freezer -one frozen meal unlabeled. -one frozen milk unlabeled with sell by date of [DATE], expired. -four frozen yogurts unlabeled with use by date of [DATE] expired. On [DATE] at 10:15 AM the South unit resident refrigerator/freezer was observed with Registered Nurse (RN) C. The following items were observed: -one opened two liter of coke unlabeled no open date. -one opened two liter of mountain dew unlabeled no open date. -one rotted orange - one opened box of thickened honey unlabeled open date of [DATE] use by date [DATE] expired. -one opened bottle of ketchup unlabeled no open date. -one opened bottle of grape jelly unlabeled no open date. -one piece of fried chicken labeled with date of [DATE] expired. RN C agreed items should be labeled, expired rotten food thrown out and staff food does not belong in the resident refridgerator. On [DATE] at 11:05 AM the Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed and said they are unsure which department was responsible to maintain the unit refrigerators. Both the NHA and DON agreed staff food does not belong in the unit refrigerators, items should be dated, labeled and expired/rotten food should be removed to prevent resident food borne illness. Review of the facility policy titled (Facility Name) Rehab and Neuro Center Food Safety Requirements revealed in part . Food will be stored, prepared and served in accordance with professional standards for food service safety. Labelling, dating and monitoring refrigerated food, so it is used by its use-by date. Review of the facility policy titled Use and Storage of Food Brought in by Family or visitors revealed in part . All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. The prepared food must be consumed by the resident with in 3 days. If not consumed within 3 days, food will be thrown away by facility staff.

Based on observation, interview, and record review the facility failed to assess for self-medication administration prior to leaving medications at bedside for one resident (R12) out of two residents reviewed during medication administration. Findings Included: Resident #12(R12) Review of the medical record demonstrated R12 was admitted to the facility 06/25/2023 with diagnoses that included congestive heart failure, hypertension, cardiomyopathy (disease of the heart muscle that makes it hard for the heart to pump blood), atrial fibrillation, venous insufficiency, chronic obstructive pulmonary disease (COPD), and Gout (build up of uric acid in bone joints). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/16/2024, demonstrated a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During medication administration on 09/26/2024 at 07:30 a.m. Registered Nurse (RN) I was observed preparing medication to be given to R12. RN I explained that R12 had medication at beside that she administered on her own. RN I explained Magnesium 400mg (milligrams) one tablet once per day was the order for the medication that the resident provided on her own. On 09/26/2024 at 07:38 a.m. R12 was observed lying in bed. Registered Nurse (RN) I asked R12 if she wanted to have her Lidocaine Patch 4% Topically applied now and R12 responded to leave it on the nightstand, and she would place it on herself later. RN I was observed to leave the Lidocaine Patch 4% topically at R12's nightstand. RN I then asked if R12 had her Magnesium 400 mg(milligrams) one tablet once per day. R12 demonstrated a bottle of Magnesium 200mg tablets and R12 explained that she took two tablets because she was ordered 400mg one tablet once per day. RN I asked R12 if she would like her breathing treatment of Ipratropium-albuterol solution for nebulization 0.5mg-3mg (2.5mg base/3ml(milliliters); amt (amount): 1 vial inhalation currently. R12 explained that she would like the vial left on the nightstand and she would administer the breathing treatment to herself after breakfast. RN I left the breathing treatment on the nightstand and left the room. On 09/26/2024 at 07:45 a.m. Registered Nurse (RN) was asked if R12 had an order to self-administer medication and an order to leave medication as R12's bedside. RN I responded yes. Review of R12's medical record did not demonstrate that a physician's order was present to self-administer any medication and did not demonstrate a physician's order to keep medication at her bedside. Review of R12's plan of care did not demonstrate any information on R12's capacity to self-administer medication or was able to have certain medications at her bedside. Review of R12's medical record demonstrated a Evaluation for Self-Administration of Medication, dated 09/07/2023, which revealed R12's preference was to documented as I prefer to utilize the facility's nursing services and the section of self-administration of medication was left blank. During an interview on 09:26/2024 at 09:00 a.m. Interim-Director of Nursing (DON) explained that residents must be evaluated for self-administration of medication and must have a physician order for self-administration of medication. Interim DON also explained that if medication was to be left at a resident's bedside the facility would supply a lock box for the resident to keep the medication at bedside. Interim- DON confirmed that the Evaluation for Self-Administration of Medication, dated 09/07/2023, demonstrated that R12 did not want to administer her own medication. Interim-DON could not provide another Evaluation for Self-Administration of Medication that had been completed for R12 demonstrating that she was capable or desired to administer her own medication. Interim-DON could not demonstrate that R12 had a physician's order to self-administer medication.

Based on observation, interview, and record review the facility failed to provide Activities of Daily Living (ADL's), including bathing/showering/shaving for one dependent resident (R1) out of two residents reviewed of ADL completion. Findings Included: Resident #1 (R1) Review of the medial record demonstrated R1 was admitted to the facility 06/27/2018 with diagnoses that included athetoid cerebral palsy (a movement disorder that causes involuntary muscle movements), hypertension, peripheral vascular disease (PVD) hyperlipidemia (high fat levels in the blood), abnormalities of gait and mobility, muscle weakness, and major depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/08/2024, demonstrated a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 09/25/2024 at 01:31 p.m. R1 was observed lying in bed with facial hair stubble that appeared had not been shaved in several days. R1 explained that he would like to be shaved but the staff have not assisted him awhile. R1 explained that the staff only seem to shave him when they feel like it. R1 could not explain that last time that he was shaved. During observation on 09/26/2024 at 10:09 a.m. R1 was observed lying in bed with facial hair stubble that appeared longer than the previous observation. R1 appeared to be sleeping at time of observation In an interview on 09/26/2024 at 10:10 a.m. Certified Nursing Aide (CNA) B explained that she was caring for R1 at this time. CNA B explained that residents were to be shaved on the day of their showers. CNA B explained that the facility used a shower sheet that was kept at the nurse's station. CNA B explained that R1 was to be showered on Monday and Thursday during the night shift. CNA B' reviewed the notebook containing R1's shower sheets and demonstrated shower sheets for the dates of 9/16/2024 (shaving was not checked off), 09/19/2024 (shower refused) and 09/23/2024 (shaving was not check off). In an interview on 09/26/2024 at 10:25 a.m. Interim-Director of Nursing (DON) explained that residents at the facility received showers/baths twice per week. Interim-DON explained that it is the expectation, with male residents, that they are shaved on the same day as the showers/baths. Interim-DON explained that shaving would be documented on the shower sheets of that Resident. Interim-DON confirmed that R1's shower sheets for 09/16/2024 did not have documentation of shaving, and confirmed R1's shower was refused on 09/19/2024, and confirmed R1's shower sheet for 09/23/2024 did not have documentation for shaving. During observation and interview on 09/26/2024 at 10:38 a.m. Interim-Director of Nursing (DON) observed, with this surveyor, that R1 was lying down in bed and appeared to be sleeping. R1 was also observed with facial stubble. Interim-DON explained that R1 should have been shaved last night. Interim-DON could not explain why R1 was not shaved last night at his shower time. Interim-DON could not produce a shower sheet from last nights scheduled shower.

Based on observation, interview, and record review the facility failed to coordinate hospice services for one resident (R9) out of one resident reviewed for coordination of hospice services resulting in the potential for care not being provided to resident receiving hospice services and the potential for residents not to be fully informed of hospice services provided. Findings Included: Resident #9 (R9) Review of the medical record demonstrated R9 was admitted to the facility 07/09/2024 with diagnoses that included benign neoplasm (tumor that does not invade neighboring tissue or metastasize) of left kidney, type 2 diabetes, abnormal weight loss, pain, repeated falls, hyperlipidemia (high fat content in blood), hyponatremia (low sodium levels in blood), hypertension, chronic obstructive pulmonary disease (COPD), osteoarthritis (chronic disease that causes breakdown in cartilage), gout (high uric acid levels), hemiplegia (condition that cause partial or complete paralysis) affecting right side. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/13/24, demonstrated a Brief Interview for Mental Status (BIMS) of 13 (cognitively intact) out of 15. During observation and interview on 09/25/2024 at 09:34 a.m. R9 was observed lying in bed. R9 explained that he currently received Hospice Services. R9 could not explain what disciplines provided services to him or the frequency that those Hospice disciplines provided that care. R9 denied bring provided a calendar of Hospice Services that were to be provided. No Hospice Service calendar was visible in R9's room. Review of R9's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/13/24, Section O- Special Treatments, Procedures, and Programs demonstrated that R9 was receiving Hospice Services at the facility. Review of R9's physician's orders demonstrated an order written 07/10/2024 which stated On Hospice- (name and telephone number of agency). Review of R9's plan of care demonstrated the problem statement, with the implementation date of 07/17/2024, which stated ADLs Functional Status/Rehabilitation Potential- I require hospice services R/T(related to) renal mass. The plan of care did not demonstrate the frequency or the schedule of Hospice Services to be provided. The plan of care did not demonstrate which Hospice Services were to be provided. In an interview on 09/25/2024 at 04:07 p.m. Registered Nurse (RN) K explained that residents that received Hospice Services would have a physician order, and all Hospice information would be located in the Hospice Notebook at the Nurse's Station that would have a calendar of when Hospice Visit were to occur and what Hospice services were to be provided. RN K demonstrated R9's Hospice Notebook. Review of R9's Hospice Notebook contained a blank Hospice Calendar and failed to demonstrate which Hospice Services were to be provided and when those services were to be provided. In an interview on 09/25/2024 at 04:13 p.m. Interim-Director of Nursing (DON) explained that it was the expectation that a Hospice Calendar be placed in a Resident's Hospice Notebook which would demonstrate what and when Hospice Services where to be provided. Interim-DON also explained that is the expectation that the residents plan of care list what Hospice Services were to be provided and when those Hospice Services were to be provided. Interim-DON was given R9's Hospice Notebook and asked to demonstrate a current Hospice Calander. Interim-DON confirmed that no current Hospice Calendar was in R'9s Hospice Notebook. Interim-DON also confirmed that the R9's Hospice care plan did not list Hospice Disciplines or frequency of those visits. Interim-DON explained that it was her opinion that R'9s Hospice Care Plan was not complete. Interim-DON was asked to provide documentation of care conference collaboration with Hospice Services. Interim-DON could not demonstrate documentation of any care conference or any meeting that had occurred with the involvement of Hospice Services.

Based on observation, interview, and record review, the facility failed to 1. Properly secure protected health information for one resident (R29) out of one resident reviewed for privacy of medical information, resulting in the potential for unauthorized disclosure, access and modification 2. Provide a privacy curtain for one resident (R8) out of one resident reviewed for privacy resulting in resident dissatisfaction and a lack of privacy. Findings include: R29 On 9/25/24 at 3:46 PM a hallway facility computer screen was observed unlocked. The electronic health record (EHR) for Resident R29 was visible. Personal, identifiable information for R29 was observed accessible to multiple staff and visitors in the common area of the hallway. Certified Nursing Assistant (CNA) D was designated as logged into the unlocked computer. Upon returning to the computer screen CNA D was interviewed and said she walked away from the screen to answer a call and did not log out or close the screen. CNA D stated I should have logged off. On 9/27/24 at 11:00 AM the Director of Nursing (DON) was interviewed and said if a staff member walks away from a EHR screen they should log out or close the screen to protect confidential patient information. R8 On 9/25/24 at 10:47 AM R8 was interviewed and stated I don't have a privacy curtain. I should have one. My other two roommates have one. Where's my privacy? R8's bed did not have a bed curtain. When asked if there was previously a bed privacy curtain R8 replied Yes, but I don't know what happened to it. On 9/25/24 at 4:15 PM there was no bed curtain observed for R8's bed. On 9/26/24 at 8:23 AM there was no bed curtain observed for R8's bed. On 09/26/24 at 10:33 AM Maintenance Director (MD) E was interviewed and said he got a work order for R8's privacy curtain two weeks ago. He removed the entire privacy curtain bracket but hasn't had a chance to reinstall due to a lack of maintenance staff to help. I usually would have that done within a couple of days. MD E agreed R8's bed should have a privacy curtain and the replacement was not timely. Record review of R8's electronic health record revealed admission to the facility on [DATE] with diagnosis that included type 2 diabetes mellites, difficulty in walking and muscle weakness. The Minimum Data Set (MDS) dated [DATE] indicated R8 had moderately impaired cognition with a BIMS (brief interview for mental status) score of 10/15. Review of the maintenance request dated 9/12/24 revealed cracked holder for privacy curtain rod. Needs to be replaced and put-up tracking and hang curtain. Comments pending took curtain rail down will install next week by 9/19/24. On 9/27/24 at 11:00 AM the DON was interviewed and agreed each resident bed should have privacy curtain to maintain resident privacy. Review of the facility policy titled Confidentiality of Personal and Medical Records revised May 2024 revealed in part . This facility honors the resident's right to secure and confidential personal and medical records. This includes the right to confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record.

Based on observation, interview, and record review, the facility failed to ensure equipment used in food service operation was maintained in good working order, resulting in the two-compartment sink not being protected against contamination from sewage or other sources of contamination and the accumulation of ice build-up in the walk-in freezer, potentially affecting all residents consuming food from the kitchen. Findings include: On 10/2/23 beginning at 10:05 AM, during a tour of the kitchen with Dietary Manager (DM) B, the following was observed: The drain line from the two-compartment prep sink was observed to not have the required minimum one-inch air gap (an unobstructed vertical space between the end of the sink drain line and the flood rim of the floor drain). Ice build-up, of at least an inch, was observed on the mechanicals (pipe carrying the outgoing freon, nut that separates the capillary tubes, and thermal expansion valve tube) of the walk-in freezer and mounds of ice had accumulated under the unit that houses the mechanicals of the freezer and on a box of frozen chicken patties. These ice mounds were varied in diameter and height but were at least two inches in diameter and two inches in height. DM B said the Maintenance Director looked at it, said he had to get some parts, and left. DM B said he did not know why the ice build-up occurred. On 10/3/23 at 1:24 PM, an observation with DM B, revealed the walk-in freezer door gasket was worn and cracked. On 10/04/23 beginning at 8:39 AM, Maintenance Director (MD) H said kitchen staff do not close the freezer door all the way which allows higher air temperatures to rush causing ice build-up. DM H added that cracks in the freezer door gasket effects the seal which also contributes to the ice build-up in the freezer. The 2013 FDA Food Code was reviewed and revealed the following: Section 4-501.11, Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. Section 5-202.13 Backflow Prevention, Air Gap: An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. On 10/4/23 at 3:30 PM during the exit conference, Nursing Home Administrator and DON did not offer additional documentation or information when asked.

Based on interview and record review, the facility failed to effectively develop and implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program that was fully sustained during transitions in leadership and regularly reviewed and analyzed data, resulting in the potential for missed opportunities to identify and prevent deviations of care delivered to facility residents. Findings include: On 10/4/23 at beginning 2:06 PM, the facility's QAPI program was reviewed with the Nursing Home Administrator (NHA). During the past year, QAPI meetings were held on 10/5/22, 1/4/23, 4/5/23 and 7/5/23. In QAPI meetings we review high acuity concerns like abuse, medication errors, and falls. The NHA provided documentation that the facility received a 3-year accreditation from CARF (Commission on Accreditation of Rehabilitation Facilities) International on 8/31/23. The NHA said that Therapy Director (TD) C was primarily responsible for writing the CARF report. On 10/4/23 at approximately 2:37 PM, TD C said a goal achieved during the process of achieving CARF accreditation was fall reduction. TD C said they identified falls as an area for improvement and wrote a goal to decrease falls by 10% from the previous year. A six-month mid-term assessment, completed June 2023, determined that they exceeded that goal. TD C said falls were discussed in QAPI meetings, but they did not evaluate if the program was on the right track during the April 2023 QAPI meeting. The NHA said reducing medication errors was another performance improvement goal. TD C said even though she was responsible for writing the CARF report, the implementation of procedures to decrease med errors would have been the responsibility of the Director of Nursing (DON) and the nursing department. The NHA said he was unable to demonstrate evidence of the QAPI process for the identification, investigation, and analysis for decreasing medication errors. The NHA stated the DON that worked on decreasing medication errors no longer works at the facility and, I don't think I can get that. I don't have any tangible tracking of it. A review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI), dated July 2023, documented in part the following: - The QAA (Quality Assessment and Assurance) Committee shall be interdisciplinary and shall: meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program; regularly review and analyze data, including data collected under the QAPI program. - The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include but is not limited to: systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; data collection and analysis at regular intervals. - The governing body and/or executive leadership is responsible and accountable for the QAPI program. - The QAA Committee shalt communicate its activities and the progress of its subcommittee activities to the governing body at least quarterly. - Medical errors and adverse events are routinely tracked. On 10/4/23 at 3:30 PM during the exit conference, Nursing Home Administrator and DON did not offer additional documentation or information when asked.

Based on observation, interview, and record review, the facility failed to: 1. Consistently document the dishmachine was operating properly; 2. Ensure expired food was not stored with active food stock; 3. Store food service equipment off the floor; 4. Effectively clean multiple surfaces in the kitchen (toasters, oven doors, oscillating fan); 5. Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, kielbasa and pork loin; and 6. Ensure the walls and cove base of the walk-in freezer and door gasket of the walk-in freezer were in good condition and cleanable. These deficient practices had the potential to affect all the residents who consumed food from the kitchen, resulting in the potential for food-borne illness. Findings include: On [DATE] beginning at 10:05 AM, during a tour of the kitchen with Dietary Manager (DM) B the following was observed: DM B presented a document titled, Sanitizer Solution Log as the document used to record the sanitizing solution for the dish machine. A review of the [DATE] Sanitizer Solution Log documented the sanitizing solution had not been checked 29 out of 30 times in the morning and nine out of 30 times in the afternoon. The [DATE] Sanitizer Solution Log documented the sanitizing solution had not been checked at all to date in the morning. A pedestal, oscillating fan was stored in the kitchen. DM B said they use the fan in the summer. The front and rear grills, blades, and pedestal were soiled with dust and dirt. On opened 46-ounce container of lemon flavored thicken water with a use-by-date of [DATE] was stored in the dairy cooler. Two flat, rectangular ice trays, used to keep ice cream frozen on the tray line, were stored on floor of the walk-in freezer. Two kitchen toasters were soiled with food debris. DM B acknowledged that the level of food debris on the toasters exceeded what may have occurred during today's breakfast service. The oven doors were soiled with a build-up of grease. DM B stated, They were last cleaned about two weeks ago. I guess. The following food items were in the walk-in freezer, kielbasa and peppers cooked [DATE] and pork loin cooked [DATE]. DM B said after these items were cooked, they put them in a container labeled with the cooked date and put it in the cooler or freezer. DM asked rhetorically, Are we supposed to take the temperature of it? DM B admitted there were no cooling logs for these items but I can get that started. The following was observed in the walk-in cooler: - An opened five-pound container of chicken salad was not labeled with an opened date and discard date. - The paint on walls of the cooler was peeling and chipping. - The cove base, near the cooler door, was cracked and soiled. The cove base was not completely sealed and securely attached to the wall. The floor in this area was soiled with food debris and paint chips. - A corner section of the wall, above the cove base, was missing. Exposing a rough and uncleanable surface On [DATE] at 1:24 PM, an observation with DM B, revealed the walk-in freezer door gasket was soiled with grime and what was identified as mold. DM B stated, We'll get right on that. DM B said that he does not utilize a cleaning schedule for the kitchen. On [DATE] at 8:50 AM, DM B stated, I will get all the items you showed me cleaned. According to the 2013 FDA Food Code: - Section ,d+[DATE].11, entitled, Safe, Unadulterated, and Honestly Presented, was reviewed and revealed, Food shall be safe, unadulterated, and, as specified under S ,d+[DATE].12, honestly presented. - Section ,d+[DATE].14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135 F to 70 F; and (2) Within a total of 6 hours from 135 F to 41 F or less. - Section ,d+[DATE].117 Warewashing Machines, Automatic Dispensing of Detergents and Sanitizers. (B) Incorporate a visual means to verify that detergents and sanitizers are delivered - Section ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. - Section ,d+[DATE].13, Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. - Section ,d+[DATE].11 Floors, Walls, and Ceilings. Except as specified under S ,d+[DATE].14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. On [DATE] at 3:30 PM during the exit conference, Nursing Home Administrator and DON did not offer additional documentation or information when asked.