Every finding on record at Mcclure Post Acute

Based on an interview and record review, the facility failed to ensure the Minimum Data Set (MDS, standardized assessment used in nursing homes to evaluate a resident's physical, psychological, and functional status) assessments were transmitted (electronically submitted to the national database) within the required 14 day timeframe for four of 19 sampled residents (Resident 12, 29, 46, and 64). This failure resulted in the delayed reporting of the residents' condition, which may negatively impact care planning, oversight, and delivery of appropriate services to meet the residents' needs. Findings:During a review of Resident 12's MDS, dated [DATE], the MDS indicated a completion date of 3/13/26.During a review of Resident 29's MDS, dated [DATE], the MDS indicated a completion date of 3/13/26.During a review of Resident 46's MDS, dated [DATE], the MDS indicated a completion date of 3/12/26.During a review of Resident 64's MDS, dated [DATE], the MDS indicated a completion date of 3/13/26.During a concurrent interview and record review on 4/9/26 at 8:26 a.m. with the MDS Registered Nurse (MDSRN), the facility provided document titled, MDS Final Validation Report, dated 4/1/26 was reviewed. The document indicated the MDS assessments for Residents 12, 29, 46, and 64 were submitted on 4/1/26 with a message of Record Submitted Late. The MDSRN stated the facility followed the Resident Assessment Instrument (RAI, standardized CMS-required system used in nursing homes to assess residents and guide their care) and confirmed the MDS assessments for Residents 12, 29, and 64 should have been submitted before 3/27/26 and Resident 46's should have been submitted by 3/26/26. The MDSRN further stated the facility waited to submit Residents 12, 29, 46, and 64's MDS assessments so they could be transmitted in a batch with other residents' MDS assessments on 4/1/26. During an interview on 4/9/26 at 12:23 p.m. with the Director of Nursing (DON), the DON confirmed the facility was responsible for ensuring the MDS assessment were submitted within the required 14 days of completion. During a review of the RAI Manual, dated October 2025, the manual indicated, MDS assessments must be submitted within 14 days of the MDS Completion Date.

Based on interview and record review, the facility failed to ensure the Quarterly Minimum Data Set (MDS, standardized assessment used in nursing homes to evaluate a resident's physical, psychological, and functional status) assessments were completed in a timely manner for two of 19 sampled residents (Resident 40 and 46) when: 1.Resident 40's Quarterly MDS was not completed within the required timeframe of 14 days from the Assessment Reference Date (ARD, specific date selected for an MDS assessment that determines the end of the observation) 2. Resident 46's Quarterly MDS was not within the required timeframe of 92 days from the prior MDS assessment. These failures resulted in the facility's inability to ensure timely and accurate assessments of Resident 40 and 46's condition and had the potential to negatively impact the residents' care planning and delivery of services to meet the residents' needs.Findings:1.During a review of Resident 40's Face Sheet (demographics), dated 4/9/26, the Face Sheet indicated Resident 40 was admitted with diagnoses including schizophrenia (serious mental health condition that affects how a person thinks, feels, and understands reality).During a concurrent interview and record review on 4/9/26 at 8:26 a.m. with the MDS Registered Nurse (MDSRN), the facility provided document titled, MDS Final Validation Report, dated 4/6/2026 was reviewed. The document indicated, Assessment Complete Late because the assessment completion date is more than 14 days after the assessment reference date for Resident 40. The MDSRN stated the facility followed the Resident Assessment Instrument (RAI, standardized CMS-required system used in nursing homes to assess residents and guide their care) Manual and the quarterly MDS should be completed within 14 days of the ARD. The MDSRN further stated Resident 40's most recent MDS has an ARD of 2/23/26, but was completed on 4/1/26, making it 23 days late.During a review of Resident 40's MDS, dated [DATE], the MDS indicated an ARD of 2/23/26 and completion date of 4/1/26.During an interview on 4/9/26 at 12:23 p.m. with the Director of Nursing (DON), the DON confirmed the facility was responsible for ensuring the completion date was within 14 days after the ARD. During a review of the RAI Manual, dated October 2025, the manual indicated, The MDS completion date . must be no later than 14 days after the ARD .2.During a review of Resident 46's Face Sheet (demographics), dated 4/9/26, the Face Sheet indicated Resident 46 was admitted with diagnoses including anxiety and hypertension (high blood pressure).During a concurrent interview and record review on 4/9/26 at 8:26 a.m. with the MDS Registered Nurse (MDSRN), the facility provided document titled, MDS Final Validation Report, dated 4/1/2026 was reviewed. The document indicated, Assessment Completed Late for Resident 46. The MDSRN stated the facility follows the Resident Assessment Instrument (RAI, standardized CMS-required system used in nursing homes to assess residents and guide their care) Manual and the quarterly MDS should be done within 92 days of the last MDS assessment. The MDSRN stated Resident 46's admission MDS was on 12/1/25 but the next MDS was not done until 3/5/26 so it was late. During an interview on 4/9/26 at 12:23 p.m. with the Director of Nursing (DON), the DON confirmed the facility was responsible for ensuring Resident 46's next MDS was completed within 92 days after the previous MDS.During a review of Resident 46's Clinical Record on 4/9/26, the clinical record indicated the comprehensive MDS assessment completed at admission had an Assessment Reference Date (ARD, date that establishes the timeframe for capturing the resident's condition and services provided for the MDS assessment) of 12/1/25 and the following MDS assessment had an ARD of 3/5/26, making it 94 days after the admission MDS.During a review of the RAI Manual, dated October 2025, the manual indicated, The Quarterly assessment is .non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous .assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored .The ARD (A2300) must be not more than 92 days after the ARD of the most recent . assessment of any type.

Based on observations, interviews, and record review, the facility failed to ensure supervision was provided during dining per physician's orders for one of 19 sampled residents (Resident 23). This failure resulted in an increased risk of choking, aspiration (entry of food or liquid into the airway or lungs), and potential respiratory complications such as death for Resident 23. During a review of Resident 23's Face Sheet (FS, demographics), dated 4/9/26, the FS indicated Resident 23 was originally admitted to the facility on [DATE] and then was readmitted after a change of condition on 2/16/26. The FS further indicated Resident 23's diagnosis was a stroke (blood flow blocked to the brain) with difficulty swallowing and speaking.During a concurrent observation and interview on 4/9/26 at 8:16 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 23's room, Resident 23 was in bed, sitting up, head tilted to left, chin resting on her neck sleeping. Resident 23's right hand was on the bedside table with her fingers in a bowl of cooked breakfast cereal with a full glass of red colored liquid next to the bowl. LVN 1 stated Resident 23 required direct one-on-one supervision during dining due to a recent stroke, history of pocketing food, and difficulty swallowing. LVN 1 confirmed Resident 23 needed one-on-one supervision during dining. During a concurrent observation and interview on 4/9/26 at 8:16 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 23's room, CNA 1 entered the room and attempted to arouse Resident 23 but was unsuccessful. CNA 1 indicated that Resident 23 required one-on-one supervision during meals and needed prompting to take small bites, swallow, and clear her mouth while eating. CNA 1 stated she had taken away Resident 23's tray after observing her eat some of her breakfast and left the full bowl of uneaten cooked breakfast cereal and juice on the bedside table for Resident 23 to finish alone while she picked up other resident's trays. During a concurrent interview and record review on 4/9/26 at 9:15 a.m. with Speech Language Pathologist (SLP), Resident 23's Electronic Medical Record (EMR) was reviewed. The EMR indicated Resident 23 experienced a stroke in February 2026 and was readmitted to the facility on [DATE]. SLP stated that due to Resident 23's difficulty eating and swallowing, the physician ordered that Resident 23 receive one-to-one supervision during dining. SLP stated the reason for supervision was to monitor Resident 23's swallow, prompt the resident to clear her mouth between bites, and maintain safety while eating and drinking. SLP reported that Resident 23 had a history of pocketing food, failing to complete swallowing, and hiding food in her room. SLP verified that Resident 23 had an episode of choking on 3/8/26. SLP emphasized that if food was left in Resident 23's room without supervision, there was a significant risk of choking, which could lead to respiratory distress or aspiration. During a concurrent observation and interview on 4/9/26 at 10:05 a.m. with SLP, SLP was wiping Resident23's face which had thick secretions from her mouth, down her chin, to her chest. Resident 23's eyes were closed, head was tilted to the left, and her gown appeared moist. There was a full glass of red liquid on the overbed table. SLP stated, food should not have been left in the resident's room unobserved. The resident needs to be observed to prevent choking and aspiration. During a review of Resident 23's Physician Order (PO), dated 2/16/26, the PO indicated, Resident 23 had a 1 to 1 eating every shift.During a review of Resident 23's PO dated 3/9/26, the PO indicated, 1:1 assistance when eating. During a review of Resident 23's, Speech Therapy Encounter Note (STN), dated 3/9/26, the STN indicated Resident 23, needs cues to double swallow to clear residue.frequent cues to swallow . and not hold food in her mouth. During a review of Resident 23's, Care Plan Report (CPR), dated 4/9/26, the CPR indicated a focus was on issues of Coughing while eating and Resident requires assistance while eating.During a review of the facility's policy and procedure (P&P) titled, Assistance with Meal/Mealtime Policy, dated December 2025, the P&P indicated, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident.During a review of the facility's P&P titled, Activities of Daily Living (ADL) supporting, dated April 2025, the P&P indicated, Residents are provided with care.as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently receive the services necessary .

Based on interview and record review, the facility failed to ensure nursing staff were adequately trained and competent regarding medication management of self-administered medications that were stored at bedside for one of 19 sampled residents (Resident 76). This failure resulted in Resident 76's medications being administered without appropriate oversight or documentation, placing the resident at risk for medication errors. Findings:During a review of Resident 76's Face Sheet (demographics), dated 4/9/26, the Face Sheet indicated Resident 76's diagnoses included acute and chronic respiratory failure with hypoxia (a short-term and ongoing breathing problem where the body is not getting enough oxygen).During a concurrent observation and interview on 4/9/26 at 11:30 a.m. with Resident 76 in his room, Resident 76 stated he kept his albuterol sulfate inhaler (medication inhaled into the lungs that helps make breathing easier) in a locked box in his room and self-administered the medication as needed. Resident 76 stated he last self-administered the albuterol on 4/7/26 at 7pm and recorded it on paper. Resident 76 stated staff did not ask him to notify them when he self-administers his medication.During an interview on 4/9/26 at 11:32 a.m. with Licensed Vocational Nurse (LVN) 2, LNV 2 was asked how staff would know when Resident 76 self-administered albuterol. LVN 2 was unaware of actions to be taken to determine when Resident 76 was self-administering his medication.During an interview on 4/9/26 at 11:35 a.m. with LVN 3, LVN 3 stated she was not sure about the process for self-administered medications kept at bedside.During an interview on 4/9/26 at 11:43 a.m. with the Director of Nursing (DON), the DON stated the facility had not provided education and training to nursing staff regarding the monitoring and documentation of self-administered medications kept at bedside. The DON further stated the expectation was at the end of every shift, staff should ask Resident 76 how many times he self-administered the medication, when it was administered, and document that information on the Medication Administration Record (MAR). The DON stated staff were not monitoring Resident 76's use of the albuterol inhaler or possible side effects of the medication. During a review of Resident 76's MAR, dated 4/9/26, the MAR did not indicate an administration of albuterol on 4/7/26. The MAR indicated the last administration of albuterol was on 3/22/26 at 2:47 p.m.During a review of the facility policy and procedure (P&P) titled, Self-Administration of Medication, dated February 2021, the P&P indicated, Nursing staff reviews the self-administered medication record for each nursing shift, and transfers pertinent information to the medication administration record (MAR) kept at the nursing station, appropriately noting that the doses were self-administered.

Based on observation, interview, and record review, the facility failed to ensure medications were stored in a safe and secure manner for one of 19 sampled residents (Resident 76) when his albuterol sulfate inhaler (medication inhaled into the lungs that helps make breathing easier) was found lying on his tray table. This failure had the potential to result in unsafe or unauthorized medication use, drug diversion, and accidental ingestion by Resident 76 or other medically vulnerable residents.Findings:During a review of Resident 76's Face Sheet (demographics), dated 4/9/26, the Face Sheet indicated Resident 76's diagnoses included acute and chronic respiratory failure with hypoxia (a short-term and ongoing breathing problem where the body is not getting enough oxygen).During a concurrent observation and interview on 4/6/26 at 4:33 p.m. with Resident 76 in his room, the albuterol inhaler was lying on Resident 76's tray table. Resident 76 stated, It was getting annoying asking the nurse when I need my puffer, so the medication was kept at his bedside. During a concurrent observation and interview on 4/6/26 at 4:55 p.m. with Licensed Vocational Nurse (LVN) 2 confirmed Resident 76's albuterol inhaler was left on his bedside table and stated medication shouldn't be left unsecured at bedside. During an interview on 4/9/26 at 11:43 a.m. with the Director of Nursing (DON), the DON confirmed the albuterol inhaler should not have been left unsecured at Resident 76's bedside. During a review of the facility's P&P titled, Storage of Medications, dated November 2020, the P&P indicated, The facility stores all drugs and biological in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments The nursing staff is responsible for maintaining medication stores and preparation areas in a clean, safe, and sanitary manner.

Based on interview and record review, for two of three sampled residents (Resident 1 and 2), the facility failed to provide required discharge notice in a timely manner when notice of proposed discharge were provided on the day of discharge. This failure had the potential to prevent residents from understanding their rights or available appeal options.During a review of Resident 1's admission Record(AR) dated 3/17/26, the AR indicated Resident 1 was admitted to the facility 11/12/25 with diagnoses that included peripheral vertigo (severe sensation of spinning), chronic kidney disease (long-term, progressive loss of kidney function), muscle weakness, difficulty walking and other symptoms and signs involving cognitive functions and awareness. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 1/26/26, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status as regards to attention, orientation, and ability to register and recall information) score of 15. A BIMS score of 13-15 is an indication of intact cognitive status. During a review of the Notice of Proposed Transfer/Discharge-V4.0 dated and signed 1/26/26, the notice indicated appeal rights and contact information, that if Resident 1 believed the proposed discharge is inappropriate, Resident 1 had the right to appeal to the appropriate state long-term agency. During a review of Resident 1's Progress Notes dated 1/26/26 and Discharge Summary and Post-Care Instructions dated 1/26/26, both documents indicated Resident 1 was discharged from the facility on 1/26/26. During a review of Resident 2's AR, dated 3/17/26, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included necrosis of the right femur, depression, toe cellulitis, and mild cognitive impairment. During a review of Resident 2's Notice of Proposed Transfer/Discharge dated 2/13/26 indicated the notice was provided to Resident 2 and signed by facility staff on 2/14/26. During a review of Social Service Note (SSN) dated 2/13/26, the SSN indicated Resident 2 was discharged on 2/14/26. During an interview on 3/17/26 at 3:04 p.m. with Social Services Director (SSD), SSD stated, when discharged from the facility, residents receive several documents that included a Discharge Summary and Post-Care Instructions, Inventory of Personal Items, a Medications list, and a Notice of Proposed Transfer/Discharge, which provides the proposed discharge date but is only given to residents on the actual day of discharge. SSD stated that the 30-day Discharge Notice is a recent development, and the facility does not have any established policy and procedure for it yet.

Based on interview and record review, for two of three sampled residents (Resident 1 and 3), the facility failed to maintain complete and accurate medical records in accordance with professional standards when:1.a.Resident 3 left the faciity on 3/9/26 without staff knowledge or permission (elopement, when a resident leaves the facility without staff knowledge or permission), and this was documented in the medical record as leaving Against Medical Advice (AMA, a situation in which a resident chooses to leave a healthcare facility or discontinue recommended care despite the facility's clinical advice to remain).1.b. Resident 3's request for room changes, as well as the facility's corresponding response, were not documented in the clinical record. 2. For Resident 1, the clinical record lacked documentation of communication between the Social Services Director (SSD) and Case Manager (CM) 2 regarding discharge plans. This failure had the potential to result in a lack of continuity of care and the inability to provide safe and effective services.1.a. During a review of Resident 3's admission Record (AR) dated 3/17/26, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included severe sepsis (a life-threatening complication of infection, requiring immediate aggressive treatment), pneumonia (lung infection), anxiety disorder (excessive, persistent fear or worry that interferes with daily life), depression (a serious, common mood disorder causing persistent sadness, loss of interest) and heart failure (a chronic, serious condition where the heart cannot pump blood efficiently). During a review of Resident 3's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/1/26, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status as regards to attention, orientation, and ability to register and recall information) score of 12. A BIMS score of eight to 12 is an indication of moderate impairment in cognitive status. During a telephone interview on 3/17/26 at 3:46 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that on 3/9/26 at 8:10 p.m., while passing medications, she saw Resident 3 in the room doorway and confirmed no medication was needed. Later, while passing medications at a different section of the unit, LVN 1 noticed Resident 3 leaving his room toward the hallway. Between 8:30-8:45 p.m., LVN 1 did not see Resident 3 in the room, but this was not unusual as Resident 3 often walked around the facility even in late evenings. After checking the resident's room and common areas without success, LVN 1 attempted to call Resident 3's cellphone several times with no answer. LVN 1 stated she searched nearby streets but did not go further due to safety concerns of being out in the dark by herself. LVN 1 informed the DON, Resident 3's physician, and the incoming NOC shift nurse about Resident 3's elopement before leaving for the day. During a review of Resident 3's Progress Notes PN, the PN indicated the following:i. On 3/9/26 at 11:24 p.m., the Nurse's note indicated, [Resident 3] left the facility without informing the staff and has not returned yet. MD and DON notified.ii. On 3/10/26 at 1:30 p.m., the Nurse's note indicated Resident 3 returned to the facility from the hospital, on a gurney with a closed nondisplaced clavicle (collar bone) fracture, swollen eye and a sling on the left arm.iii. On 3/10/26 at 1:56 p.m., the IDT (Interdisciplinary Team, a group composed of individuals representing different departments of the facility) Note indicated, the IDT met to discuss Resident 3's departure from the facility Against Medical Advice (AMA) and subsequent hospitalization. The IDT determined that after Resident 3 left the facility premises, the facility was no longer responsible for Resident 3's supervision or care, and that the fall and injury happened outside the facility's oversight.The PN did not indicate whether the Night nurse continued searching for Resident 3 or checked on Resident 3's location, and the Night shift nurse did not provide any documentation.During a concurrent interview and record review on 3/19/26 at 11:28 a.m. with Case Manager (CM) 1, IDT Notes dated 3/10/26 and the facility's policy and procedure (P&P) titled Discharging a Resident Against Medical Advice, copyrighted 2001 were reviewed. CM 1 stated the NOC shift documentation by LVN 1 lacked details about Resident 3's departure and whether risks of leaving the facility AMA were explained. CM 1 stated, although the IDT Notes the next day addressed the lack of documentation, no IDT members were present when Resident 3 left unnoticed. CM 1 also stated, since Resident 3 was alert and able to make healthcare decisions, it was considered AMA, even if staff were unaware of Resident 3 leaving the facility. The P&P indicated the facility's discharge policy requires documentation of the reason for requesting discontinuation of care, clinical risk of discontinuing care information provided to the resident and why it is in the best interest of the resident to stay at the facility, resident's consent for discharge and any information provided by the resident regarding the setting and care-giving arrangements made for the resident after discharge. CM 1 stated Resident 3's clinical record did not include this required information.1.b. During an interview on 3/17/26 at 11:44 a.m. with Resident 3, Resident 3 stated requesting a room change due to a bathroom issue with a roommate, but the facility has not responded to this request.During a concurrent interview and record review on 3/17/26 at 11:14 a.m. with CM 1, CM 1 stated Resident 3 had complained about a bathroom issue with a roommate and was offered a room change, which Resident 3 declined. However, CM 1 stated there was no documentation regarding the room change or offer. 2. During a review of Resident 1's AR dated 3/17/26, the AR indicated Resident 1 was admitted to the facility 11/12/25 with diagnoses that included peripheral vertigo (severe sensation of spinning), chronic kidney disease (long-term, progressive loss of kidney function), muscle weakness, difficulty walking and other symptoms and signs involving cognitive functions and awareness.During an interview on 3/17/26 at 3:04 p.m. with Social Services Director (SSD), SSD stated Resident 1 had a case manager (CM 2) for community resources. SSD stated calling CM 2 about finding an Independent Living Facility (ILF) for Resident 1's discharge but could not recall the exact date of the telephone call, she believed it was 1/19/26.During a review of Resident 1's discharge care plan dated 11/12/25, the care plan indicated Resident 1 needed placement assistance, with interventions that included coordinating referral to outside resources.During a telephone interview on 3/17/26 at 3:32 p.m. with CM 2, CM 2 stated SSD contacted her on 1/26/26, to inform her that the facility found an ILF for Resident 1. CM 2 stated requesting SSD to provide the name and address of the ILF so she could arrange a tour; SSD responded that the information would be sent via a text message. CM 2 stated waiting throughout the day for this information but later found out that Resident 1 had been discharged that afternoon.During a review of Resident 1's Discharge Summary and Post-Care Instructions V2 (DSPCI) dated 1/26/26, the DSPCI indicated Resident 1 was discharged to an ILF on 1/26/26.

Based on observation, interview and record review, the facility did not provide privacy to one (1) out of four (4) sampled residents during phone conversations. This failure resulted in facility staff overhearing Resident 1's phone conversations, violation of rights to privacy and placed her at risk of being upset. During a record review of Resident 1's admission record, indicated that Resident 1 was admitted to the facility on [DATE]. During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used in identifying problems to be addressed in plan of care), dated 1/20/26, the record indicated that Resident 1 had clear speech, was able to make herself understood, and was able to understand others. MDS also indicated that it was very important for Resident 1 to be able to use a phone in private. During a phone interview on 3/16/26 at 9:10 a.m. Resident 2's Family Representative (FR 1) stated, it was important for them to communicate with Resident 2 over the phone on an ongoing basis to keep Resident 2's spirits high. FR 1 stated since they needed to call facility's phone situated at the nursing station, it was hard for him to hear Resident 2 due to Resident 2's altered speech and background noises. FR 1 stated it had been almost one year that Resident 2 had to come to the nursing station to talk to FR 1 over the phone and at times, she would refuse to do that. FR 1 stated Resident 2 did not have any timely and private access to a telephone in the facility. During an interview on 3/17/26 at 12:35 p.m. Resident 1 stated there was no privacy provided to her when she was on the phone. Resident 1 stated the staff there or the nurses would turn around and tell the other nurses what she had just said. Resident 1 stated she felt as if there was no awareness from staff, that she needed to be on the phone in private. During an interview on 3/17/26 at 1:10 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated the residents received phone calls at the front desk or the nurse's station. CNA 1 stated those areas always had facility staff present at all times. CNA 1 also stated that she assisted Resident 1 to the phone at the nurse's station only two days ago, and she stayed with Resident 1 the whole time. During an interview with Activity Director (AD) on 3/17/26 at 1:48 p.m., the AD stated facility had at least four (4) residents who did not have their personal cell phones and needed to use facility phone to call their loved ones. AD stated, however Resident 1 and Resident 2 actively used the phone at the nursing station on a frequent basis. During an observation on 3/17/26 at 2:07 p.m. Resident 1 was in her wheelchair in the hallway using the corded phone at the nurse's station. There were multiple staff, including Licensed Vocational Nurse (LVN) 1 sitting at the nurse's station and Occupational Therapist (OT) 1 standing behind Resident 1, while she was on the phone. During an interview on 3/17/26 at 3:30 p.m. LVN 1 stated he did not feel if Resident 1 was provided with any privacy during her phone conversations earlier that day. LVN 1 stated Resident 1 needed to be in a place where no one was around, or she should be provided with a wireless phone in the room. During an interview on 3/17/26 at 3:50 p.m. OT 1 stated the residents had a right to privacy while using the phone. OT 1 stated that she wasn't even aware that Resident 1 was on the phone. OT 1 stated her being in the area where Resident 1 while making her personal phone call invaded Resident 1's privacy. During an interview on 3/17/26 at 3:59 p.m. the Assistant Director of Nursing (ADON) stated if privacy is invaded during a phone call, any reasonable person would be upset. During a review of facility's Policy and Procedure (P&P) titled, Resident Rights dated August 2009, the P&P indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include that resident's right to. Use a telephone in privacy. Residents are entitled to exercise their rights and privileges to the fullest extent possible.

Based on interview and record review, for two of two residents (Resident 2 and Resident 3) who were discharged , the facility failed to develop and implement an effective discharge planning process for their transition to post-discharge care when:1.For Resident 2, the facility failed to assist in obtaining a government ID and bank card before discharge. The facility did not arrange primary care or pharmacy services for medication follow-up. This had the potential to result in Resident 2 lacking funds for his ILF (Independent Living Facility) stay and potentially facing homelessness.2.For Resident 3, the facility failed to establish a primary care provider and pharmacy for medication refills after discharge. This failure had the potential to result in unnecessary re-admissions.1.During a review of Resident 2's admission Record (AR) printed 1/15/26, the AR indicated Resident 2 was admitted to the facility in February 2024 with multiple diagnoses that included cognitive communication deficit (impairment in communication such as speaking, listening, reading, or writing caused by impaired memory and attention), depression (persistent sadness, loss of interest in activities) and stage 3 chronic kidney disease (the kidneys have mild to moderate damage and are less able to filter waste and fluid out of your blood). The AR also indicated Resident 2 was discharged from the facility on 12/9/25.During a telephone interview on 1/15/26 at 1:06 p.m. with Family Friend (FF), FF stated Resident 2 was discharged from the facility to an ILF without any means to pay rent, as he had lost his ID and debit card. FF stated, consequently, Resident 2 left the ILF, became homeless, and was eventually taken to the hospital ER for a medical issue.During a review of Resident 2's Social Service Note (SSN), late entry, dated 12/9/25, the SSN indicated Resident 2 was discharged to an ILF. The SSN indicated discharge instructions were reviewed with Resident 2 as provided by the Interdisciplinary Team (IDT, a group composed of individuals representing different departments of the facility) that included follow-up appointments and a medication plan. During an interview on 1/21/26 at 10:38 a.m. with Social Services Director (SSD), SSD stated Resident 2 did not have his ID and debit card. SSD stated that once Resident 2 obtained them, Resident 2 could pay rent at his new residence (ILF). SSD stated she did not assist Resident 2 in acquiring these items before discharge, but Resident 2 received post-discharge instructions on the day of discharge.During a review of Resident 2's Physician's Order dated 12/9/25, the physician's order indicated home health services and a primary care physician appointment after discharge.During a review of Resident 2's Discharge Summary and Post-Care Instructions (DCPCI) dated 12/9/25, the DCPCI indicated the section Post-Discharge Plan of Care Services, Referrals, and Equipment lacked complete information. Specifically, the fields for primary care physician name and appointment details, phone number, address, and pharmacy information were left blank. A copy of the DCPCI was provided to Resident 2 at the time of discharge.During a telephone interview on 1/21/26 at 10:52 a.m. with Independent Living Facility Owner (ILFO), ILFO stated she was unaware Resident 2 lacked an ID or debit card. ILFO stated Resident 2 said he was going to the bank with a friend but did not return. A few days later, a local hospital informed ILFO that Resident 2 had visited the Emergency Department (ED) for medication. ILFO confirmed Resident 2 has not returned to the ILF.During a telephone interview on 1/21/26 at 12:04 p.m. with Home Health Registered Nurse (HHRN) 1, HHRN 1 stated Resident 2 did not have a medication list during visit at the ILF. HHRN also stated there was no established pharmacy or primary care physician.During a concurrent interview and record review on 1/21/26 at 12:30 p.m. with Case Manager (CM), CM stated Resident 2's medical record lacked documentation of the pharmacy for medication pick-up and did not indicate if a primary care physician was established for follow-up. CM also stated there was no discharge planning documented until the actual day of discharge.2. During a review of Resident 3's AR, the AR indicated Resident 3 was admitted to the facility in September 2025 with diagnoses that included myopathy (diseases that affect skeletal muscles or the muscles that connect to your bones), chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs, results in swelling and irritation inside the airways), epilepsy (a brain condition that causes recurring seizures), anxiety disorder (repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak, panic attacks, within minutes), and spinal stenosis (narrowing of the space inside the back bone putting pressure on the spinal cord and nerves). Resident 3 was discharged from the facility on 12/12/25.During a review of Resident 3's Discharge Summary (DC) dated 12/12/25, the DC indicated while it recorded Resident 3's discharge date , it lacked information on the discharge location and transportation method.During an interview on 1/21/26 at 2:02 p.m. with SSD, SSD stated Resident 3 was discharged to ILF.During a review of Resident 3's DCPCI dated 12/12/25, the DCPCI indicated the incomplete information in the Post-Discharge Plan of Care Services, Referrals, and Equipment section. Specifically, the fields for primary care physician name and appointment details, phone number, address, and pharmacy information were left blank. The DCPCI indicated a copy of the document was given to Resident 3 at the time of discharge.During a review of the facility's policy and procedure (P&P) titled Discharge Summary and Plan last revised March 2025, the P&P indicated if the resident has no primary care provider (PCP), staff will assist in finding one and document their efforts. Discharge planning should specify the discharge destination and include the final discharge plan detailing where the resident will live, follow-up care from other providers, and contact information for those providers, as well as instructions on when and how to contact the continuing care provider.

Based on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: 1. Unlabeled, undated food items were stored in the kitchen refrigerator. 2. [NAME] (CK) 1 did not wear a beard restraint while preparing resident food. 3. Expired and moldy food items were stored in the resident refrigerator. These failures had the potential for contamination of food resulting in food borne illness for the 55 residents who received food from the kitchen and used the resident refrigerator. Findings: During an observation on [DATE], at 9:47 a.m. the kitchen refrigerator was observed with one covered container of unlabeled and undated onions, one covered container of unlabeled and undated peas, and one pack of undated turkey burgers. During an observation on [DATE], at 10:49 a.m. the resident refrigerator was observed with one opened bottle of milk with an expiration date of [DATE], one pack of garlic with an expiration date of [DATE] and one container of blueberries and strawberries dated [DATE] that had mold. During an observation on [DATE], at 12:05 p.m., in the kitchen, CK 1 was observed wearing a surgical mask that did not cover CK 1's entire beard, while preparing resident salads for lunch. During an interview on [DATE], at 2:55 p.m., with Registered Dietician (RD), RD stated it was important to label and date food so they could have known when they were expired. RD stated staff should have discarded food in the kitchen and resident refrigerators that were unlabeled, undated, expired and moldy to prevent cross contamination and food borne illness. RD stated CK 1 should have worn a beard restraint when CK 1 prepared resident food to prevent food borne illness. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated 2001, the P&P indicated, Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. During a review of the facility's P&P titled, Sanitation and Infection Control, dated 2023, the P&P indicated, Subject: Food Brought in From Outside Sources . Food that does not have a manufacturer's printed dated must be thrown out 3 days from the time it was brought in. During a review of the facility's P&P titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, dated 2001, the P&P indicated, Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens.

Based on observation and record review, the facility failed to ensure that resident bedrooms were limited to a maximum of four residents for one out of 24 rooms. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff, affect resident's right to privacy, dignity and lack of sufficient space for storage of resident belongings. Findings: During an observation on 3/11/25, room [ROOM NUMBER] was occupied by five residents. During a review of the Facility's Daily Census, dated 3/10/25, the census indicated room [ROOM NUMBER] was occupied by five residents. According to the Code of Federal Regulations, Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents. Bedrooms must . Accommodate no more than four residents.

Based on interview and record review, for one of one sampled resident (Resident 20) reviewed for vision impairment, the facility did not assist Resident 20 in making appointments for cataract evaluation. This failure had the potential to result in worsening of visual function without treatment. Definition: Cataract, a clouding of the normally clear lens of the eye, leading to blurry and hazy vision. Cataract Evaluation, a comprehensive eye exam to assess the presence, severity, and potential impact of cataracts, as well as overall eye health, to determine the best course of treatment, which may include surgery. Ophthalmology, the branch of medicine focused on the eyes and vision, encompassing the diagnosis, treatment, and prevention of eye diseases and disorders, including surgical procedures and vision correction. Findings: During a review of Resident 20's clinical record, the Admission Record indicated Resident 20 was admitted to the facility in July 2021 with diagnoses that included major depressive disorder (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities) and hypertension (high blood pressure). Resident 20's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 12/21/24 indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15. A score of 13-15 is an indication of intact cognitive status. During a review of Resident 20's MDS dated [DATE], the MDS indicated, under Section F-Preferences for Customary Routine and Activities (an interview for activity preferences), for Resident 20, it was very important to have books, newspapers, and magazines to read and to keep up with news while in the facility. During an observation and concurrent interview on 3/10/25 at 10:51 a.m. with Resident 20, while Resident 20 watched television in the room, Resident 20 stated she could not see what was shown on the screen as it was blurry. Resident 20 stated being diagnosed with cataract by an eye doctor in the last year and was told by Social Services Director (SSD) that facility would look for a surgeon to perform surgery on her eye. Resident 20 stated she has not heard back from SSD since. During an interview on 3/11/25 at 1:23 p.m. with SSD, SSD stated Resident 20 was seen by the facility's ophthalmologist (eye doctor) in December 2024. Review of Ophthalmology Consultation dated 12/11/24 indicated Resident 20 complained of blurry vision and inability to read or see TV, and with a diagnosis of having cataract on the left eye. The ophthalmologist recommendations included referral to a specialist for cataract extraction (a surgical procedure to remove a cloudy lens [cataract] lens of the eye and, in most cases, replace it with an artificial lens) evaluation. During a review of Resident 20's Order Summary Report dated 3/12/25, the Order Summary Report indicated a physician's order dated 12/11/24 for eye consult for eye health with follow-up as indicated. During a follow-up interview on 3/11/25 at 1:39 p.m. with SSD, SSD stated she did not see the recommendation for Resident 20's referral for cataract extraction. SSD stated all the residents at the facility were seen by the facility's ophthalmologist every six months and she only looked at the six-month follow-up for Resident 20. SSD stated she has not referred Resident 20 to an eye surgeon. During a review of the facility's policy and procedure (P&P) titled Eye Care Services, undated, the P&P indicated Eye care services will be made available to residents upon request, referral, or when a clinical need is identified. Residents will receive eye care services in accordance with physician's orders .may include but are not limited to: eye exams .provision of corrective lenses, treatment for eye disease and follow-up care . Follow-up visits will be scheduled and coordinated as needed based on the results of the eye examination.

Based on interview and record review, licensed nursing staff did not notify the doctor for changes in condition for one of 15 sampled residents (Resident 49). Staff did not report continued low food intake, pain, and low blood pressures. This failure resulted in Resident 49 becoming unresponsive with a low blood sugar and sent to the hospital emergency department where she experienced a cardiac arrest (condition when heart suddenly and unexpectedly stops beating) and died . Findings: During a review of Resident 49's clinical document, titled Admission Record, the Admission Record showed the facility admitted Resident 49 on [DATE] with diagnoses including Crohn's Disease (chronic inflammatory bowel disease). During a record review of Resident 49's clinical document Weights and Vitals Summary, dated [DATE], the document indicated Resident 49's blood pressure was ,d+[DATE] on [DATE]. There was no documentation in the clinical record which showed the doctor had been notified. During an interview on [DATE] at 9:45 a.m. with the Director of Nursing (DON), DON stated staff should have retaken the blood pressure and notified the doctor if it was still low. In a concurrent record review, the DON confirmed there was no documentation in the clinical record which showed the doctor had been notified. During a record review of the Resident 49's Nutritional Risk Assessment, dated [DATE], the document showed Resident 49 was At high risk for malnutrition . During a record review of Resident 49's clinical document titled, Documentation Survey Report v2, dated [DATE], the document showed Resident 49's percentage of food intake on multiple meals between [DATE] to [DATE] was zero to 26% intake. There was no documentation in the clinical record which showed the doctor had been notified. During a record review of Resident 49's Nutritional Risk Assessment (Admission/Annual) - V 5.0, dated [DATE], the document showed Resident 49 was Not feeling well and her roommate reported to the Registered Dietitian (RD) Resident 49 was in a lot of pain, hadn't eaten breakfast that morning and was Zoning in and out. There was no documentation which showed the RD reported this information to the licensed nursing staff or the doctor had been notified. The RD was not available to be interviewed. During an interview on [DATE] at 2:45 p.m. with DON, DON confirmed there was no documentation in the clinical record which showed the doctor or nurse had been notified regarding the low food intake, pain, or mental status change. The DON stated when someone is at risk for malnutrition, she expected staff to monitor the intake, observe for dehydration, and skin breakdown. The DON also stated staff should have been monitoring Resident 49's blood sugar since hypoglycemia (low blood sugar) was a potential outcome for low food intake. The DON stated signs of low blood sugar included becoming pale, sweaty, and a potential altered level of consciousness. During a record review of Resident 49's Progress Notes *New*, dated [DATE] to [DATE], the Progress Notes showed on [DATE] at 7:04 a.m., licensed nursing staff reported Resident 49 had gotten Little to no sleep due to pain which had not been relieved by medication. There was no documentation in the clinical record which showed the doctor had been notified. During an interview on [DATE] at 2:26 p.m. with DON, DON confirmed the staff had not notified the doctor regarding the unrelieved pain. Further review of document Progress Notes *New*, dated [DATE] to [DATE], the notes showed later that morning on [DATE] at 10:50 a.m., staff found Resident 49 unresponsive with a blood sugar level of 56. (normal range: ,d+[DATE]). Staff called 911 and Patient 49 was sent to the hospital emergency department (ED). During a record review of Resident 49's ED to Hosp-Admission (discharged ) ., dated [DATE], the record showed Resident 49 arrived at the ED with a blood pressure of ,d+[DATE] and hemoglobin of 6.5.(Hemoglobin: protein in red blood cells that is responsible for delivering oxygen to the tissues. Normal range: ,d+[DATE]). Resident 49's diagnoses included septic shock and a GI bleed (septic shock: life-threating condition caused by a severe localized or system-wide infection) (GI: gastrointestinal). Resident 49 was transferred to the hospital Intensive Care Unit where she went into cardiac arrest and died . During an interview on [DATE] at 10:57 a.m. with the facility's physician (MD 1), MD1 stated he could not recall if anyone had notified him regarding Patient 49's low blood pressure readings. He stated he was aware of the pain and poor appetite but that the GI team never stabilized her (GI: gastrointestinal) and that maybe a feeding tube (Feeding Tube: tube placed directly into the stomach to deliver liquid food) would have helped. MD 1 stated Resident 49 was A mess. During an interview on [DATE] at 11 a.m. with the Emergency Doctor (MD 2), MD 2 stated it would have been useful to have a physician assess Patient 49 and check her blood sugar when she was described as Zoning in and out. MD 2 stated Patient 49's blood cultures from the ED showed Enterobacter (intestinal bacteria) which meant that the bacteria source for her sepsis came from the GI track. MD 2 stated, not having a proper diet can contribute to the development of a GI bleed and having a feeding tube placed would have helped. During a record review of the Resident 49's clinical document titled, Care Plan Report dated [DATE], the care plan showed Resident 49 was at risk for malnutrition. Goals included Will identify physical symptoms or conditions that could lead to a decreased appetite or ability to eat. During a record review of facility's Policy and Procedures (P and P) titled, Nutritional assessment dated 2001, the P & P showed As part of the comprehensive assessment, the nutritional assessment will be a systemic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. On multivariate analysis, there was a significant increase in mortality in patients with malnutrition. Patients with malnutrition had greater rates of sepsis events, perforation and GI bleed. On multivariate analysis, malnutrition appeared to significantly increase mortality. [Malnutrition Imparts Worse Outcomes in Patients with Diverticulitis: A Nationwide Inpatient Sample Database Study: [NAME], Ayham Khrais, [NAME] Le, Sushil Ahlawat. NIH National Library of Medicine:pubmed.ncbi.[NAME].nih.gov/35989747/]

Based on observation, interview, and record review, the facility failed to allow one out of 15 Residents (Resident 42) to exercise their right to self-determination when Resident 42 was not provided nutrition in accordance with their preferences. This failure had the potential to result in Residents 42 feeling upset and disrespected. Findings: During a review of Resident 42's Admission Record, printed 3/13/25, the record indicated Resident 42 was admitted to the facility in December 2024 with a diagnosis of protein-calorie malnutrition and depression. During a concurrent observation and interview on 3/10/25, at 12:36 p.m. with Resident 42, Resident 42's lunch tray was observed with one regular serving of vegetables. Resident 42 stated they were supposed to get an additional large portion of vegetables with their regular vegetables. Resident 42 stated they felt upset and disrespected that staff did not follow their food prefrences. During a concurrent observation and interview on 3/11/25, at 12:45 p.m. with Registered Dietician (RD), Resident 42's lunch tray was observed with one regular serving of vegetables. RD stated Resident 42 should have got an additional large portion of vegetables and added a large portion of vegetables. RD stated it was important to honor resident preferences. During a review of Resident 42's Lunch Tray Ticket, dated 3/10/25, the ticket indicated, Notes: Add: Large portion vegetable. During a review of Resident 42's Lunch Tray Ticket, dated 3/11/25, the ticket indicated Notes: Add: Large portion vegetable. During a review of Resident 42's Dietary Interview/Pre-Screen, dated December 2024, the interview indicated Special Preferences . Lunch . add: vegetable. During a review of the facility's policy and procedure (P&P) titled, Resident Food Preferences, dated 2001, the P&P indicated, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. During a review of the facility's P&P titled, Resident Rights, dated 2001, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to . self - determination.

Based on interview and record review, for one of two sampled residents (Resident 24) reviewed for pain management, the facility failed to ensure pain management was provided consistent with professional standards of practice when facility did not administer pain medication to address Resident 24's severe pain. This failure had the potential to result in severe discomfort. Findings: During a review of Resident 24's Admission Record, the Admission Record indicated Resident 24 was admitted to the facility in April 2024 with diagnoses that included complete traumatic amputation (a surgical procedure where a limb or part of a limb is removed) at level between knee and ankle and osteomyelitis (a bone infection). During a review of Resident 24's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/2/25 indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine resident's cognitive status in regards to attention, orientation, and ability to register and recall information) score of 14. A score of 13-15 is an indication of intact cognitive status. During an interview on 3/10/25 at 10:49 a.m. with Resident 24, Resident 24 stated having headaches and severe pain on the left amputated leg. Resident 24 described pain intensity as 10 out of 10 (on a scale of 1-10, one as the absence of pain and 10 being the worst pain). Resident 24 also stated being given pain medication that does not help much with pain relief. During a concurrent interview and record review on 3/12/25 at 12:39 p.m. with Director of Nursing (DON), Resident 24's Medication Administration Records (MARs) and Order Summary Report (OSR) were reviewed. The OSR indicated a physician's order dated 12/27/24 to give oxycodone-acetaminophen (a narcotic pain medication) 5-325 milligram (mg) 1 tablet every 4 hours as needed for moderate pain (4-6). Resident 24's January 2025 MAR indicated a physician's order to give oxycodone-acetaminophen (Percocet, a narcotic pain medication) 5-325 mg 1 tablet by mouth every 4 hours for moderate pain (4-6). The MAR for January 2025 indicated Resident 24 had severe pain (7-10) but was given pain medication indicated for moderate pain (4-6) on the following dates; 1/20/25, 1/21/25, 1/22/25, 1/23/25, 1/24/25, 1/25/25, 1/26/25, 1/27/25, 1/28/25, and 1/29/25. The MAR for February 2025 indicated Resident 24 had severe pain (7-10) but was given pain medication indicated for moderate pain (4-6) on the following dates; 2/5/25, 2/24/25 and 2/26/25. The MAR for March 2025 indicated Resident had severe pain (7-10) but was given pain medication indicated for moderate pain (4-6) on the following dates; 3/4/25, 3/9/25 and 3/10/25. DON stated the MARs did not indicate a pain medication order for when Resident 24 had severe pain. DON also stated the licensed staff should have called Resident 24's physician to request for pain medication indicated for severe pain. During a review of the Consultant Pharmacist's Medication Regimen Review (CPMRR) dated 1/20/25, the CPMRR indicated Percocet (oxycodone-acetaminophen) was administered outside of parameters (refer to the specific aspects of pain that are evaluated during assessment, including intensity and quality). The recommendation was for staff to review and reinforce proper procedure with staff. During an interview on 3/12/25 at 12:46 p.m. with Assistant Director of Nursing (ADON), ADON stated she had followed up on the medication regimen recommendation by giving in-service education to the licensed staff but did not call the doctor to request pain medication. During a concurrent interview and record review on 3/12/25 at 1:25 p.m. with DON, DON stated a new physician's order for severe pain was obtained from the physician. The OSR dated 3/12/25 indicated a new order dated 3/12/25 for oxycodone-acetaminophen 5-325 mg 2 tablets every 4 hours as needed for severe pain (7-10). During a review of the facility's policy and procedure (P&P) titled Pain Assessment and Management, undated, the P&P indicated pain management is a multidisciplinary process that includes interventions that are consistent with the resident's goals for treatment which are defined and documented in the care plan. It also indicated pain management interventions should reflect the sources, type and severity of pain. During a review of Resident 24's pain care plan last revised 4/18/24, the care plan indicated for staff to administer medications as ordered and allow time to participate in activities of daily living to minimize discomfort.

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure a complete medical records when Resident 1's Treatment Administration Record (TAR) had missing signatures. This failure had the potential to result in uncoordinated care, and unnecessary, painful duplicate wound care. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility in October 2024 with diagnoses of malnutrition, cancer of the kidney, anemia (abnormally low level of red blood cells) and diabetes mellitus (condition of uncontrolled high blood sugar). During a review of Resident 1's progress notes dated 10/10/24, the progress notes indicated Resident 1 had a wound from pressure on the sacrum (large triangular bone at the base of the spine) diagnosed as a stage 4 pressure ulcer (also know as bed sore, most severe stage of a pressure sore, where the damage extends through all layers of skin and tissue, exposing underlying muscle, tendon, or bone, often with significant tissue loss and a high risk of infection). During a review of Resident 1's pressure ulcer care plan dated 10/11/24, the care plan indicated for treatments to be performed as ordered. During a review of Resident 1's Order Summary Report dated 10/13/24, the Order Summary Report indicated the treatment for Resident 1's sacrum pressure ulcer was: every day shift was to cleanse wound with normal saline, pat dry, apply santyl (ointment, treatment of choice to remove damaged tissue from chronic wounds) and cover with optifoam (type of foam dressing). During an interview on 11/22/24 at 10:20 a.m. with Resident 1, Resident 1 stated he had a wound on his buttock which needed to be cleaned and re-dressed every day. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 10/16/24, the MDS indicated Resident 1 had a score of 12 on the Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of eight to 12 is an indication of moderate impairment; a score of 13 to 15 is an indication of intact cognitive status). During a review of Resident 1's TAR for October 2024, the TAR indicated the dates, times, and initials of the nursing staff who completed wound care treatments. The TAR inidcated no entries os the data for the following dates: 10/11/24, 10/14/24, 10/15/24, 10/20/24, 10/21/24, and 10/28/24. During a telephone interview on 11/25/24 at 1:04 p.m. with Treatment Nurse (TN), TN stated TN had been on duty as the treatment nurse on the days Resident 1's TAR was missing initials in October. TN stated she had forgotten to enter the date, time and her initials after providing Resident 1's treatment. During a review of the facility's policy and procedure (P&P) titled, Wound Care, revised October 2010, the P&P indicated, after wound care was provided, The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason (s) why. 10. The signature and title of the person recording the data. During a review of the facility's P&P titled, Charting and Documentation, undated, indicated information to be documented in the resident's medical record included treatments and services performed. The P&P also indicated the documentation of the treatments and services performed will include specific details including date and time the procedure was performed, the name and title of the individual who provided the care, and the signature and title of the individual documenting the treatment.

Based on interview and record review, the facility failed to follow the facility abuse policy and procedure to protect and prevent further potential abuse for one of four sampled residents (Resident 1) when the facility allowed Certified Nursing Assistant (CNA) 1 to continue to provide direct patient care after Resident 1 made an abuse allegation. The failure to complete a thorough investigation of CNA 1 had pushed and slapped Resident 1 ' s arm during linen change resulted in psychosocial harm for Resident 1 and the potential for physical abuse for other residents. Findings: During a record review of Resident 1 ' s Admission Record dated 8/5/24, the admission record indicated Resident 1 had diagnosis of femoral shaft fracture of left femur (broken thigh bone). During a record review of Resident 1 ' s Minimum Data Set (MDS-an assessment used to guide care) dated 7/22/24, the assessment indicated Resident 1 had a Brief Interview of Mental Status exam (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status) score of 12 out of 15 and indicated mildly impaired cognition. During a review of Resident 1 ' s care plan dated 7/16/24, the care plan indicated Resident 1 is at risk for ADL [Activities of Daily Living, Activities of daily living are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating.] / mobility decline and requires .will have needs anticipated and met by staff .2 person assist with ADLs .encourage to participate in ADLs to promote independence .monitor for changes in condition or declines in ability to participate in ADLs, decreased strength, increased weakness, or changes in cognition . During a phone interview on 9/10/24, at 11:51 a.m., with Resident 1, Resident 1 stated on 8/3/24 at 3 a.m. during a change of soiled bed linen, CNA 1 pushed Resident 1 ' s arm with force and then slapped Resident 1 ' s arm, when Resident 1 told CNA 1 the linen was still wet and dirty underneath her. Resident 1 stated she yelled out in pain and reported to Licensed Vocational Nurse (LVN) that CNA 1 had slapped her. Resident 1 stated she also called 911 and reported it to the police. Resident 1 stated having CNA 1 to continue to work at the facility on that day, made her fearful of retaliation and scared. Resident 1 stated I was ready to call 911 again. During a phone interview on 9/13/24 at 11:15 a.m., with CNA 1, CNA 1 stated on 8/3/24, she was removed from caring for Resident 1 by LVN 1. CNA 1 stated she continued to work the remainder of her shift providing care to the other 20 patients. CNA 1 denied the accusation. During a phone interview on 9/13/24, at 11:26 a.m., with LVN 1, LVN 1 stated LVN 1 was the charge nurse on duty on 8/3/24. LVN 1 stated CNA 1 was providing ADL care to Resident 1 and changing the dirty linen, when Resident 1 reported CNA 1 had slapped her arm. LVN stated after the Resident 1 called the police at 3:20 a.m., LVN 1 informed the DON of the incident. LVN 1 stated the DON instructed LVN 1 to remove CNA 1 from providing care for Resident 1 but CNA 1 could continue to work providing care to the other 20 patients for the remainder of the shift. During an interview on 9/10/24, at 12:35 p.m., with the Director of Nursing (DON), the DON stated LVN 1 told the DON of Resident 1 ' s complaint of being alleged hit on 8/3/24 at 3:30 a.m., by LVN 1. The DON stated she told LVN 1 to remove the CNA 1 from Resident 1 ' s care but let CNA 1 continue to work her full shift providing care to other residents. The DON stated the abuse investigation was completed on 8/6/24. During a review of Resident 1's undated investigation summary report, the report indicated Resident 1's allegation of abuse incident was completed and signed on 8/6/24 by the DON. The report indicated it was faxed to the Department on 8/7/24. During a concurrent interview and review of the facility provided document titled Detail Time and Job undated, with the DON, the DON stated CNA 1 clocked in, and started her shift on 8/2/24 at 11:00 p.m., and clocked out for lunch break on 8/3/24 at 03:00 a.m. The DON stated CNA 1 then clocked back in on 8/3/24 at 3:31 a.m. and clocked out at the end of the shift on 8/3/24 at 8:04 a.m. The DON stated CNA 1 stayed 30 minutes overtime to write a narrative of the incident. During a review of the facility's policy and procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised September 2022, the P&P indicated Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food safely when the low-temperature dishwasher did not have sanitizer running through it. This failure increased the residents' risk for foodborne illness. Findings During a concurrent observation and interview on 2/20/24 at 9:48 a.m. with Dietary Aide (DA) 1 and Dietary Supervisor (DS), in the kitchen, DA 1 used a test strip to check the sanitizer level in the dishwasher. The test strip did not change color. DA 1 stated, the test strip showed no sanitizer was present. During a concurrent observation and interview on 2/20/24 at 9:55 a.m. with Registered Dietician (RD), in the kitchen, RD used a test strip to check the sanitizer level in the dishwasher. The test strip did not change color. RD stated, the test strip showed no sanitizer was present. RD stated, the dishes that were previously washed would be rewashed and sanitized by hand. RD stated, that the dishwasher was a low temperature dishwasher and needed sanitizer to sanitize the dishes. RD stated, using dishes washed in a low temperature dishwasher, without sanitizer, increased the risk of the spread of food bourne illness. During a concurrent observation and interview on 2/20/24 at 10:30 a.m. with RD, in the the kitchen, RD tested the sanitizer in the dishwasher with a test strip. The test strip changed color and registered 100 ppm. RD stated, the test strip registered 100 ppm of sanitizer, which was the correct amount. RD stated, she had discovered the level of sanitizer in the bucket below the dishwasher, had gotten lower than the tube that drew the sanitizer into the dishwasher and therefore, no sanitizer was going into the dishwasher. RD stated, she pushed the tube down into the sanitizer to fix the problem.

Based on observation, interview, and record review, the facility failed to ensure that one out of two medication carts (medication cart #2), the medications stored in the medication cart had all their necessary labeling identifying medication stocks on hand. Resident 21's had one medication bottle without any identifying label and another bottle had no pharmacy label and torn out manufacturer's label. This failure had a potential to affect Resident 21's health and safety when unlabeled medications were in stored in the medication cart with current medications on hand for administration. Findings: During a concurrent observation and interview on 02/22/24 at 1:52 P.M., with Registered Nurse (RN) 1, with the medication cart #2. In medication cart#2's the top drawer were two bottles that had no pharmacy labels. The bottle had a black marker with Resident 21's name and Dapsone (antibiotics and anti-inflammatory medication used to treat skin disease). The second bottle of medication had manufacturer's label that had torn area indicating the medication is Bictegravir/emtricitabine/tenofovir alafenamide - (Biktarvy- fixed-dose combination antiretroviral medication), the bottle had no resident name. During a concurrent observation and interview on 02/22/24 at 02:10 P.M., with Director of Nurses (DON), while checking Resident 21's medications, DON stated, when the resident brought their medication supplies from an outside pharmacy, the licensed nurse would verify with the resident's physician. DON stated the admitting nurse would list the medication on the log and send it for verification. After the medication was verified with the physician, they can put the medication on rotation to be administered according to the physicians order's. DON stated, the Dapsone should have not been in the medication cart. During a concurrent interview and record review on 02/22/24 at 02:37 P.M., with DON, DON reviewed Outside Pharmacy Record the log indicated there was no Dapsone on the list when Resident 21 was admitted and Biktarvy had an unknown amount listed. During a concurrent interview and record review on 2/23/24 7:31 A.M., with RN 2, RN 2 reviewed the Outside Pharmacy Record, and stated it was her initials listed when Resident 21 was admitted on [DATE], but RN 2 stated does not remember accepting the Dapsone. RN 2 stated, the amount listed on the log was three tablets of Biktarby, and not three bottles. RN 2 stated, they count the tablets when accepting the medications brought in by the resident. During a review of the facility's policy and procedure titled Medication Labeling and Storage with revision date of February 2023, indicated Medication Labeling 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceuticals practices. 2. The medication label includes, at minimum: a. medication name (generic and/or brand); b. prescribed dose; c. strength; d. expiration date, when applicable; e. resident's name; f. route of administration; and g. appropriate instructions and precautions . 8. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.

Based on observation, interview and record review the facility failed to ensure one of five sampled residents received treatment to maintain vision. This failure resulted in Resident 32 not being referred to an ophthalmologist for cataracts. Findings Resident 32's facesheet, dated 2/22/24, indicated he was admitted to the facility in January of 2022. Resident 32's Multi Data Set (MDS - an assessment tool used to plan care), dated 1/25/24, indicated his Brief Interview for Mental Status (an assessment tool measuring cognitive function) score was 12, which indicated he was moderately cognitively impaired. During an interview on 2/21/24 at 10:20 a.m. with Resident 32, Resident 32 stated, he had cataracts, which were supposed to have been operated on and removed. Resident 32 stated, he did not know why it was taking so long for the cataracts to be removed. During an interview on 2/22/24 at 8:25 a.m. with Resident 32, Resident 32 stated, his cataracts affected his vision. Resident 32 stated, his vision was getting worse, that he liked to watch TV and he was having a harder time seeing the picture on the TV. Resident 32 stated, he needed to have his cataracts taken out as soon as possible. During an interview on 2/22/24 at 8:34 a.m. with Social Service Designee (SSD), SSD stated, SSD scheduled optometrists' examinations of facility residents. SSD stated, Resident 32 was evaluated by the optometrist on 7/12/23. SSD stated, the optometrist gave her the Optometrist Visit Notes (OVN) for Resident 32, which indicated Resident 32 had cataracts and needed to be referred to an outside ophthalmologist. SSD stated, Resident 32 had not yet been seen by an ophthalmologist and did not yet have an appointment with an ophthalmologist. SSD stated, she faxed a referral to the ophthalmologist's office on 2/21/24 at 10:55 a.m. During an interview on 2/22/24 at 9:33 a.m. with Director of Nursing (DON), DON stated, SSD was responsible for referring Resident 32 to the ophthalmologist for his cataracts. During a review of Resident 32's OVN, dated 7/12/23, the OVN indicated, Resident 32 had cataracts in both eyes and was to be referred to an outside ophthalmologist. During a review of a facility fax cover sheet (FCS), dated 2/21/24, the FCS indicated, a referral had been faxed to ophthalmology requesting a consult for Resident 32 regarding his cataracts.