Every finding on record at Meadville Convalescent Home

Based on interviews and facility policy review the facility failed to inform residents/resident representatives that their chosen attending physician was unable to meet requirements as the facility sought to seek alternate physician for provision of care and treatment without attempt to work with the residents' chosen attending physicians or mediate differences for nine (9) of eleven (11) sampled residents; Resident #2, Residents #3, Resident #4, Resident #5, Resident #7, Resident #8, Resident #9, Resident #10 and Resident #11.Findings Included:Policy review of the facility policy titled, Standard of Care with Revision Date 9/15/22 revealed, It is the policy of this facility to provide a standard of treatment and care most beneficial to residents.Regardless of payment methods, all residents shall have access to.Care that meets their needs, Their attending physician, Clinical and administrative staff.In providing care to all residents our staff will be.effective communicators with one another.Policy review of the facility policy titled, MEDICAL, DENTAL AND L.I.P. PROVIDERS: SELECTION, APPOINTMENTS AND COMMUNICATIONS with Revision Date 11/28/2017 revealed POLICY: The facility shall support each residents' right to fully choose a personal physician, dentist and other licensed independent practitioner (L.I.P).PHYSICIAN COMMUNICATIONS: Residents and/or family members may request information regarding the physicians and other practitioners responsible for his/her care. (Proper Name) facilities shall provide the health care provider's name, credentials and phone number to the resident/family.Record review of Residents' Rights with Revision Date 10/10/22 revealed, The resident has the right to a dignified existence, self-determination.3. Choice of attending physician. The resident has a right to choose his or her attending physician. On 11/11/25 at 1:00 PM during an interview the facility Administrator stated that the facility decided, without input from residents who received wound care from the Medical Director (MD) at the local wound care clinic, or their resident representatives, that wound care would be changed to in facility wound care performed by a certified wound care nurse practitioner. He stated that no printed letters were posted to residents or their representatives. He stated that Resident #3's contact was contacted but not his RR, even though Progress Note review for Resident #3 revealed that facility staff spoke to the RR on 8/11/25 two days prior to the first wound care clinic appointments missed by the resident with no documentation of change in the plan of care that included setting or provider. The Administrator stated that the change was initiated despite strong opposition of MD #1 and MD #2. He confirmed that there was no reason that the residents could not have received care both at the wound care clinic and in the facility. The Administrator informed the State Agency (SA) that on 10/13/25 he had sent an email to the collaborating physician for Nurse Practitioner (NP) #1, who was MD #1 and to MD #2 for whom the NP also took call, and revoked her privileges in the facility due to a decision (that) is administrative and compliance-driven-designed solely to unify our clinical processes-and is not a reflection of individual performance. The Administrator reported that on 10/31/25 he sent a letter to the only two attending physicians that practiced in the facility as a formal notice of termination of admitting and attending privileges. He said that on 10/31/25 he had not identified compliance, safety or care concerns and that he had not used printed, verbal or electronic means to impart any concerns, issues or complaints to NP #1, MD #1 or MD #2. He stated that the decision was made to facilitate a change of direction for the facility.On 11/10/25 at 3:50 PM an interview with Resident #11, the Resident Council President, revealed the council met the last Tuesday of each month. She explained that anyone can request to attend the meetings if they feel they need to. She reported that no staff had attended any Resident Council Meeting and notified the council that the facility had changed Medical Directors or explained any reason why MD #1 or MD #2 or NP #1 may have their privileges at the facility revoked. She stated that she had not been notified personally regarding any changes or options for new medical personnel or procedures to see her attending physician of choice. She stated that if she had a choice, she would keep her current attending physician and not have to make an appointment and go to his office to see him.On 11/10/25 at 7:52 AM a telephone interview with MD #2 revealed he was the attending physician for eighteen (18) residents at the facility. He reported that MD #1 was the attending physician for twenty-three (23) residents. He reported that they had received an email on 10/13/25 from the facility administrator in which privileges for Nurse Practitioner (NP) #1 were revoked without cause or reason given. He stated that he had later received a printed, posted letter dated 10/31/25 that stated that his admitting and attending privileges in the facility were revoked effective 11/30/25 without any cause or reason given. He stated that he had never received any explanation for the reason behind the revocations and that the facility had not made any attempts to list, address or mediate any concerns or issues with him. He stated that residents and their representatives had called him with questions and concerns regarding resident care. On 11/11/25 at 1:08 PM an interview with NP #1 revealed she had taken call for MD #1 and MD #2 for their residents at the facility for over a year and that MD #1 was her collaborating physician. She stated that she had visited the facility frequently and made rounds for MD #1 every other month. She added that she usually visited the facility twice weekly. She stated that she had been notified by MD #1 that her privileges at the facility had been revoked without explanation. She stated that the facility had not made her aware of any concerns or complaints regarding her practice or her care of the residents or her documentation.Resident #2:On 11/11/25 at 9:05 AM a telephone interview with the RR for Resident #2 revealed she reported that the Administrator had notified her that the facility was making some changes and that residents would still have access to their primary physician of choice, but that MD #2 would no longer be able to attend to Resident #2 in the facility. She stated that Resident #2 had been receiving wound care from Medical Director #1 at the local wound care clinic except for two weeks in August 2025 and that she did not believe the resident had any negative results from receiving wound care in the facility by a NP, but that she had not been offered a choice. Resident #2's RP stated that Resident #2, was getting wound care at the hospital wound care clinic. A lady (unable to recall name or title) called me and asked if I would like to do wound care at the hospital with a doctor or just do dressing changes at the facility. We decided to let (Medical Director #2) continue wound care. Then, when I came for a visit a nurse (unable to recall name) told me that the Administrator put a stop to wound care at the hospital. That left the residents without other options. She said that it was true that she had agreed for Resident #2 to receive dressing changes by the contract NP at the facility, but the way it was explained to her she had not understood that meant Resident #2 would not still receive evaluations and treatments by Medical Director #1 at the clinic. She stated that she had not been notified that NP #1 was no longer able to provide care for Resident #1.Record review of the admission Record for Resident #2 revealed the facility admitted the resident on 4/10/25 and the resident had diagnoses of congestive heart failure, chronic peripheral venous insufficiency, pressure ulcer of sacral region stage 4. Resident's daughter was her RR. MD #2 was listed as the resident's primary physician.Record review of the Quarterly Minimum Data Set (MDS) for Resident #2 revealed the resident with Assessment Reference Date (ARD) 7/17/25 revealed the resident was not able to complete Brief interview for Mental Status (BIMS). The facility assessment documented that the resident and family participated in assessment and goal setting.Resident #3:On 11/13/25 at 10:26 AM RR for Resident #3 returned call to SA and stated that he had not been notified in August 2025 of change to resident's wound care. He stated that he considered wound care setting and provider from the local wound care clinic by Medical Director #1 to in facility by a contract nurse practitioner a significant change. He stated that he would not have agreed to the change of setting or provider because the providers were one of the deciding factors that led him to seek a referral to the facility. Record review of the admission Record for Resident #3 revealed the facility admitted the resident on 9/30/25 with Initial admission Date 4/03/24 and the resident had diagnoses of osteomyelitis of vertebra, sacral and sacrococcygeal region with onset date 4/04/24, peripheral vascular disease, diabetes, dementia and stage 3 pressure ulcer of right heel and other site. MD #1 was listed as the resident's primary physician. Record review of the Quarterly MDS for Resident #3 with ARD of 9/25/25 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment. The MDS review revealed the facility assessed Resident #3 required supervision for eating and was dependent for all other activities of daily living, required a wheelchair for mobility and had unhealed pressure ulcers and had two (2) Stage 3 pressure ulcers and one (1) Stage 4 pressure ulcer. The facility assessment documented family participated in assessment and goal setting for the resident.Resident #4:On 11/10/25 at 2:00 PM observation and an interview with Resident #4 revealed he stated that he received wound care at the local wound care clinic by Medical Director #1. He stated that his wound was almost well. He stated that he was very satisfied with the care he received for his wound and with his attending physician, MD #2. He said that he was not aware of any changes with his medical personnel.Record review of the admission Record for Resident #4 revealed the facility admitted the resident on 6/25/25 with initial admission date 4/18/24 and the resident had diagnoses of hemiplegia, hemiparesis, dysphagia and aphagia following cerebral infarction affecting left non-dominant side, chronic ulcer of left foot, diabetes and atherosclerotic heart disease. MD #1 was listed as the resident's primary physician.Record review of the Quarterly MDS with ARD 10/24/25 for Resident #4 revealed the facility assessed the resident had a BIMS score of 14, which indicated no cognitive impairment. The MDS review revealed that the facility assessed Resident #4 required set-up to partial/moderate assistance for activities of daily living, required a wheelchair for mobility, was at risk for developing pressure ulcers and had one diabetic foot ulcer for which he received application of medications and dressing to feet. The facility assessment documented that resident participated in his assessment and goal setting.On 11/11/25 at 9:00 AM SA attempted to contact the RR for Resident #4 via telephone without success.Resident #5:On 11/10/25 at 2:41 PM an interview with Resident #5 revealed she stated that MD #1 was her attending physician of choice and that she was very satisfied with her care. She stated that she considered MD #1 attentive and felt she received adequate medical attention. She stated that no one had notified her of a change of medical director or that she would not be able to be seen by MD #1 in the facility. She stated that she thought it was silly for her to have to make an appointment and wait for the facility van to be available to transport her to the office of the physician she had chosen upon admission by the facility who was familiar with her and her care. She stated, I would much rather have my local doctor who has been taking care of me for years. She stated that no staff had notified her that NP #1 was no longer able to come to the facility to see her. She reported that she was notified of changes to medical personnel by her RR.On 11/10/25 at 5:15 PM an interview with the RR for Resident #5 revealed she had been contacted by the Administrator regarding a change in medical personnel at the facility and Resident #5's care needs. She said she had not signed a change of physician request because she, nor Resident #5, wanted to change attending physicians, and she was afraid that if she didn't the facility may treat Resident #5 differently or try to discharge Resident #5. She confirmed that she felt the Administrator had attempted to manipulate her into signing the change form by listing the benefits of new physicians, but that she didn't understand the benefit for Resident #5 since her attending physician and NP #1 had always provided excellent care. Record review of the admission Record for Resident #5 revealed the facility admitted the resident on 10/30/25 and she had initial admission date 4/01/24. The resident had diagnoses listed as bilateral primary osteoarthritis of knees, metabolic encephalopathy, asthma, chronic kidney disease stage 3, dysphagia following cerebral infarction and atrial fibrillation. MD #2 was listed as the resident's primary physician. Record review of the Quarterly MDS with ARD 10/08/25 for Resident #5 revealed the resident had a BIMS score of 15, which indicated no cognitive impairment. The MDS documented that the resident and her family were active participants in the assessment [NAME] and goal setting.Resident #7:On 11/10/25 at 1:46 PM observation and interview with Resident #7 revealed the resident was alert, oriented to person and place and was operating his mechanical wheelchair in the hallways without assistance. He stated that MD #2 was his doctor and visited him at the facility at least every week. He stated that NP #1 had visited multiple times a week and that he had not been notified that she was not going to be coming back. He said that he was very satisfied with the care provided by MD #2 and by NP #1 and that no one had explained anything to him regarding changing physicians. He adamantly expressed that MD #2 was his physician and he did not want any other physician. He confirmed that he was his own RR and made decisions for himself.Record review of the admission Record for Resident #7 revealed the facility admitted the resident on 4/13/24 with Initial admission Date 9/08/08 and the resident had diagnoses of congenital malformation of nervous and musculoskeletal systems, atherosclerotic heart disease and peripheral vascular disease. MD #1 was listed as the resident's primary physician and the resident was documented as his own Responsible Party (RP).Record review of the Quarterly MDS for Resident #7 with ARD 9/30/25 revealed the resident had a BIMS score of 14, which indicated no cognitive impairment. MDS review revealed the facility assessed the resident participated in the assessment and goal setting.Resident #8:On 11/10/25 at 2:20 PM an interview with Resident #8 revealed that his attending physician was MD #2. He stated that no one had discussed change in his medical care providers with him except MD #2. He stated that he had not been notified of a change of medical directors by any staff at the facility and that he only found out that NP #1 was no longer providing care for him after he asked someone. He said that he hated that because NP #1 visited every week and checked on him and he missed her. He stated that he was worried and upset because no facility staff had notified him of changes and he wanted MD #2 to continue to be his primary and attending physician and that no one had explained the need to change to him or his RR.On 11/12/25 at 2:00 PM an interview with the RR for Resident #8 revealed she described Resident #8 as very upset regarding the changes in his medical team. She stated that no one had contacted her or provided any notification or explanation for the revocation of the resident's attending physician's privileges or offered any alternative options for care. She stated that she had not been notified of the change of medical directors. The RR explained that her first concern was the availability of access to the resident's primary physician. The RR for Resident #8 stated that she had visited the facility on 11/12/25 and attended a care plan meeting for Resident #8 during which there had been no mention of change of medical director or information regarding options for attending physician until she asked staff about the subject at the end of the meeting. She said that when she asked, she was told that all inquiries were being directed to the Administrator and she and Resident #8 had met with the Administrator and AIT. She said that she was afraid of what might happen because when she voiced concerns about the quality of care the AIT had said, Well, he can go somewhere else. The RR stated she considered the comment a threat that the facility may try to discharge Resident #8 and That pissed me off and made me not want to hear anymore from her. The RR confirmed that Resident #8 was cognitively intact and very much involved in decision making regarding his care. She stated, We make decisions together, but we were not offered a choice.Record review of the admission Record for Resident #8 revealed the facility admitted the resident on 10/30/25 with initial admission date 10/19/23, and the resident had diagnoses of diabetes, legal blindness, chronic kidney disease and hypertension. MD #1 was listed as the resident's primary physician and his wife was his RR.Record review of the MDS with ARD 11/06/25 for Resident #8 revealed the resident had a BIMS score of 15, which indicated no cognitive impairment. MDS review revealed the resident and his family participated in assessment and goal setting. On 11/12/25 at 4:15 PM an interview with the Social Services Director (SSD) that she assisted the resident council with monthly meetings and arranged and attended care plan meetings. She stated that the Administrator or anyone that wanted, could request to attend the resident council meeting through her or the Activity Director or the Resident Council President. She reported that no one had requested an audience with the council to discuss change of Medical Director. She stated that the RR for Resident #8 brought up possible physician change during the Quarterly Care Plan Meeting on 11/12/25 and, following the instructions of the Administrator and AIT, the RR was instructed to direct questions related to medical personnel changes to the Administrator and AIT. The SSD stated that Resident #6's RR had also voiced questions about physician choice during care plan meeting on 11/12/25 and the AIT had escorted him to the Administrator's office to discuss those changes. She said that the RR for Resident #6 wanted to know who his mother's doctor was going to be. She confirmed that the health care team involved in the care plan meeting did not present to, or discuss with, any resident or RR the fact that the facility had a new Medical Director and had not notified anyone that there may be a need to make decisions regarding their choice of attending physician to take effect in a matter of days.Resident #9:On 11/11/25 at 10:35 AM during a telephone interview the RR for Resident #9 reported, the Administrator called and explained everything and had made it sound like we could switch doctors, but I expressed doubts about changing physicians, he told me that she could 'find another nursing home'. She said that her main concern was centered around what the Administrator said about how the resident would have to go to MD #2's office to see her current attending physician of choice, MD#2. She stated, I don't like it. I'm very pleased with the way he (MD #2) cared for my mama. He is attentive and visits often. She (Resident #10) really likes him. I don't know how well my mom will handle it; she's elderly and has dementia and doesn't handle change well. Record review of the admission Record for Resident #9 revealed the facility admitted the resident on 9/02/25 with initial admission date of 9/09/24 and the resident had diagnoses of osteoarthritis, diabetes, dementia and hypertension. Record review of the Quarterly MDS for Resident #9 with ARD 9/30/25 revealed Resident #3 had a BIMS score of 9, which indicated moderate cognitive impairment; the MDS review revealed the facility assessment documented that the resident's family were involved in assessment and goal setting. Resident #10:On 11/11/25 at 9:50 AM a telephone interview with the Rr for Resident #10 revealed she stated that Resident #10's physician of choice was MD #2, she stated, We love him and we don't want to change. She said that the Administrator had contacted her by telephone and, he said I would have to come in and sign paperwork to change from Medical Director #2. If we don't change, we don't want to get kicked out. I told him we want (MD #2). The RR said that the Administrator had told her that MD #2 would not be a doctor allowed to see residents in the facility after 12/01/25. She said that after he finished his spill about everything he told me that I needed to come on by and sign because (MD #2) won't be a doctor there anymore after December first. She said that she felt the Administrator had tried to manipulate her into accepting a different physician for the resident and was afraid that if she did not Resident #10 may face retribution or be forced to move to a different facility. She reported that no one had notified her that NP #1 was no longer providing care for Resident #10.On 11/11/25 at 1:55 PM an interview with Resident #10 revealed Resident #10 stated, My doctor is (MD #2). He is a good doctor. I like him. Nobody checked with me about changing doctors.Record review of the admission Record for Resident #10 revealed the facility admitted the resident on 12/20/23 and the resident had diagnoses of dementia, diabetes and heart failure. Record review of the Quarterly MDS with ARD 8/28/25 for Resident #10 revealed the resident had a BIMS score of 07, which indicated severely impaired cognition.Resident #11Record review of the admission Record for Resident #11 revealed the facility admitted the resident on 10/03/25 and the resident had diagnoses of dysphagia following cerebral infarction and anxiety.Record review of the Quarterly MDS with ARD 9/12/25 for Resident #11 revealed she had a BIMS score of 15, which indicated no cognitive impairment and the facility assessment documented that the resident participated in assessment and goal setting.On 11/11/25 at 4:09 PM an interview with LPN #1 and record review of the Physician Change Form dated 10/17/25 confirmed that she had encountered Resident #11 sitting on the front porch of the facility on 10/17/25 and the resident told her that she had not been notified that NP #1 was no longer providing care for residents in the facility and voiced concern regarding her care. Resident #11 and her RR completed and signed a Physician Change Form which documented the physician choice of Resident #1 and her RR. On 11/12/25 at 12:00 PM an interview with the Administrator revealed the stated, We needed to change medical directors, and we hired the best. He uses his own nurse practitioners and uses a team approach. (Medical Director #2) had noticed some issues and said that he didn't want (NP #1) on his team. I told (MD #1) and (MD #2) I hoped we could work something out. In the beginning when we let go of (Medical Director #1) I told (MD #2) that I wasn't planning to make any changes to attending physicians. I talked with (Medical Director #2) and he said he didn't want to work with (NP #1) because he wasn't satisfied with her charting. He called me after reviewing the charts. He said that Medical Director #2 told him that given the hostility and refusal of MD #2 to listen it would be better to move all residents to his care. The Administrator stated, My intent was to send out letters and emails I contacted ninety-five percent (95%) of all the RRs, all that I could get ahold of. They will have a choice of having (Medical Director #2) as their attending. He stated that Medical Director #2 had advised him not to communicate with attendings whose privileges were revoked to discuss concerns or deficient practices. He said that he had attempted to talk with MD #2 after sending letters of revocation of privileges, but that he stopped when MD #2 called him names. He stated, I didn't tell them (residents/RRs) they had a choice of attending because of the way it had played out. The Administrator confirmed that the facility informed residents and/or their RRs of their right to choose their own physician, which physicians had attending privileges at the facility and how to contact their chosen physician during the admission process with the SSD. He stated that residents chose their physician prior to admission. He confirmed that he had met with the AIT, Resident #8 and his RR on the morning of 11/12/25. He confirmed that all staff had been instructed to refer any questions regarding changes in medical director or attending physicians to him or the AIT. On 11/12/25 at 5:15 PM an interview with the Administrator revealed he stated that he had not met with the resident council to provide information regarding change in facility medical director. He confirmed that he had not met with, discussed or sought the input of residents or their responsible parties regarding revocation of privileges of MD #1, MD #2 or NP #1. He stated that he had not considered meeting or contacting MD #2 or MD #1 to review concerns or expectations or differences to determine whether they or NP #1 were able and willing to meet facility, state and federal requirements to continue to practice admitting and attending privileges in the facility using printed or electronic communication.

Based on record review, facility policy review and interviews, the facility failed to ensure the resident's right to be informed of, and participate in, treatment decisions, including the right to be fully informed in advance of the care to be furnished, the type of practitioner providing treatment, and the risks and benefits of proposed care for one (1) of ten (10) sampled residents (Resident #3).Findings Included:A policy review of the facility's policy titled Standard of Care, with a revision date of 9/15/25, revealed the policy stated, It is the policy of this facility to provide a standard of treatment and care most beneficial to residents. Regardless of payment methods, all residents shall have access to. Care that meets their needs, Their attending physician, Clinical and administrative staff. In providing care to all residents our staff will be. effective communicators with one another.A policy review of the facility's policy titled Medical, Dental and L.I.P. Providers: Selection, Appointments and Communications, with a revision date of 11/28/17, revealed the policy stated, The facility shall support each resident's right to fully choose a personal physician, dentist, and other licensed independent practitioner. Residents and/or family members may request information regarding the physicians and other practitioners responsible for his/her care. A.H.M. facilities shall provide the health care provider's name, credentials and phone number to the resident/family.A record review of the admission Record for Resident #3 revealed Resident #3 was admitted on [DATE] with an initial admission date of 4/03/24. Diagnoses included osteomyelitis of vertebra, sacral and sacrococcygeal region (onset 4/04/24), peripheral vascular disease, diabetes, dementia, and Stage 3 pressure ulcers of the right heel and other sites. Medical Director (MD) #1 was the documented primary physician, and the resident's power of attorney (POA) was his nephew.A record review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date 9/25/25 revealed a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The MDS revealed Resident #3 required supervision for eating, was dependent on all other ADLs, used a wheelchair for mobility, and had unhealed pressure ulcers, including two Stage 3 ulcers and one Stage 4 ulcer.A review of the Wound Log dated 8/06/25 revealed Medical Director #1 documented that wound cultures obtained three months earlier grew Proteus, Staph, and Enterococcus, with sensitivities indicating Zyvox and Vancomycin as drugs of choice. He documented that a repeat culture might be considered the following week and that a Percutaneous Intravenous Central Catheter (PICC) line could be needed if indicated.A record review of a progress note dated 8/11/25 revealed, Verbal consent obtained per resident's RP (Family Member/Not Responsible Party) for MDB to see resident, entered as a late entry by the DON on 8/20/25.A record review of progress notes dated 8/11/25 at 17:28, entered by LPN #1, revealed communication with the Resident Representative (RR) regarding a thyroid nodule and consultation for biopsy. The RR stated, I say leave it alone. MD #2, the Director of Nursing (DON), and the administrator in training were notified. The RR was also informed of the residents' swallowing difficulties.On 11/11/25 at 1:00 PM, an interview with the Administrator revealed the facility decided-without input from affected residents or their representatives-to discontinue sending residents, including Resident #3, to the local wound care clinic where they had been treated by Medical Director #1. Instead, the facility transferred wound care to a certified wound care nurse practitioner providing infacility services. He acknowledged no printed letters were issued, no notifications were made to residents or their RPs, and Resident #3's RR was not contacted, despite documentation that the facility had communicated with the RR regarding other care matters on 8/11/25. He confirmed the change occurred despite opposition from both MD #1 and MD #2 and stated there was no reason residents could not continue receiving wound care both in the clinic and in the facility.On 11/12/25 at 10:57 AM, a telephone interview with Resident #3's RR and POA revealed he had not been notified of the change in Medical Director, the revocation of attending physician privileges, or the transition to an infacility wound care. He confirmed he received no verbal, written, or electronic communication regarding changes in providers or treatment locations and had not been informed of any need to make decisions regarding physician participation. He stated he believed Resident #3 had continued attending weekly wound care clinic visits and was unaware that the resident had missed appointments. He reported that Resident #3 could not make medical decisions and that his placement decision was based on his trust in MD #1 and MD #2.On 11/13/25 at 10:04 AM, during a telephone interview, Medical Director #1 stated he was concerned about Resident #3's sacral and forefoot wounds, which required ongoing monitoring for infection. He stated he had planned to evaluate the resident for potential intravenous antibiotic therapy, including possible PICC line placement, and that this plan was documented in the Wound Log provided to the facility. He stated he was unable to evaluate the resident's wounds for three weeks in August while the facility diverted the resident to in house treatment by a wound care nurse practitioner.

Based on observations, interviews, record review, and facility statement review the facility failed to provide follow physician orders when providing peg site care for one (1) of two (2) residents who require peg site care. Resident #34. Findings Include:Record review of a typed statement on facility letterhead, undated, and signed by the Director of Nursing (DON) revealed We do not have a policy on peg care.During an observation on 08/20/2025 at 2:43 PM, revealed LPN #2 cleaned the peg site using a Q-tip with normal saline. She cleaned site back and forward three times in a circular motion without rotating Q-tip, then applied a dressing. She did not dry site prior to applying dressing.In an interview on 08/20/2025 at 4:10 PM, LPN #2 confirmed she did not rotate the Q-tips while cleaning the peg site and did not dry the peg site before applying the cover dressing. She stated she should have cleaned and dried the site as ordered by the physician. She stated Resident #34 could have skin irritation at the site due to not being dried before applying the dressing and get an infection from method she used cleaning the site.On 08/21/2025 2:05 PM, in an interview the Director of Nursing (DON) stated LPN #2 should have used a Q-tip, went around site one time and disposed of the Q-Tip. She should have used a new Q-tip each time. She stated it is done to prevent the spread of infection. The further stated the peg site should be dried to prevent the site from harboring bacteria.A record review of Resident #34's Care Profile revealed a physician order dated 8/20/25 Clean peg site with NS (normal saline), pat dry, apply drain sponge, change daily and monitor for s/sx (signs and symptoms) of infection.A record review of Resident #34 admission Record revealed an admission date of 3/1/24 with diagnoses that included Dysphagia Oropharyngeal Phase and other developmental Disorders of speech and language.A record review of Resident #34's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/5/25 revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #34 is cognitively intact.

Based on observation, interviews, facility policy review and record review the facility failed to respect a resident's dignity, as evidenced by leaving a feeding pump exposed in a public area for one (1) of two (2) residents receiving Percutaneous Endoscopic Gastrostomy feedings. Resident #34.Findings Include:Record review of the facility policy Our Residents' Rights, reviewed 05/18/2021, revealed, .Right to a Dignified Existence: Be treated with consideration, respect, and dignity, recognizing each resident's individuality.On 08/19/2025 at 12:54 PM, during an observation Resident #35 was observed in the hallway by the hair salon door, with a peg tube formula flowing at 50 milliliters/hour (ml/hr). There was not a privacy covering over the feeding pump.On 08/20/2025 at 10:53 AM, Resident #34 was observed sitting on the front porch in her wheelchair with the peg feeding formula exposed and flowing. There was not a privacy cover on the feeding pump.On 08/20/25 at 10:56 AM, during an interview, the transportation aide stated Resident #34's feeding pump is always exposed. She stated the only time she has seen it covered is when the resident goes to a physician appointment.On 08/21/2025 at 1:59 PM, in an interview the Director of Nursing (DON) stated she had spoken to management about covering peg tube feedings and was told that they did not make a cover to keep the peg feeding bag from being exposed. She confirmed it should be covered and it's a dignity issue. She stated they will put something in place to cover it.A record review of Resident #34 admission Record revealed an admission date of 3/1/24 with diagnoses that included Dysphagia Oropharyngeal Phase and other developmental Disorders of speech and language.A record review of Resident #34's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/05/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicates Resident #34 was cognitively intact.

Based on observation, interviews and record review and facility policy review, the facility failed to follow the care plan while providing Percutaneous Endoscopic Gastrostomy (peg) tube care for one (1) of four (4) observations. Resident #34. Findings include: A review of the facility policy, Comprehensive Plan of Care revised 2/17/25, reveals, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality A record review of the Care Plan Report revealed a care plan Focus: The resident has an alteration in gastrointestinal status (PEG STATUS) . with an initiation date of 3/1/24.Interventions/Task.Clean peg site with NS (normal saline), pat dry, apply drain sponge . On 08/20/25 at 1:40 PM, in an interview with Licensed Practical Nurse (LPN) #4, who is responsible for the Minimum Data Set (MDS) and care plans, she stated that the care plan is used by all staff and informs them of the residents' needs. She emphasized that the best course of action is to follow the care plan and warned that residents may suffer serious consequences if it is not followed. On 08/20/2025 at 2:43 PM, during an observation of peg site care with LPN#2 wound care nurse, revealed LPN #2 cleaned the peg site and applied a dressing. She did not dry site prior to applying dressing. On 08/20/2025 at 4:10 PM, in an interview LPN #2, confirmed that she did not dry the peg site. She stated that she should have dried the site to prevent infection. She added that residents can experience skin irritation at the site if it is not dried before applying the dressing. On 08/21/2025 2:05 PM, in an interview with Director of Nursing (DON) stated LPN #2 should have dried the site to prevent the possibility of bacteria. It should be dried to prevent the site from harboring bacteria. She stated she expects staff to follow the care plan at all times. A record review of Resident #34's Care Profile revealed a physician order dated 8/20/25, Clean peg site with NS (normal saline), pat dry, apply drain sponge, change daily and monitor for s/sx (signs and symptoms) of infection. A record review of Resident #34 admission Record revealed an admission date of 3/1/24 with diagnoses that included Dysphagia Oropharyngeal Phase and other developmental Disorders of speech and language. A record review of Resident #34 Minimum Data Set (MDS) with Assessment Reference Date (ARD) 6/15/25 revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicates Resident #34 is cognitively intact.

Based on observation, interviews, and facility policy review the facility failed to ensure expired nutritional supplements were removed from a storage area for one (1) of (1) observation. Findings include:A review of the facility policy, Medication Storage revised [DATE] revealed . is the facility's policy . housed on our premises will be stored appropriately according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security .On [DATE] at 3:30 PM, an observation of the medication storage room, where the nutritional supplements were stored, conducted with Licensed Practical Nurse (LPN) #1 revealed (11) cartons of Med Pass 2.0 Fortified Nutritional Shake, (32) ounces each. Nine (9) cartons expired on [DATE], and two (2) expired on [DATE]. During this time, the State Agency (SA) interviewed LPN #1, who stated that all nurses are responsible for checking the storage room for expired items. She noted that administering expired Med Pass can cause stomach issues and may lead to hospitalization.At 2:06 PM on [DATE], during an interview, the Director of Nursing (DON) stated that night nurses are responsible for checking for expired items stored in the medication room. She explained that expired products could be spoiled and may cause gastrointestinal (GI) issues for residents who consume them.

Based on observations, interviews, and facility policy, the facility failed to ensure that respiratory care was provided in accordance with professional standards of practice for one (1) of (13) residents sampled. Resident #7. Specifically, an Oxygen in Use sign was not posted on Resident #7s door who was receiving oxygen therapy.Findings include:Record review of the facility policy Oxygen. revised 06/14/2023 revealed, .2c. Precautionary signs readable from five (5) feet must be maintained on the door or gate where oxygen is stored.On 08/19/2025 at 11:50 AM, during an observation, Resident #7 was seated in a wheelchair at his bedside receiving oxygen via nasal cannula at a flow rate of two (2) liters per minute. There was no Oxygen in Use signage on the door to alert staff and visitors of active oxygen therapy.On 08/18/2025 at 12:00 PM, during a follow-up observation, Licensed Practical Nurse (LPN) #3 confirmed that there was no Oxygen in Use sign posted. LPN#3 immediately posted the appropriate signage on the door and agreed that a sign should have been placed for safety. The Director of Nursing (DON) was also made aware at this time, of the lack of signage posted and agreed a sign should have been on the door for safety.A record review of the Telephone/Verbal Order Signature Details for order date range 5/18/25 to 6/27/25 revealed a physician's order dated 6/26/25 O2@ (at) 2L (liters) via NC (nasal cannula) as needed r/t (related to) SOB (shortness of breath)/COPD. A record review of the admission Record revealed the resident was admitted on [DATE] with diagnoses that included Other Specified Chronic Obstructive Pulmonary Disease (COPD), Acute and Chronic Respiratory Failure with Hypoxia, and unspecified Asthma, Uncomplicated.

Based on record review, staff, and Resident Representative (RR) interviews and facility policy review, the facility failed to notify the resident's RR of change a in the resident's condition for one (1) of four (4) sampled residents. (Resident #1) Findings include: Review of the facility's policy titled, Notification of Significant Changes, dated 10/17/14, revealed, POLICY: The facility shall immediately inform the resident, consult with the resident's physician, and if known, notify the resident's legal representative or an appropriate family member of the following: .Significant change in resident's physical, mental or psychosocial status . On 5/30/24 at 12:20 PM, during a telephone interview with the RR for Resident #1, he reported that he had not been notified that Resident #1 had a change of condition on 12/03/23. He stated that he was not notified until the resident experienced another change of condition on 12/06/23. Record review of the Progress Notes, for Resident #1 revealed that on 12/03/23 at 2:40 AM, the resident had an elevated temperature and productive cough and tested positive for COVID-19. There was no documentation of notification of the resident's RR. Record review of Progress Notes, for Resident #1 revealed that on 12/06/23 at 1:54 PM, there was a change noted in the resident's condition. The nurse noted a finger stick blood sugar revealed a reading as High. The Nurse Practitioner was notified, and new orders received regarding the resident's insulin orders. There was documentation, at that time, that there was an unsuccessful attempt to notify the RR. At 3:24 PM, the resident was unresponsive to verbal or tactile stimulation and the resident was transferred to a local acute care facility. Once again, there was an unsuccessful attempt to notify the RR. The RR returned the call at 4:05 PM and was notified of the resident's change of condition and transfer. On 5/30/24 at 2:25 PM, an interview with the Director of Nurses (DON) revealed that nurses were supposed to notify residents' RR of a change of condition, which would include a positive COVID-19 test. She stated that nurses were also supposed to document in Nurses Progress Notes that the RR was notified along with the time, date, and RR's response. She stated that if the nurse were unable to reach the RR by telephone, the attempt should be documented and passed along with instructions for the on-coming nurse to notify the RR. The DON stated she had not notified the RR of the change of condition for Resident #1 on 12/03/23, and was not able to find any documentation that an attempt was made. On 5/30/24 at 2:35 PM, during an interview with Charge Nurse #1, she revealed she had not notified the RR for Resident #1 of the resident's change of condition on 12/03/23, or at any time prior to 12/6/23. On 5/30/24 at 3:00 PM, an interview with Licensed Practical Nurse (LPN) #2, revealed she was not on duty on 12/03/23, but was assigned to the care of Resident #1 on 12/04/23 and 12/05/23. She stated the resident was on infection control precautions for COVID-19, but was alert and oriented with a cough. She stated that she had not notified Resident #1's RR of the change of condition. Record review of the Admission Record for Resident #1, revealed the facility admitted the resident on 12/1/22 and discharged the resident on 12/9/23. The resident had diagnoses that included Unspecified Dementia with Anxiety, Type 2 Diabetes. There was a diagnosis of COVID-19 with an onset date of 12/3/23.

Based on record review, interviews and facility policy review, the facility failed to ensure Advance Directives were completed according to the resident preference for two (2) of (2) residents reviewed for Advance Directives. This deficient practice had the potential to affect all residents who do not have an Advance Directive. Resident #7 and Resident #41. Findings Include: Review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives Policy, revised 8/23/22, revealed, Policy: It is the policy of this facility to support and facilitate a resident's right .to formulate an advance directive. Policy Explanation and Compliance Guidelines: 1. On admission, the facility will determine if the resident has executed an advance directive and, if not, determine whether the resident would like to formulate an advance directive. 2. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about . an advance directive. 3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff . Resident # 7 Record review of the Code Status form dated 7/17/23 revealed CODE CLASSIFICATION .CODE A- All resident are considered Code A unless otherwise specified and will receive .FULL RESUSCITATION . Further record review revealed there was no documentation in the medical record that Resident #7 had an advance directive or had received information on formulating an advance directive. Record review of the Admission Record revealed Resident #7 was admitted by the facility on 7/17/23. The resident's diagnosis included Unspecified Cord Compression, Muscle Weakness, Lack of Coordination and Osteoarthritis. Record review of the Minimum Date Set (MDS) with Assessment Reference Date (ARD) of 1/9/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact Resident #41 Record review of the Code Status for dated 6/26/23 revealed CODE CLASSIFICATION .CODE A- All resident are considered Code A unless otherwise specified and will receive .FULL RESUSCITATION . Record review of the Admission Record revealed the facility admitted Resident #41 on 6/28/23 with diagnoses including Major Depressive Disorder. A review of the MDS for Resident #41, with an ARD of 4/7/24, revealed a BIMS score of 13, which indicated the resident was cognitively intact. Further record review revealed there was no documentation in the medical record that Resident #41 had an advance directive or had received information on formulating an advance directive. On 4/22/24 at 11:22 AM, in an interview with the Social Service Director, she confirmed the current Code Status form on all resident files cannot be considered an Advance Directive. She revealed that when starting in the position two weeks ago, it came to her attention that there were no advance directives in the residents' charts or electronic records. She pointed out that since that time she has obtained the correct forms and is in the process of getting the correct forms signed and uploaded to the residents' charts. On 4/23/24 at 8:48 AM, in an interview with the Administrator, he revealed he was made aware yesterday the current form being used, as an advance directive, was not correct. He confirmed that none of the residents in the facility have an Advance Directive in their chart. However, the correct form is currently being uploaded into every resident's chart. He pointed out that by not offering residents an Advance Directive, it could cause nursing staff to elect a treatment during an emergency that the resident may not prefer or desire.

Based on observation, interviews, record review, and facility policy review, the facility failed to monitor and record freezer and refrigerator temperatures daily and discard expired foods for one (1) of four (4) kitchen observations. This has the potential to affect 48 of the 52 residents that reside in the facility. Findings include: Review of facility's policy titled, Food Safety Requirements, dated [DATE], revealed Policy: .Food will also be stored, prepared, disturbed, and served in accordance with professional standards for food service safety . Policy Explanation and Compliance Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handling process . Elements of the process include the following: b. Storage of food in a manner that helps prevent deterioration or contamination of the food including from growth of microorganisms . 3 . c. Refrigerated storage . c . Practices to maintain safe refrigerated storage include: i. Monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals during all hours of operation . iv. Labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so it is used by its use-by-date or frozen (where applicable) discarded; and v. Keeping foods covered or in tight containers . On [DATE] at 11:35 AM, the initial tour of the kitchen with the Dietary [NAME] (DC), revealed seven (7) 32-ounce bottles of a browning and seasoning sauce, with an expiration date of [DATE]. One of these bottles was opened and in the kitchen area. The was also a 32-ounce carton of opened liquid eggs, without a legible opened date. On [DATE] at 11:47 AM, while continuing the kitchen tour with the Dietary Manager (DM), review of the refrigerator/freezer/temperature logs, revealed the logs were pre-filled with temperatures for the entire month of [DATE] for three (3) of the six (6) units that required temperature checks. The logs for the additional three (3) units revealed no record of daily temperature checks. Review of the [DATE] refrigerator/freezer temperature logs revealed only five (5) of the six (6) units were monitored. On [DATE] at 11:58 AM, in an interview the DM, she stated staff know better. She confirmed all expired items are to be pulled on their expiration date. She stated Dietary Aid (DA) #1 is responsible for removing expired items from the storage. She stated staff should check the temperature on all units daily and record, as that lets staff know that the units are functioning properly. On [DATE] at 12:15 PM, in an interview with DA #1, stated she is responsible for checking all the freezer and refrigerator temperature logs. She admitted she pre-filled the refrigerator/freezer temperature logs due to trying to catch up on the logs, because there are times when she does not check them. On [DATE] at 10:50 AM, in an interview with the DM, stated all the unit's refrigerator/freezer temperature logs should be checked daily and revealed that it is her responsibility to check the logs. She confirmed that they did not have documentation of all the units being checked daily. On [DATE] 1:00 PM in an interview with Administrator stated he expects DM and staff to know and understand the regulations and requirements and follow them.

Based on staff interview, record review, and facility policy review, the facility failed to accurately submit direct care staffing information based on payroll data to the Centers for Medicare and Medicaid (CMS) as required for the first quarter of Fiscal Year (FY) 2024 (October - December 2023) for one (1) of four (4) quarters reviewed. Finding include: Record review of facility's policy titled, Nursing Services and Sufficient Staff, revised 10/12/22, revealed, Policy: It is the policy of this facility to provide sufficient staff .The facility's census, acuity, and diagnoses of the resident population will be considered based on the facility assessment. Policy Explanation and Compliance Guidelines . 7. The facility is responsible for submitting timely and accurate staffing data through the CMS Payroll-Based Journal (PBJ) system. Record review of the Payroll Based Journal (PBJ) Staffing Data report from the Certification and Survey Provider Enhanced Reports (CASPER) database revealed the facility failed to have Licensed Nursing Coverage 24 Hours/Day. The dates were identified as 10/29 Sunday (SU), 10/31 Tuesday (TU), 11/26 SU, 11/27 Monday (MO), 11/28 TU and 11/29 Wednesday (WE). The Administrator stated in an interview on 4/21/24 at 12:16 PM, that he was aware that the facility failed to electronically submit PBJ staffing data to CMS accurately. He revealed that the inaccurate submission was related to a glitch in the software that was being utilized by the corporation. The Administrator stated that the Human Resources Coordinator (HRC) was responsible for submitting the PBJ staffing data for the facilities. He stated that he thought the glitch had been corrected but failed to follow up. The Director of Nursing (DON) revealed in an interview on 4/22/24 at 9:15 AM, that she was not aware of the PBJ staffing error that had been submitted to CMS. The DON deferred to the HRC as to why this error occurred. The Licensed Practical Nurse (LPN) #5/Educator revealed in an interview on 4/22/24 2:48 PM, that she was not aware that the facility failed to electronically submit PBJ staffing data to CMS accurately in the first quarter of FY 2024. Upon review of the staffing grids, LPN #5 revealed there was documentation that 10/29 (SU); 10/31 (TU); 11/26 (SU); 11/27 (MO); 11/28 (TU); 11/29 (WE) were appropriately staffed. The Human Resource Coordinator (HRC) revealed in an interview on 4/22/24 at 2:55 PM, that she was not aware that the facility failed to electronically submit PBJ staffing data to CMS accurately in the first quarter of FY 2024, but was aware that there had been an error in last quarter of 2023. The HRC stated that she was responsible for submitting the PBJ staffing data for the facility. She stated that the facility utilized a payroll software that at times did not accurately pull numbers. Upon review of the submitted data, it was noted that the reported information was not accurate, as it failed to account for salaried personnel that had worked, thus creating a shortage. The HRC confirmed that she had not been rechecking numbers, as she thought glitch had been corrected.

Based on observations and staff interviews the facility failed to ensure tiles in the resident shower area were free from black grime and broken tiles were repaired and floors in three (3) common areas were free from cracked tiles and gaps in the floor for one (1) of four (4) days of survey. Findings include: During an observation and interview on 4/24/24 at 9:06 AM, of the resident shower, the floor was noted to have buckling floor tile near the entrance of the shower. Inside the shower, dark black grime was noted in the corners. An interview with Certified Nursing Aide (CNA) #1 revealed she was the shower aide. She explained that the floor tile has been buckling for a while and the tile near the toilet has been broken for a long time. She stated she had made previous maintenance staff aware of the tile, but it had not been repaired yet. She confirmed the black grime in the corners of the resident shower. During an observation on 4/24/24 at 9:51 AM, of the resident shower and facility hallways with the Maintenance Director, he revealed that he was aware of the numerous cracked tiles and gaps in the floor throughout the facility in high traffic areas. He explained that he had been patching, as best he could. He revealed every time he replaced some of the tiles, more tiles became cracked and at this point, it's a no-win situation. The Maintenance Director stated he was not aware that the shower room had tile coming up and buckling. He confirmed that some of the cracks in the tile could be considered trip hazards and could cause injury to residents and employees, as they were large enough to cause an uneven surface. On 4/24/24 at 10:51 AM, during an observation and interview with the Administrator revealed that he was aware of the numerous cracked tiles and gaps in the floor throughout the facility. He explained that the maintenance staff have been patching the broken tile as best they could, however the facility was old and needed updating throughout. The Administrator revealed he was not aware that the shower room had tile coming up and buckling throughout and confirmed that this could be a hazard that could cause injury to residents and staff.

Based on observations, staff interviews, record review and facility policy review the facility failed to ensure a resident was free from a physical restraint offer as evidenced by failure to identify a seatbelt as a restraint for one (1) of 15 sampled residents. Resident #1 Findings include: Record review of facility's policy titled, Restraints, revised 11/28/17, revealed, Policy: . The use of restraint shall be based on comprehensive resident assessment that includes the physical assessment to identify medical conditions that may be causing behavior changes in resident. The assessment will also be performed to determine the safety and protective needs of the resident prior to the application of restraint . Documentation: Documentation in the medical record should include: Restraint order, including the rationale for the restraint, the type of restraint . the duration (timeframe) for the restraint application .Alternatives or less restrictive interventions attempted .The resident's medical conditions or symptoms that warranted the use of restraint, The resident's response to the restraint, including the rational for continued use of the intervention, Assessment and reassessments of the resident, Revision to the treatment plan, Unanticipated changes in residence condition, Condition/behavior required of the resident for release of restraints, The discussion with resident family regarding need for restraints . During an interview on 04/21/24 at 12:53 PM, with Licensed Practical Nurse (LPN) #6, she revealed Resident #1 has always worn the seatbelt. LPN #6 confirmed there was not an order in place for the seatbelt. LPN #6 also revealed that there was no restraint flow sheet in place. In an observation on 04/21/24 at 1:43 PM, Resident #1 was sitting in her wheelchair with a seatbelt intact and no one in the room with her. The resident was unable to demonstrate the ability to open the seatbelt on her own. During an interview on 04/22/24 at 12:53 PM, the Director of Nursing (DON) stated the seat belt on the wheelchair met the definition of a restraint, as defined by facility policy. The DON revealed the facility had recently conducted an audit of restraints and had somehow missed the seatbelt used by Resident #1. The DON stated the facility's interdisciplinary team is responsible for collaborating with other facility staff regarding this issue and a physician's order, consent with reassessment and monitoring tools should be in place for all restraints. During an interview with the Administrator on 04/24/24 at 1:07 PM, confirmed a physician's order, consent with reassessment, as well as a monitoring tool should be in place for all restraints. Record review of the Order Summary Report, with active orders as of 4/23/24, revealed there was no physician order for the use of a seat belt as a restraint. Further review of the medical record revealed there was no documentation of an assessment regarding the use of a seat belt or the use of any type of least restrictive device, nor was there a restraint flowsheet in place for use. Record review of the Admission Record revealed Resident #1 readmitted on [DATE] with diagnoses that included Intracranial Injury with Loss of consciousness, status unknown and Other developmental disorders of speech and language. Record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/16/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 02, which indicated the resident had severe cognitive impairment. Further review of the MDS revealed the resident was dependent on staff for assistance with all her activities of daily living.

Based on interview, record review, and facility policy review, the facility failed to ensure physician orders were implemented and followed as ordered for one (1) of 15 sampled residents. Resident #11 Findings include: Record review of facility's policy titled, Standard of Care, revised 9/15/22, revealed, POLICY: It is the policy of this facility to provide a standard of treatment and care most beneficial to residents and to offer the highest quality services in a caring atmosphere Regardless .all residents shall have access to the following: .Care that is timely. Care that meets their needs . On 4/21/24 at 1:08 PM, in an interview with Resident # 11, he revealed he had been hospitalized because of low potassium. Record review of the Progress Notes dated 10/14/23 revealed the resident was transferred to a local acute care hospital related to critical labs received related to the resident's potassium levels. Record review of a Consultation Report dated 1/3/24 revealed . Renal U/S-(ultrasound) CKD 4 (chronic kidney disease) . Record review of Progress Note dated 1/5/24 revealed related to Situation: Elevated BUN (Blood Urea Nitrogen)and creat (creatinine) remains after fluids . Record review of a Consultation Report dated 2/12/24, from the office of the Nephrologist revealed . Order outpatient renal ultrasound . Record review of the medical records for Resident #11 revealed there was no documentation that a renal ultrasound had been ordered by the facility on 1/3/24 or 2/12/24 for Resident #11 as recommended by the nephrologist. Further review indicated no results for a renal ultrasound were in the medical record. On 4/23/24 at 1:37 PM, in an interview with the Director of Nursing (DON), she stated the Charge Nurse is responsible for taking off physician orders and following up with orders. She stated when the Charge Nurse is not here, the cart nurse is responsible for taking orders off. The DON revealed she was not aware the renal ultrasound had not been done, until it was brought to her attention. She stated it was just missed. She stated the resident sees a Nephrologist in a nearby town, as Resident #11 is in Renal Failure. The DON revealed renal ultrasounds are ordered to check the function of a resident's kidneys. On 4/23/24 at 3:08 PM, in an interview with Licensed Practical Nurse (LPN)#1/Charge Nurse, she revealed she was not aware Resident #11 had an ordered renal ultrasound that was not done. She stated she is responsible for taking orders off and putting them on the calendar. LPN #1 revealed that she is the one that took the order off, but she must have not followed it through to make sure that it was done. On 4/24/24 at 11:20 AM, in an interview with the Nephrology Medical Assistant stated all test results are reviewed at the time they are received. She revealed Resident #11 was seen by the Nephrologist on 1/3/24 and 2/12/24, and both times, a renal ultrasound was ordered, but had not been done. She stated it's important that all orders are followed in a timely manner, so that the physician can review the results of the test and make medication changes, as needed. On 4/24/24 at 12:34 PM, in an interview with DON, she stated the renal ultrasound from the 1/3/24 Nephrologist visit was scheduled, however, the resident got sick was hospitalized for an extended period of time and the renal ultrasound was not rescheduled when resident returned to facility. On 04/24/24 at 12:56 PM, in an interview with the Administrator, he stated he expects the Charge Nurse to have a system in place to monitor and review orders to make sure they are followed. Record review of the Admission Record revealed the facility originally admitted Resident #11 on 5/23/13 with current diagnoses that included Type 2 Diabetes Mellitus and Chronic Kidney Disease, Stage 4 (SEVERE). Record review of the Minimum Data Set (MDS) for Resident #11, with an Assessment Reference Date (ARD) of 11/5/24, revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact.

Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure that a resident's CPAP (Continuous positive airway pressure) mask was properly stored, when not in use, for one (1) of (1) residents reviewed that required respiratory care. Resident #11. Findings include: Review of facility's policy titled, Oxygen, Nebulizer, CPAP/BIPAP (Bilevel positive airway pressure), with a revision date of 6/14/23, revealed, It is the policy of this facility to clean, disinfect, label and store supplies, nebulizer supplies, CPAP and BIPAP supplies appropriately . 3.vi. While not in use, store oxygen tubing, mask/cannula, nebulizer mask and tubing, and CPAP/BIPAP mask and tubing in a labeled (date) storage bag . On 04/21/24 at 1:08 PM, during an interview and observation with Resident #11, a CPAP mask was lying on table by the resident's bed. It was not in a labeled storage bag. Resident #11 stated it is never put in a bag. On 04/21/24 at 1:30 PM, in an interview with Licensed Practical Nurse (LPN) #1/Charge Nurse confirmed Resident #11's CPAP mask should be in a bag to keep it clean, as the bag will prevent germs from getting in it. On 04/24/24 10:26 AM, in an interview with LPN #3/IP (Infection Preventionist) stated when not in use, Resident #11's CPAP mask should be in a bag to prevent bacteria from getting on the mask and causing infection. She IP confirmed the staff should make sure this is done. On 4/24/24 at 12:56 PM, in an interview the Administrator stated he certainly expected staff to have knowledge of CPAP care and staff to monitor usage and follow protocol for safe storage when not in use. Record review of the Order Summary Report, with active orders as of 4/24/24 revealed an order dated 3/7/24 Wear CPAP @ (at) night . related to Sleep Apnea, Unspecified. Record review of the Admission Record for Resident #11 revealed the facility admitted the resident on 5/23/13 .Current diagnoses included sleep apnea. Review of the Minimum Data Set (MDS), for Resident #11, with an Assessment Reference Date (ARD) of 4/4/24, revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident is cognitively intact.

Based on observation, interviews, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan to reflect the use of restraints for one (1) of 15 sampled residents. Resident #1 Findings include: Record review of facility policy titled, Comprehensive Plan of Care, revised 10/10/22, revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . In an observation on 04/21/24 at 1:43 PM, Resident #1 was sitting in her wheelchair with a seatbelt intact. The resident was sitting alone in her room. The resident was unable to demonstrate the ability to open the seatbelt on her own. Record review of the care plan revealed Focus: Safety: Resident may have lap belt positioner . Goal . Resident will remain safe .Interventions .Monitor q (every) 2 (hours) while out of bed for proper application and correct if necessary. Perform safety risk evaluation .as needed . Further review of the care plan revealed there was not a restraint re-assessment since admission in February 2015 nor a physician's order for the use of a restraint or monitoring of the seatbelt restraint. During an interview on 4/22/24 at 12:53 PM, with the Director of Nursing (DON), she confirmed upon review of the care plan for Resident #1, there was a need for goals and interventions related to the use of a seat belt. The DON revealed the resident was a longtime resident, and this was somehow missing. The DON stated the facility interdisciplinary team is responsible for collaborating with other facility staff regarding this issue and a physician's order, consent with reassessment and monitoring tools that should be in place for all residents who use restraints. An interview was conducted with the Administrator on 4/24/24 at 1:07 PM, at which time the Administrator confirmed the care plans for Resident #1 did not reflect that the facility interdisciplinary team collaborated with other facility staff regarding the appropriateness of the use of a seatbelt for Resident #1, with a physician's order, consent with reassessment, along with a monitoring in place for the use of the restraint. Record review of the Admission Record revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included Intracranial Injury with Loss of Consciousness, status unknown and Other developmental disorders of speech and language.

Based on interviews, record reviews, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) for one (1) of 16 MDS assessments reviewed for accuracy. Resident #28 Findings Include: A record review of the facility's Comprehensive Assessment and Re-Assessment policy with revision date 11/28/2017 revealed, . The facility shall comply with Resident Assessment Instrument (R.A.I.) guidelines for comprehensive assessments and re-assessments .The sources of information for the M.D.S. include: Review of the resident's record . Review of Resident #28's Face Sheet revealed the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #28's Quarterly MDS with an Assessment Reference Date (ARD) of 07/14/2022 revealed, . Section C- Cognitive Patterns C0500 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Section N-Medications N0410E: Medication received: Days: anticoagulant was listed as seven (7). A record review of Resident #28's Physician's Telephone Orders dated 6/7/2022 at 2:50 PM, revealed Discontinue (D/C) [MEDICATION(S)] per (Proper Name . A record review of Resident #28's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #28's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/30/2022 at 2:20 PM, an interview with Licensed Practical Nurse (LPN) #2/MDS nurse, confirmed Resident #28's Quarterly MDS revealed the resident had received 7 doses of anticoagulant medication during the look-back period. The MDS nurse stated the resident's MDS had been coded in error, as the [MEDICATION(S)] had been discontinued on 6/7/2022. On 08/31/22 at 11:40 AM, during an interview with the Director of Nursing (DON), she explained she expects the MDS nurse to review medical records and accurately code the MDS. The DON stated prior to transmission of the MDS, Registered Nurse (RN) #1 reviews and signs the MDS assessments and meets with herself and the MDS nurse to review the MDS for accuracy prior to transmission. The DON confirmed the inaccurate anticoagulant coding was overlooked. On 08/31/22 at 11:52 AM, during an interview with RN #1, she explained she reviews and signs all MDS assessments prior to transmission. The nurse stated she meets with the DON and MDS nurse for a final review of the MDS prior to the transmission, but confirmed that Resident #28's last Quarterly MDS was transmitted with the incorrect coding for anticoagulants.

Based on observation, staff interviews, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety related to food items not dated with a use-by date, and food items not discarded after the expiration date, for one (1) of three (3) kitchen observations. Findings Include: A review of the facility's Food Service Operational Standards for Purchasing, Receiving, Cooking and Storage of Food policy with a revised date of ,d+[DATE] revealed, The facility receives, stores, prepares, distributes and serves food under sanitary conditions to prevent the spread of food borne illness and to reduce those practices that result in food contamination and compromised food safety Follow First In First Out .foods should be labeled before being stored in the refrigerator or freezer .The date mark indicates the date of preparation or the discard date .Commercially processed foods will have a use by date. This use by date should be followed . On [DATE] at 11:35 AM, the State Agency (SA) conducted an initial tour of the kitchen with the Cook and observed the following: 1. In the Dry Storage room, there was an opened (6) pound (lb.) bag of Brownie Mix, a six (6) lb. bag of Blueberry Muffin Mix, a five (5) lb. bag of Basic American Foods Mashed Potatoes, a 16-ounce (oz) container of Imitations Bacon Bits, a five (5) lb. bag of Originals Villa Frizzoni Noodles, and a five (5) lb. container of Peanut Kid: Creamy Peanut Butter with no opened or use by dates. 2. In the freezer, there was an open ten (10) lb. bag of Tater Tots, a ten (10) lb. bag of French Fries, and a 2 lb. bag of shredded lettuce with no opened or use by dates. 3. In the Dry Storage room, there were two (2) five (5) oz. cans of Salsa De Arah Gelatizados with the expiration date of [DATE] and a 70 oz. container of Tostitos Salsa with the expiration date of [DATE]. On [DATE] at 11:52 AM, during an interview with the Dietary Manager (DM), she stated that she and the Assistant DM are responsible for discarding expired foods. On [DATE] at 10:00 AM, during an interview with the DM, she stated that expired food items could cause harm to the residents. She confirmed that food items should be checked daily for expired items and labeling. On [DATE] at 02:18 PM, during an interview, the Administrator stated that the residents are at risk for a possible illness if they consume expired food products. He stated that it is very important to check the dates on food and that he does not expect to find expired items in the kitchen. Record review of an Associate In-Service Record, dated [DATE], revealed Points Covered/Overview .receiving and storage of food . revealed dietary staff received training on storage of food items.

Based on staff interview, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) assessment, related to hospice for Resident #50, anti-coagulant medications for Resident #25, and oxygen therapy for Resident #30; for three (3) of 20 residents MDS assessments reviewed. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) Version 3.0 Manual, revised (MONTH) 2019, revealed the RAI process is the basis for the accurate assessment of each resident. Resident #50 Review of Resident #50's Significant Change Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/15/19, revealed, Special Treatments and Programs, documented, none of the above, and Hospice was left blank. Review of Resident #50's physician's orders [REDACTED]. During an interview, on 12/05/19 at 12:55 PM, Registered Nurse (RN) #1/MDS Coordinator, confirmed Resident #50's MDS, with an ARD of 11/15/19, was not accurately coded for hospice, and it would affect the Care Area Assessments (CAAs), which trigger care plans. RN #1 stated the Resident Assessment Instrument (RAI) manual is followed to complete the MDS correctly. Resident #30 Review of Resident #30's most recent Quarterly MDS assessment, with an ARD of 10/21/19, revealed the assessment did not document oxygen therapy. Observations of Resident #30 on 12/03/19 at 10:13 AM, 11:55 AM, 2:50 PM, and 3:39 PM; and on 12/04/19 at 8:51 AM, revealed Resident #30 was lying in bed with oxygen via nasal cannula (NC). A review of Resident # 30's (MONTH) 2019 physician's orders [REDACTED]. An interview, on 12/05/19 at 9:40 AM, with the MDS/Care Plan Nurse/Licensed Practical Nurse (LPN) #1, confirmed Resident #30 had been on oxygen at the time of the most recent quarterly MDS assessment, dated 10/21/19. LPN #1 confirmed Resident #30's assessment was not marked to indicate the resident received oxygen, while a resident of the facility. LPN #1 stated it was overlooked when the assessment was completed. Resident #25 Review of Resident #25's Quarterly MDS assessment, with an ARD of 10/15/19, revealed the resident received an Anti-coagulant medication for four (4) days. Review of physician orders, dated 12/14/16, revealed Resident #25 had an for [MEDICATION NAME] 75 milligrams (mg), by mouth for circulation. There was no order for an anti-coagulant medication for Resident #25. During an interview, on 12/05/19 at 12:42 PM, LPN #1/Care Plan Nurse, and the Director of Nursing (DON), stated Resident #25's MDS assessment was marked to indicate the resident was taking an anticoagulant, but the MDS assessment was incorrectly marked, because [MEDICATION NAME] is an anti-platelet, not an anti-coagulant.

Based on staff interview, record review, and facility policy review, the facility failed to refer a resident for a Level II screening, when she was identified with a newly evident serious mental disorder, for one (1) of five (5) resident Pre-admission Screening and Resident Review (PASARR)s reviewed, Resident #31. Findings include: Review of the facility's Admission to Facility + Admission Checklist, revised 11/28/17, revealed a Pre-Admission Screening (PAS) must be completed prior to admission. The policy did not address if a resident was later assessed or identified with newly evident or possible serious mental diagnosis, or a related condition, to refer the resident for a Level II screening. Review of Resident #31's Pre-Admission Screening, dated 08/21/18, documented the resident had no major mental illness, but was taking [MEDICAL CONDITION] medications. Review of a letter from the state-designated screening authority, dated 08/27/18, indicated Resident #31 had a Negative Level I screening, and was appropriate for nursing home placement. No Level ll screening was required at the time of admission to the facility. A review of Resident # 31's History and Physical, dated 08/21/19, from admission for a Geri-psyche stay, revealed the resident was involved in disagreements with other residents and made threatening remarks. A review of physician's orders [REDACTED]. There was no indication in the medical record that the resident had been referred for a level ll screening, with this new [DIAGNOSES REDACTED]. An interview on 12/04/19 at 11:35 PM, with Licensed Practical Nurse (LPN) #2, revealed Resident #31 was hospitalized at a Geri-psyche unit a few months ago, because she became threatening to staff and others. An interview on 12/04/19 at 11:50 AM, with the Director of Nursing (DON), revealed she did not think Resident #31 had been referred for a level ll screening, after being diagnosed with [REDACTED]. The DON confirmed the resident went out for a Geri-psyche hospitalization , related to her becoming threatening to staff and other residents. An interview on 12/05/19 at 8:50 AM, with LPN #3, revealed she completed the PAS form when residents were admitted . LPN #3 confirmed Resident # 31 had a negative level l screening, so the resident did not get referred for a level ll screening on admission. LPN #3 stated she was unaware she should refer a resident for a level II PASARR evaluation, if a resident was identified with a newly evident or possible serious mental diagnosis. LPN #3 confirmed Resident #31 was threatening staff and other residents and was admitted to Geri-psyche. LPN #3 confirmed Resident #31 returned with a [DIAGNOSES REDACTED].