Every finding on record at Mineral Springs

Based on observation, interview and record review, the facility failed to ensure that food was stored and dishwares were sanitized in accordance with professional standards for food service safety for 1 of 1 kitchen and 1 of 2 kitchenettes observed. Findings include: Observation on 7/28/26 at 9:35 a.m. with Staff A (Dietary Manager) of the facility's dishwashing machine (Model XL-HT) in the kitchen revealed the breakfast dishes were being cleaned and the final rinse temperature of 160 F (degrees Fahrenheit). Further observation of the next run of the machine a few minutes later revealed a final rinse temperature of 175 F. Interview on 7/28/26 at 9:35 a.m. with Staff A confirmed the above and revealed that the machine was a high-temperature unit and the final rinse temperature should be above 180 F. Observation on 7/28/26 at 9:50 a.m. with Staff A of the facility's dish washing machine revealed a final rinse temperature of 176 F. Review on 7/28/26 of the Dish Machine Temperature Logs for revealed the following dates that the final rinse temperature was below 180 F with no documented corrective action: Breakfast on 6/10/26, 6/13/26, 6/14/26, 6/18/26, 6/20/26, 6/26/26, 6/27/26, 6/28/26, 6/30/26, 7/4/26, 7/5/26, 7/6/26 and 7/7/26 at 170 F;Lunch on 6/8/26, 6/20/26 (173 F), 6/27/26, 6/28/26, 7/4/26, 7/5/26 and 7/6/26 at 170 FDinner on 6/9/26, 6/16/26, 7/6/26 and 7/10/26 at 170 F.Further review of these logs revealed, Please log WASH and RINSE temperature prior to washing dishes. For temperatures not meeting manufacturer recommendations, please contact your supervisor immediately, and that the required temperature for the rinse was 180 F. Review on 7/29/26 of the facility's policy titled Warewashing revised 12/2024 revealed, . All dishware, serviceware, and utensils will be cleaned and sanitized after each use . Procedures . 2. All dish machine water temperatures will be maintained in accordance with manufacturer recommendations for high temperature . machines . Review on 7/29/26 of the manufacturer's Installation and Operation Manual for the XL-HT dishwasher machine, provided by the facility, revealed, .1.0 Specification Information XL-HT Models . Rinse Temperature (Minimum)( F) 180-195. Rinse Temperature (Recommended)( F) 185 . Observation on 7/28/26 at 10:05 a.m. of the [NAME] Unit's kitchenette revealed the following in the refrigerator:Undated containers of watermelon, eggs, egg salad and pasta with red sauce;A grocery store snack container of fresh fruit with a sell by date of 7/12/26 that was watery looking;A container of chicken and corn with blue/green fuzz on the corn dated 6/19/26. Interview on 7/29/26 at 10:05 p.m. with Staff A confirmed the above observations. Review on 7/29/26 of the facility's policy titled Guidelines for Food Brought in for Individual Residents revised 4/23/26 revealed, .All resident food and drink must be . labeled with resident name and date food was brought in. Food will be discarded . 3 days after date on the label, unless otherwise stated . Review on 7/29/26 of the facility's policy titled Nourishment Rooms dated 8/2025 revealed, . 8. Food items stored in the nourishment refrigerators shall be labeled and dated. 9. Unopened, commercially packaged food with expiration dates shall be discarded by the use by date. 10. Opened food containers shall be dated by nursing staff with an open date and a use by date. Opened food containers shall be discarded by the use by date.

Based on interview and record review it was determined that the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 1 resident reviewed for behavioral-emotional well being in a final sample of 18 residents. (Resident identifier is #42). Findings include: Review on 7/29/26 of Resident #42's nursing note, dated 6/25/26, written by Staff G (Registered Nurse), revealed Resident #42 has expressed that [pronoun omitted] wishes to seek counseling services. states [sic] that (pronoun omitted) is feeling more down. is [sic] angry about the loss of independence that (pronoun omitted) is feeling. has [sic] been refusing hygiene care and refusing to change [pronoun omitted] clothes. note [sic] and voicemail left with social worker. Interview on 7/29/26 at approximately 1:30 p.m. with Staff F (Director of Social Services) confirmed that on 6/25/26 Staff F received a voicemail requesting counseling services. Staff F did not arrange for counseling services. Review on 7/29/26 of provider orders revealed Staff C (Nurse Practitioner) ordered a referral to counseling services on 7/20/26. Interview on 7/30/26 at approximately 12:15 p.m. with Staff C confirmed that he/she ordered a referral to counseling services on 7/20/26. Interview on 7/29/26 with Staff D (Administrator) revealed that behavioral services were seeing residents at the facility on 7/7/26 and confirmed that Resident #42 had not been seen.

Based on record review and interview, the facility failed to refer residents with an evident or possible serious mental disorder for a Level II Pre-admission Screening and Resident Review (PASARR) for 1 of 1 resident reviewed for PASARR in a final sample of 18 residents (Resident identifier is #1).Findings include:Review on 7/29/26 of Resident #1's medical record revealed that Resident #1 was admitted to the facility in November 2025.Review on 7/29/26 of Resident #1's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/28/25, revealed in Section I, Active Diagnosis, under Psychiatric/Mood Disorder), Anxiety, Depression, and Post Traumatic Stress Disorder were check yes.Review on 7/29/26 of Resident #1's pre-admission Level 1 PASARR form (completed on 11/28/25 and signed by a medical professional) revealed, revealed that in Section II titled PASARR Level I Screening for Mental Illness (MI), NO was answered to indicate that Resident #1 did not have a diagnosis of mental illness. Therefore, at that time, the facility failed to refer the resident to the appropriate state-designated authority for evaluation and determination.Review on 7/29/26 of Resident #1's significant change Level I PASARR form (completed on 4/15/26 and signed by a medical professional) revealed:Section 2A: Suspected Diagnosis: Major depression, and other, specify: dissociative identity disorder, Current Psychiatric Medication: Duloxetine (antidepressant), Trazodone (antidepressant), and Seroquel (antipsychotic), and Associated with a mental health agency, Medication management, Individual/group therapy, and other treatment, specify: case management were checked yes.Section 2B: Interpersonal Function: Easily upset/anxious, Excessive irritability, Fearful of strangers and Social isolation was checked yes.Section 2C: Concentration/Task Limitations: Requires assistance with tasks in which the individual should be physically capable of performing and Serious difficulty concentrating was checked yes.Section 2D: Adaptation to Changes: Agitation due to adaption to changes was checked yes.Section 8: Level 1 Screening Summary: Length of stay requesting for Level II - Long-term care was checked.Interview on 7/29/26 at 1:30 p.m. with Staff D (Administrator) confirmed the above findings and that Resident #1 never had a Level II PASARR as required from their PASARR Level I screening.

Based on interview and record review, the facility failed to ensure to ensure that every resident receives specialized rehabilitative services as determined by their comprehensive plan of care to assist them to attain, maintain or restore their highest practicable level of physical for 1 of 1 residents reviewed for rehab (rehabilitation) services in a final sample of 18 residents. (Resident identifier is #4.) Findings include:Review on 7/28/26 of Resident #4's Care Plans revealed: [name omitted] requires assistance for ADL (Activities of Daily Living) care ,.eating, ., Created on 9/16/25. Interventions: . Monitor for decline in ADL function, Refer to rehabilitation therapy if decline in ADL's noted. [name omitted] is at nutritional risk due to variable intake, dysphagia, ., Created on 9/24/25. Goal .[name omitted] will exhibit no overt dysphagia with texture modification, compensatory measures during the next 90 days, Target Date 9/30/26. Review on 7/28/26 of Resident #4's medical record revealed the following progress notes: 6/12/26 11:20 a.m. that resident had difficulty swallowing [pronoun omitted] medication this morning. 6/12/26 5:57 p.m. This resident has difficulty swallowing as evidenced by loss of fluids and solids from [pronoun omitted] mouth while attempting to drink water and eat mashed potatoes and pureed vegetables while being fed. 6/22/26 11:41 a.m. Resident is having difficulty swallowing per aide regarding breakfast at which time pocketing of food was noted. Review on 7/28/26 of Resident #4's current diet order dated 4/23/26 revealed: Regular/Liberalized, Dysphagia Advanced, additional directions: puree fruits/vegs (vegetables), finger foods. Interview on 7/30/26 at approximately 11:15 a.m. with Staff B (Speech Therapist) revealed he/she had not been notified of Resident #4 having difficulty swallowing or pocketing food. Further interview revealed that he/she would expect nursing staff to notify Staff B, and Staff B would then evaluated Resident #4. Staff B also confirmed that last time Resident #4 was receiving Speech Therapy was 4/15/26. Review on 7/30/26 of Resident #4's Speech Therapy Discharge summary, dated [DATE], revealed: . Swallowing Abilities WFL (within functional limits) .Interview on 7/30/26 at approximately 12:00 p.m. with Staff C (Doctor of Nursing Practice) revealed that he/she had not been notified of Resident #4's increase with difficulty swallowing or pocketing food.

Based on observation, interview, and record review, the facility failed to follow the care plan to provide activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 of 1 residents reviewed for dementia care in a final sample of 18 residents. (Resident Identifier is #7).Findings include:Review on 7/30/26 of Resident #7's Care Plan revealed the following: Focus: Resident #7 expresses interest in learning about the following leisure activities, decorations and crafts, created on 11/1/24 and revised on 1/15/26.Goal: Resident #7 will initiate participation in leisure events of a crafts once a week, created on 1/15/26 and revised on 7/24/26.Interventions: Introduce calendar of events, highlighting opportunities to spectate/participate in crafting and social events, created on 1/15/26.Focus: Resident #7 exhibits or is at risk for limited and/or meaningful engagement related to: crafting and social events, created on 1/15/26.Goal: Establish Resident #7's desire to increase social participation and relationships, created 1/15/26 and revised on 7/24/26.Interventions: Provide one-to-one visits 2xs per week, individualized to Resident #7's interest and needs, created on 1/15/26.Review on 7/30/26 of Resident #7's comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/24/26 under section F0500 - Interview for Activity Preferences revealed that while Resident #7 was in the facility, that very important was coded for do your favorite activities and do things with groups of activities.Observation and interview on 7/30/26 at 11:24 a.m. with Resident #7 revealed that Resident #7 was in bed watching television. Resident #7 stated that while in her room, he/she likes to watch television. He/she really likes arts and crafts. He/she would like to be asked and if he/she was up to it, he/she would go. Interview further revealed that the facility was not providing one-to-one visits two times a week with Resident #7.Review on 7/30/26 of June and July 2026 Activity Calendars revealed that there were weekly arts and crafts scheduled for June and independent crafts and room visits scheduled two times a week for July.Review on 7/30/26 of Resident #7's activities participation documentation for June 2026 and July 2026 revealed that there was no documentation that Resident #7 attended any activities in June or July and no documentation that Resident #7 refused.Interview on 7/30/26 at approximately 11:30 a.m. with Staff E (Director of Activities) confirmed the above findings.Review on 7/30/26 of the facility policy, Activities, revised 1/10/26, revealed, .2. Activities will be designed with the intent to: a. Enhance the resident's sense of well-being, belonging, and usefulness. B. Create opportunities for each resident to have a meaningful life. c. Promote or enhance physical activity. d. Promote or enhance cognition. E. Promote or enhance emotional health. f. Promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence. g. Reflect resident's interests and age. h. Reflect cultural and religious interests of the residents. i. Reflect choices of residents. 4. Activities may be conducted in different ways: a. One-to-one Programs. B. Person Appropriate - activities relevant to the specific needs, interests, culture, background, etc. for the resident they are developed for. c. Program of Activities - to include a combination of large and small groups, one-to-one, and self-directed as the resident desires to attend . 9. Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs.

Based on interview and record review, the facility failed to follow established smoking policies for 1 of 1 residents reviewed for smoking in a final sample of 18 residents (Resident identifier is #92.) Findings include: Review on 7/30/26 of the facility policy titled, Resident Smoking-Smoke Free Facility, Revision Date 7/10/24, revealed: . Therefore, it is the policy of this facility to promote smoking cessation efforts while ensuring resident safety as related to residents who smoke. 8. Residents with a history of smoking will be further assessed to determine whether or not interventions are needed to help them cope with the Smoke Free policy. Examples include pharmacological and/or behavioral interventions to curb urges to smoke.17. The interdisciplinary team, with guidance from the physician, will help to support the resident's right to make an informed decision, regarding smoking by: . c. Providing educational materials regarding smoking and smoking cessation. d. Developing a safe smoking plan, or an individualized plan to quit smoking.Review on 7/28/26 of Resident #92's Progress Notes revealed a progress note dated, 7/17/26, 7:30 p.m., . [Name Omitted] took resident outside for a walk, during which the resident smoked a cigarette. Review on 7/29/26 of Resident #92's, Smoking and Safety Assessment, Dated 7/17/26 revealed, . Which of the following products does the resident use? Tobacco was checked, Evaluation, . Lethargic/falls asleep easily during tasks was checked, Burned skin, clothing, furniture or other was checked, Drops ashes on self was checked, Concerns, Unable to hold tobacco or other smoking products safely was checked, Unable to extinguish tobacco or other smoking products safely was checked, Unable to use ashtray to extinguish tobacco or other smoking products was checked. Smoking Safety Notes: per home caregiver resident has burn holes in all of [pronoun omitted] furniture and clothes at home. Resident found numerous times fallen asleep while smoking with cigarettes burned onto [pronoun omitted] clothing and smoldering papers on a table. Resident was smoking two packs per day at home.Review in 7/29/26 of the facility provided list of Smoking, updated on 7/28/26 revealed Resident #92's name was not on the list of residents that smoke at the facility. Interview on 7/29/26 at approximately 1:00 p.m. with Staff D (Administrator) revealed the facility did not consider Resident #92 a smoker. Further interview revealed smoking cessation had not been offered to Resident #92.Review on 7/30/26 of Resident #92's care plans revealed Resident #92 did not have a care plan for smoking or an individualized plan to quit smoking. Interview on 7/30/26 at approximately 10:20 a.m. with Staff J (Licensed Practical Nurse) confirmed the above findings.

Based on interview, record review, and observation, the facility failed to follow physician's orders for 1 of 1 residents reviewed for antibiotic use in a final sample of 18 residents. (Resident identifier is #80.)Findings include:[NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication .Resident #80 Observation on 7/28/26 at approximately 10:30 a.m. of Resident #80 in bed revealed he/she had an IV (intravenous) pump was infusing Vancomyocin at 150 ml (milliters) per hour. Review on 7/29/26 of Resident #80's physician's orders revealed the following order: Vancomyocin HCL (Hyrdrochloride) in Dextrose Intravenous Solution 1.25-5 gm (gram)/250 ml (milliliter), Dated 7/27/26, Directions: Nurse to attach vial and bag to vial mate prior to infusion, Activate then infuse 250 ml (1gm) intravenously every 12 hours at a rate 167 ml/hour over 90 minutes.Interview on 7/29/26 at approximately 12:30 p.m. with Staff I (Registered Nurse) confirmed he/she was the nurse on 7/28/26 that hung and set up Resident #80's IV pump infusion rate at 150 ml per hour. Further interview confirmed that it was not ordered rate.

Based on observation, interview, and record review, it was determined that the facility failed to follow the health care provider's order for a therapeutic diet for a swallowing issue for 1 of 2 residents reviewed for nutrition in a final sample of 14 residents (Resident identifier is #43). Findings include:Review on 8/5/25 of Resident #43's physician's order revealed a dietary order dated 4/10/25 for Regular/Liberalized dysphagia (difficulty swallowing) advanced texture, pureed fruit and vegetables. Review on 8/5/25 of Resident #43's Care Plan revealed that Resident #43 was at nutritional risk for dysphagia with a goal of exhibiting no overt dysphagia with texture modification with a target date of 9/11/25. Further review revealed there was an intervention to provide a dysphagia diet as ordered. Observation on 8/5/25 at 12:15 p.m. of Resident #43 revealed that he/she was in their bed with their lunch tray set up in front of them with Resident #43's meal ticket which read Pureed Fruits and Vegetables. Further observation revealed there was a bowl of sliced whole pears on the tray. Interview on 8/5/25 at 12:23 p.m. with Staff A (Licensed Nursing Assistant) confirmed that the pears were served to Resident #43 whole. Interview on 8/5/25 at 12:25 p.m. with Staff B (Dietician) and Staff C (Dietary Manager) confirmed that Resident #43's fruits and vegetables should have been pureed. Observation on 8/6/25 at 8:13 a.m. of Resident #43 in the dining room eating breakfast revealed a bowl of watermelon, that had been cut into pieces. Interview on 8/6/25 at 8:20 a.m. with Staff D (Medication Nursing Assistant) confirmed that the watermelon was not pureed. Review on 8/6/25 of Resident #43's Speech Therapy Discharge Summary signed by Staff F (Speech Language Pathologist) on 7/3/25 revealed that Resident #43 had been on services for dysphagia therapy from 6/3/25 through 7/3/25. Further review revealed that the discharge recommendations were for pureed fruits and vegetables. Interview on 8/6/25 at 12:00 p.m. with Staff F confirmed that Resident #43's had recently been treated for swallowing issues and that the Resident's fruit and vegetables should have been pureed. Review on 8/6/25 of the facility's Diet and Nutrition Care Manual, page 2-20 revealed . Dysphagia Puree (Level 1) Diet . All foods are pureed to simulate a soft food bolus, eliminating the whole chewing phase . Food . Fruits (include a variety; with more fruit than juice as appropriate) Pureed consistency . Review on 8/6/25 of the facility's policy titled Therapeutic Diet Orders, implemented 9/1/24, revealed . The facility provides all residents with foods in the appropriate form . as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care . 5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form . as prescribed .

Based on interview, record review, and policy review, it was determined that the facility failed to ensure that medical records were accurately documented for 1 out of 1 resident reviewed for Post Traumatic Stress Disorder. (Resident Identifier is #202.) Findings include: Review on 2/20/25 of Resident #202's medical record revealed a diagnosis list, dated 2/13/25, that showed Resident #202 had a diagnosis of Post Traumatic Stress Disorder. Further review of Resident #202's medical record revealed a Social Services Assessment and Documentation, signed on 2/17/25 by Staff F (Social Worker). Section C of the assessment titled Mental Health and Wellness .4. Trauma History: Does the patient/resident report or does the medical record reflect any history of trauma and/or Post-Traumatic Stress Disorder (PTSD)? The box is shaded in for the answer 2 NO Interview on 2/20/25 at 1:49 P.M. with Staff F revealed that he/she did not ask Resident #202 about the trauma and did not completed the assessment accurately. Review on 2/20/25 of the facility's policy titled: Trauma Informed Care dated 09/01/2024 2. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), Admission Assessment, the history and physical and social history/assessment, and others. 6. The facility will identify triggers which may re-traumatize residents with a history trauma. Trigger-specific interventions will identity way to decrease the resident's exposure to triggers which re-traumatize the resident , as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the residents care plan.

Based on observation, interview and manufacturer's instruction review, it was determined that the facility failed to ensure that medications were labeled and dated in accordance with currently acceptable professional principles for 2 out of 2 medication carts observed. (Resident identifiers are #152 and #36.) Findings include: Observation on 2/19/25 at 9:07 a.m. of the [NAME] Front medication cart revealed a small clear plastic medication cup in the top drawer containing 3 pills (medications). The cup was unlabeled and undated. Interview on 2/19/25 at 9:10 a.m. with Staff C (Registered Nurse) confirmed the above findings and revealed that the medications belonged to Resident #36. Observation on 2/19/25 at 9:45 a.m. of the [NAME] Woods medication cart revealed one Symbicort inhaler, not in a box or bag, with no resident identifier or open date or open expiration date. Further observation revealed an Advair Diskus inhaler in a box for Resident #152 without an open date or open expiration date. The pharmacy instructions on the box stated to discard one month after opening. Interview on 2/19/25 at 9:50 a.m. with Staff E (Registered Nurse) confirmed the above findings and revealed that both inhalers had been used. Staff E did not know to whom the Symbicort belonged. Review on 2/19/25 of the Manufacturer's Instructions for Symbicort revealed that the inhaler should be discarded when the labeled number of inhalations and have been used or within 3 months after removal from the pouch. Review on 2/19/25 of the Manufacturer's Instructions for the use of Advair Diskus revealed that the inhaler should be discarded one month after opening the foil pouch or when the counter reads 0.

Based on interview and record review, it was determined that the facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, for 4 days in the month of September 2024. Findings include: Review on 2/19/25 of the Facility's Payroll Based Journal Staffing Data Report for Quarter 4 2024 (July 1-September 30, 2024) revealed that there were no RN hours submitted for the following days: 9/1/24, 9/15/24, 9/28/25, and 9/29/24. Interview on 2/20/25 at 1:00 p.m. with Staff D (Director of Nursing) confirmed the above findings and revealed that the facility could not provide documentation to show that there was an RN on duty during the above dates.

Based on interview and record review, it was determined that the facility failed to follow physician's orders for 1 of 2 residents review for pain management in a final sample of 15 residents (Resident identifier is #44.) Findings include: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . Review on 2/20/25 of Resident #44's Medication Administration Record (MAR) revealed a physician order for Acetaminophen Tablet 325 mg [milligrams] Give 2 tablet by mouth every 4 hours as needed for Mild Pain More than 3 doses in 48 hours, notify physician/advanced practice nurse . Review on 2/20/25 of Resident #44's MAR for January and February 2025 revealed that Resident #44 received 4 doses within 48 hours of the above PRN order during the following time periods: Between 1/28/25 and 1/29/25 (1/28/25 at 1:28 am. and 3:54 p.m., 1/29/25 at 4:47 p.m. and 11:07 p.m.,) Between 2/4/25 and 2/6/25 (2/4/25 at 4:36 p.m., 2/5/25 at 1:26 a.m. and 10:51 a.m., 2/6/25 at 2:36 a.m.) Further review of Resident #44's MAR for January and February 2025 revealed that Resident #44 was reporting pain at 5 or above on a numeric pain scale of 1 to 10 for the following days: 1/2/25 at 6:19 a.m., 1/6/25 at 7:18 p.m., 1/9/25 at 7:45 a.m. and 4:49 p.m., 1/13/25 at 4:27 p.m., 1/17/25 at 2:09 a.m., 1/18/25 at 2:31 a.m., 1/20/25 at 5:06 a.m., 4:41 p.m. and 11: 07 p.m., 1/22/25 at 4:59 p.m., 1/23/25 at 6:43 a.m., 1/25/25 at 5:58 a.m., 1/26/25 at 2:36 p.m. and 6:53 p.m., 1/27/25 at 4:39 p.m., 1/28/25 at 1:28 a.m. and 3:54 p.m., 1/29/25 at 11:07 p.m., 1/30/25 at 11:55 a.m. and 5:58 p.m. and 1/31/25 at 4:20 p.m. 2/1/25 at 1:57 a.m., 2/2/25 at 5:21 a.m. and 11:54 p.m., 2/4/25 at 4:36 p.m., 2/5/25 at 1:26 a.m. and 10:51 a.m., 2/6/25 at 2:36 a.m., 2/7/25 at 12:47 a.m. , 2/8/25 at 2:18 a.m., 2/9/25 at 12:49 a.m., 2/10/25 at 2:05 a.m., 2/12/25 at 1:36 a.m., 2/13/25 at 3:50 p.m., 2/16/25 at 6:34 a.m., 2/17/25 at 5:43 a.m., 2/18/25 at 6:04 a.m., 2/19/25 at 2:37 p.m., and 2/20/25 at 3:04 a.m. Review on 2/20/25 of Resident #44's medical record revealed no documentation that the provider was notified when Resident #44 used more than 3 doses in 48 hours of the Acetaminophen PRN order or that they were given Acetaminophen when experiencing pain outside of the PRN order parameters. Interview on 2/20/25 at approximately 1:20 p.m. with Staff A (Nurse Manager) confirmed that there was no documentation that the provider was notified when Resident #44 used more than 3 doses in 48 hours of the Acetaminophen PRN order. Staff A revealed that mild pain would be considered less than 5 on a numeric pain scale of 1 to 10. Staff A also confirmed that Resident #44 was given Acetaminophen outside of the PRN order parameters and there was no documentation that the provider was notified. Interview on 2/20/25 at approximately 2 p.m. with Staff G (Advanced Practical Registered Nurse) confirmed that they had not been notified that Resident #44 had used more than 3 doses in 48 hours of the Acetaminophen PRN order or that they were given Acetaminophen when experiencing pain outside of the PRN order parameters.

Based on interview and record review, it was determined that the facility failed to inform each resident before, or at the time of admission, of services available in the facility and of charges for those services for 1 resident in a final sample of 15 residents. (Resident identifier is #43.) Findings include: Interview on 2/19/25 at approximately 12:00 p.m. with Resident #43's DPOA (Durable Power of Attorney) revealed that his/her spouse was admitted to the facility in December 2024. He/she stated that they gave the facility their prescription card but was told that they needed to use the facility's pharmacy. Interview revealed they have been billed monthly for co-pays from the facility's pharmacy. They would not have co-pays at their pharmacy and the facility did not tell them they would be charged. Interview on 2/21/25 at approximately 8:30 a.m. with Staff B (Admissions Coordinator) revealed that during the admission process, the option of using an outside pharmacy was not discussed with Resident #43 or their DPOA. Staff B also revealed that Resident #43's DPOA gave him/her an outside pharmacy prescription card during admission. Review on 2/21/25 of the facility policy titled Arrangements with Noncontract Pharmacy, dated 8/20, revealed the following: Policy, A resident or responsible party may request that medications be obtained from a pharmacy other than the facility's contract provider pharmacy, .Procedures, 1. The facility informs the resident and/or responsible party of relevant policies and procedures related to purchasing medications from a noncontract pharmacy

Based on interview and record review, it was determined that the facility failed to ensure the residents' right to formulate advance directives for 2 out of 2 residents reviewed for Advance Directives in a final sample of 15 residents. (Resident Identifier's are #102 and #152.) Findings include: Resident #102 Review on 2/19/25 of Resident #102's medical record revealed a physician's order, dated 2/15/25, for Full Code (meaning the patient wishes to receive all possible life-saving measures in the event of a cardiac or respiratory arrest). Further review of Resident #102's medical record revealed a Portable Do Not Resuscitate (DNR) form, dated 7/11/22, that indicated Resident #102 was a DNR (meaning the patient wishes not to have cardiopulmonary resuscitation attempted on them if their heart or breathing stops). Review on 2/20/25 of Resident #102's care plan for advanced directives revealed Resident #102's code status was DNR. Interview on 2/20/25 at approximately 12:20 p.m. with Staff C (Registered Nurse) confirmed the above findings. Resident #152 Review on 2/19/25 of Resident #152's physician orders revealed an order for DNR, dated 2/18/25. Review on 2/19/25 of Resident #152's care plan for advanced directive revealed was Full Code, dated 2/14/25. Interview on 2/20/25 at approximately 11:30 a.m. with Staff A (Nurse Manager) confirmed the above findings. 37488

Based on interview and record review, it was determined that the facility failed to follow established infection control guidelines for facility water management by not having a system to monitor control measures to minimize the risk of Legionella and other opportunistic pathogens that has the potential to effect the facility census of 48 residents who resided at the facility. Findings include: Interview on 9/11/24 at approximately 10:30 a.m. with Staff D (Infection Preventionist) revealed they did not know if the facility had a system to monitor control measures in place to prevent the introduction and spread of Legionella. Review on 9/12/24 of the facility's policy, Legionella Water Management, dated 2017, revealed: .These domestic unmixed water tanks have a high-volume use and high temperature that make it completely inhospitable for the Legionella bacteria to grow. These tanks are also purged at the base to remove any settled impurities monthly by the maintenance staff using the TELS Maintenance System. All basement boiler and water flow systems are monitored for flow, pressure, temperature, and function daily .In the event of the plumbing maintenance or repair that disturbs the integrity of piping in the domestic water supply system: all fixtures directly supplied by the plumbing that is maintained or repaired, must flush for ten minutes .Baseboard heating systems, facility air conditioners, stored emergency water, eyewash stations, nebulizers, oxygen concentrators, outside watering spigots . Review on 9/12/24 of the facility's boiler room daily inspection and maintenance logs, revealed the following: -In August 2024, 10 out of 31 days, the temperature and pressures were monitored; -In September 2024, 4 out of 14 days, the temperature and pressures were monitored. The facility was unable to provided evidence of additional documentation for the control measures in place to prevent the introduction and spread of Legionella. Interview on 9/12/24 at 11:14 a.m. with Staff I (Maintenance Director) confirmed the above findings.

Based on record review and interview, it was determined that the facility failed to provide sufficient nursing staff, as determined by their facility assessment, to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in a census of 48 residents. Interview on 9/10/24 at approximately 1:40 p.m. with Resident #26 revealed that he/she was frequently told that staff were too busy and it caused delays in the care that he/she needed, and medications administered were frequently late. Interview on 9/10/24 at approximately 1:00 p.m. with Resident #45 revealed that the facility was short staffed, and it caused longer responses to call lights and getting the assistance he/she needed. Resident #45 stated: I waited on the toilet for 45 minutes the other day. Interview on 9/11/24 at approximately 8:00 a.m. with Staff H (Licensed Nursing Assistant (LNA)) and Staff L (Medication Nursing Assistant (MNA)) revealed that at times, it is just an MNA on a unit and the nurse from the other unit would need to come over for medication administration, causing late administatration of tube feeds and insulins. Staff H and Staff L stated that residents were not receiving the care needed for basic incontinence and showers were not being given because of low staffing. The residents have had an increase in incontinence because we don't have enough staff to answer the call lights and others who are incontinent have to sit and wait until we can get to them to be changed. Interview on 9/11/24 at approximately 9:00 a.m. with Resident #21 (Resident Council President) revealed that staffing was a real problem in the facility and worse on the 3-11 and 11-7 shifts. He/she said that sometimes there was only 1 nurse in the facility for 50 residents. Interview on 9/11/24 at approximately 10:00 a.m. with Staff R (LNA) revealed that when there was only 1 LNA to 25 residents, and it makes it very difficult for residents to get showers. Interview on 9/11/24 at approximately 3:00 p.m. with Staff P (LNA) revealed that he/she works 7-3 shift. He/she stated that when he/she knows that there was only 1 LNA scheduled for 3-11 shift, he/she would make sure that the residents who are 2 assists were put back in bed prior to him/her leaving to help the LNA who was scheduled for 3-11 p.m. shift. Interview on 9/11/24 at approximately 3:00 p.m. with Staff Q (LNA) revealed that he/she works 3-11 and 11-7. He/she stated that during many shifts, he/she was the only LNA on the Bretten Woods unit. Staff Q stated that when there was 1 LNA on a shift, it is difficult during meals, some residents will eat in bed and the residents who need assistance or supervision with meals, he/she would bring them out to the nursing station to watch them while he/she was feeding other residents. Staff Q said that residents would wait for incontinent care if he/she was the only LNA on shift. This happens more often than not stated Staff Q. Review on 9/12/24 of the facility assessment revealed: .Staffing break down with Census . based on 45 - 50 Residents . Days (7 a.m. -3 p.m.): [NAME] Woods: 1 Nurse/Medtech; 2 LNA's. [NAME]: 1 Nurse; 1 Medtech; 2 LNA's. Evenings (3 p.m. -11 p.m.) [NAME] Woods: 1 Nurse/Medtech; 2 LNA's. [NAME]: 1 Nurse; 2 LNA's. Nights (11 p.m. -7 a.m.) [NAME] Woods: 1 Nurse/Medtech; 1 LNA. [NAME]: 1 Nurse; 1 LNA. Review on 9/12/24 of the Facility Daily Staffing Sheets for 7/1/24 to 9/11/24 revealed: [NAME] Woods -On 7/1/24 3 p.m. - 11p.m., there was 1 LNA (there should have been 2) and 11 p.m. to 7 a.m., there was no nurse/med tech (should have been 1); -On 7/2/24 3 p.m. - 5 p.m., there was no nurse/med tech (there should have been 1), from 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2), and on 11 p.m. to 7 a.m., there was no nurse/med tech (should have been 1); -On 7/3/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2) and 11 p.m. to 7 a.m., there was no nurse/med tech (there should have been 1); -On 7/4/24 3 p.m. - 11 p.m. there was 1 LNA (there should have been 2); -On 7/5/24 3 p.m. - 7 p.m., there was no LNA (there should have been 2), 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2), and 11 p.m. to 7 a.m., there was no nurse/med tech (there should have been 1); -On 7/7/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/8/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 7/9/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); - On 7/10/24 11 p.m. - 7 a.m., there was no nurse/med tech (there should have been 1); -On 7/11/24 11 p.m. - 7 a.m., there was no nurse/med tech (there should have been 1); -On 7/12/24 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2) and 11 p.m. - 7 a.m., there was no nurse/med tech (there should have been 1); -On 7/13/24 7 a.m. - 3 p.m., there was 1 LNA (there should have been 2), 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/14/24 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/15/24 3 p.m. - 11 p.m. and 11 p.m. - 7 a.m., there was no nurse/medtech (there should have been 1); -On 7/16/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/17/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 7/18/24 3 p.m. - 7 p.m., there was no LNA (there should have been 2); -On 7/19/24 7 a.m. - 3 p.m., there was 1 LNA (there should have been 2), 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2), 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2), and 11 p.m. - 7 a.m., there was no nurse/medtech (there should have been 1); -On 7/22/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 7/23/24 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/24/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2), 5 p.m. - 5 a.m., there was no nurse/medtech (there should have been 1); -On 7/25/24 11 p.m. - 7 a.m., there was no nurse/medtech (there should have been 1); -On 7/26/24 3 p.m. - 11 p.m. and 11 p.m - 7 a.m., there was no nurse/medtech (there should have been 1); -On 7/27/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/29/24 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2) and 11 p.m - 7 a.m., there was no nurse/medtech (there should have been 1); -On 7/30/24 7 p.m. - 11 p.m. there was 1 LNA (there should have been 2) and 11 p.m. - 3 a.m., there was no LNA (there should have been 1); -On 8/6/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 8/16/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 8/20/24 7 a.m. - 3 p.m., there was 1 LNA (there should have been 2); -On 8/23/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 8/24/24 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 8/25/24 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 8/30/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 9/1/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 9/2/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 9/4/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 9/9/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2). [NAME] -On 7/2/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/3/24 3 p.m. -7 p.m., there was 1 LNA (there should have been 2); -On 7/4/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 7/5/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/7/24 11 p.m. to 7 a.m., there was no nurse/med tech (there should have been 1); -On 7/8/24 from 3p.m. - 11 p.m. there was 1 LNA (there should have been 2); -On 7/9/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/13/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2) and 3 p.m. - 11 p.m. there was no nurse (there should have been 1); -On 7/14/24 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/15/24 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2) and 3 p.m. - 11 p.m. there was no medtech (there should have been 1); -On 7/16/24 7 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/16/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 7/17/24 3 p.m. - 11 p.m. there was no medtech (there should have been 1); -On 7/18/24 3 p.m. -7 p.m., there was no nurse/medteach (there should have been 1) and 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/19/24 7 a.m. - 3 p.m., there was 1 LNA (there should have been 2) and 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/20/24 11 p.m. - 7 a.m., there was no nurse/medtech (there should have been 1); -On 7/21/24 11 p.m. - 7 a.m., there was no nurse/medtech (there should have been 1); -On 7/22/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2) and 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 7/23/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 7/24/24 3 p.m. - 7 p.m., there was no nurse/medtech (there should have been 1) and 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 7/26/24 3 p.m. - 11 p.m., there was 1 LNA and no medtech (there should have been 2 LNA's and 1 medtech); -On 7/30/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 8/2/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2); -On 8/4/24 11 p.m. - 7 a.m., there was no LNA (there should have been 1); -On 8/8/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 8/9/24 3 p.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 8/11/24 11 p.m. - 7 a.m., there was no LNA (there should have been 1); -On 8/14/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 8/17/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 8/19/24 3 p.m. - 11 p.m., there was 1 LNA and no medtech (there should have been 2 LNA's and 1 medtech); -On 8/23/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 8/25/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 8/26/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 8/27/24 3 p.m. - 7 p.m., there was no nurse or medtech (there should have been 1); -On 8/29/24 3 p.m. - 7 p.m., there was no nurse (there should have been 1) and 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 8/30/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 8/31/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 9/1/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 9/2/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 9/3/24 7 a.m. - 3 p.m., there was no medtech (there should have been 1); -On 9/4/24 7 a.m. - 3 p.m. and 3 p.m. -11 p.m., there was no medtech (there should have been 1); -On 9/5/24 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 9/6/24 11 p.m. - 7 a.m., there was no nurse/medtech (there should have been 1); -On 9/8/24 7 a.m. - 3p.m., there was 1 LNA and no medtech (there should have been 2 LNA's and 1 medtech) and 3 p.m. - 11 p.m., there was no medtech (there should have been 1); -On 9/9/24 7 a.m. - 7 p.m., there was 1 LNA (there should have been 2); -On 9/10/24 5 p.m. - 8 p.m., there was 1 nurse/medtech (there should have been 2); -On 9/11/24 3 p.m. - 11 p.m., there was 1 LNA (there should have been 2). Interview on 9/12/24 at approximately 10:30 a.m. with Staff B (Scheduler) confirmed the above staffing. Review on 9/12/24 of the daily census for 7/1/24 to 9/11/24 revealed that the facility has maintained a census of 45 to 50 residents during the above noted shifts. Interview on 9/12/24 at approximately 1:20 p.m. with Staff K (Advanced Practice Registered Nurse) stated he/she had concerns with staffing and residents not getting care such as consistent wound care. Staff K stated that he/she was doing wound care for residents himself/herself once the orders were placed to ensure they getting done. 38218 49819

Based on interview and record review, it was determined the facility failed to designate an Infection Preventionist that completed specialized training in infection prevention and control. Findings include: Record review on 9/11/24 revealed that the facility could not provide evidence of specialized training in infection control for Staff D (Infection Preventionist). Interview on 9/11/24 at 10:30 a.m. with Staff D revealed that Staff D was hired on 5/23/24 and was currently designated as the Infection Preventionist. Interview on 9/11/24 at 12:00 p.m. with Staff E (Director of Nursing) confirmed the above findings. Review on 9/11/24 of the facility's job description for Infection Preventionist, revised 8/3/20, revealed: .Specific Education/Vocational Requirements .2. Must complete specialized training in infection prevention within 90 days of hire . Review on 9/12/24 of the facility's policy, Infection Prevention and Control Program (IPCP), revised 7/1/24, revealed: .The Infection Preventionist develops, implements, monitors and maintains the IPCP and fulfills the basic requirements for the role .

Based on interview and record review, it was determined that the facility failed to ensure the activities program was directed by a qualified professional for a facility census of 78 residents. Findings include: Interview on 9/11/24 at 9:56 a.m. with Staff C (Director of Activities) revealed that he/she was promoted to Director of Activities in September 2024. He/she had been working as an activities aid at the facility since June 2024. Interview further revealed that Staff C had no prior certifications in activities, degrees in recreation, or any prior experience working in an activity program. Interview on 9/11/24 at 10:00 a.m. with Staff A (Administrator) confirmed the above findings and that Staff C was not qualified. Review on 9/11/24 of the facility's job description for Director of Recreation Services, revised 4/25/17, revealed: . Education/Vocational Requirements: 1. Certification in accordance with regulatory agencies governing the center, by the National Certification Council of Activity Professionals (ADC) or the National Council of Therapeutic Recreation Certification (CTRS), or 2. Bachelor degree in therapeutic recreation preferred or completion of the NAAP/NCCAP Basic and Advanced Management Course for Activity Professionals, or 3. Has 2 years' experience in a social or recreational program within the last 5 years, one of which was full time in a patient activity program in a health care setting .

Based on interview and record review, it was determined that the facility failed to follow physician orders or provide medications timely for 5 residents in a final sample of 19 residents (Resident Identifiers are #1, #17, #26, #34, #47). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336 - Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . [NAME], [NAME]; [NAME], [NAME] A.; [NAME], Wendy; and [NAME], [NAME]. Clinical Nursing Skills & Techniques. 10th ed. [NAME], Pennsylvania: Elsevier, 2022. Page 597 - Safe Medication Preparation: Right Time With time-critical medications (e.g., antibiotics, anticoagulants, insulin, immunosuppressives), early or delayed administration of the maintenance doses of more than 30 minutes before or after the scheduled dose will most likely cause harm or result in subtherapuetic responses in a patient. 26364 Resident #47 Review on 9/12/24 of Resident #47's August 2024 and September 2024 Medication Administration Audit report revealed the following medication administrations were documented as given outside of the ordered timeframe's: -Ativan Oral Tablet 0.5 milligram (mg) (Antianxiety), Give 1 tablet via PEG-Tube [Percutaneous endoscopic gastrosomy] every morning [7 a.m. -10 a.m.] and at bedtime for anxiety: 8/15/24 morning dose administered at 3:56 p.m; 8/16/24 morning dose administered at 10:40 a.m.; 8/19/24 morning dose administered at 1:43 p.m ; 8/20/24 bed time dose administered at 8:38 a.m.; 8/21/24 morning dose administered at 10:08 a.m. and bed time dose at 5:25 p.m.; 8/22/24 morning dose administered at 2:22 p.m.; 8/23/24 morning dose administered at 10:25 a.m.; 8/24/24 morning dose administered at 10:31 a.m.; 8/26/24 morning dose administered at 10:44 a.m.; 8/28/24 morning dose administered at 10:54 a.m.; 8/29/24 morning dose administered at 10:47 a.m.: 8/31/24 morning dose administered at 2:42 p.m.; 9/2/24 morning dose administered at 11:15 a.m.; 9/3/24 morning dose administered at 11:12 a.m. and bed time dose at 5:45 p.m.; 9/10/24 morning dose administered at 10:27 a.m.; 9/11/24 morning dose administered at 10:56 a.m. -Eliquis Oral Tablet 2.5 mg (Anticoagulant), Give 0.5 tablet via J-Tube [jejunostomy] two times a day for A-fib [Atrial fibrillation] scheduled for administration in AM and PM: 8/15/204 morning dose administered at 3:58 p.m. and the evening dose administered 5:45 p.m. (only 2 hours between doses); 8/19/24 morning dose administered at 1:42 p.m.; 8/31/24 morning dose administered at 2:46 p.m.; 9/2/24 administered at 11:15 a.m. and 4:40 p.m. Interview on 9/12/24 at approximately 1:00 p.m. with Staff D (Staff Development) confirmed that the above medications were administered outside of the ordered time frames. 38218 Resident #1 Review on 9/12/24 of Resident #1's July 2024's Treatment Administration Record revealed the following physician's order: Apply Aquacel AG Maxorb and cover with Coban. Change daily. One time a day for skin breakdown, wound. Start Date 7/17/24. Further review on 7/23, 7/24, 7/26, 7/28 and 7/30 revealed this was not documented as being performed. Interview on 9/12/24 at approximately 11:00 a.m. with Staff E (Director of Nursing) confirmed Resident #1's dressings were not documented as being changed. Resident #34 Review on 9/12/24 of Resident #34's September Medication Administration Audit Report revealed the following: -9/12/24 Lantus 40 Units was scheduled for 7:00 a.m. and was administered at 9:18 a.m.; -9/9/24 All by mouth (PO) and Lantus 40 Units were scheduled for 7:00 a.m. were administered at 12:30 p.m.; - 9/9/24 Hydralazine HCL (Hydrochloric Acid) 100 mg was scheduled at 7:00 a.m. and at 2:00 p.m. On this date, Resident #34 received Hydralazine HCL at 12:30 p.m. and again at 2:01 p.m.; -9/3/24 All PO medication that was scheduled for 7:00 a.m. was administered at 9:49 a.m.; -9/2/24 Metoprolol Succinate Extended Release (ER) 100 mg was scheduled for 7:00 a.m. and was administered at 10:44 a.m.; -9/1/24 All PO medication that was scheduled for 7:00 a.m. and was administered at 10:00 a.m Interview on 9/12/24 at approximately 1:30 p.m. with Staff K (Advance Practice Registered Nurse) revealed that he/she was not aware of Resident #34's late medication administration. Staff K also revealed that on 9/9/24 he/she would have expected Resident #34's 2:00 p.m. dose of Hydralazine to be held. Resident #17 Review on 9/12/24 of Resident #17's August and September 2024's Medication Administration Record (MAR) revealed the following physician's order: Weigh weekly, (dry weight 241) update Provider for 3 pound or more weight gain since previous weight, in the morning every Mon [Monday] for CHF [congestive heart failure] diuretic use, Start Date 8/26/24. Further review revealed Resident #17's weight was 253.2 on 8/26 there was no weight obtained on 9/2 and 9/9. Interview on 9/12/24 at approximately 1:30 p.m. with Staff K confirmed the weights were not obtained. Staff K revealed that he/she was unaware that Resident #17's weights were not obtained and that no one notified Staff K of Resident #17's weight gain on 8/26. 47129 Resident #26 Review on 9/11/24 of Resident #26's medical record revealed a physicians order for Lotrisone Cream 1-0.005, apply to both feet topically two times a day for foot [fungal] rash for 3 months, with a start date of 8/27/24. Review on 9/11/24 of Resident #26's August 2024 MAR revealed the Lotrisone Cream was not signed off as administered from 8/19/24 through 8/30/24. Review on 9/11/24 of Nurses Note 8/19/24 through 8/30/24 revealed med unavailable or waiting on delivery for Lotrisone. Interview on 9/12/24 at approximately 10:30 a.m. with Staff G (Registered Nurse) confirmed Lotrisone was not given the above dates. Interview on 9/10/24 at 1:36 p.m. with Resident #26 revealed that Resident #26 had cataract surgery on 6/12/24 and he was given 2 orders for eyes drops to be administered multiple times a day for so many days. Resident #26 stated that when he/she was out of the facility at an appointment, he/she missed receiving the eye drops and when he/she returned to the facility, the eye drops were never given, therefore, there were times he/she missed receiving the maximum amount he/she was supposed to receive them in a day. Review on 9/12/24 of Resident #26's June 2024 and July 2024 MAR revealed the following: -Moxifloxacin HCI Opthmalic Solution 0.5%, Instill drop in left eye four times a day for cataract surgery, start date 6/15/24, discharge date [DATE]. Resident #26 was not administered drops 11 out of 49 times during the period reviewed. -Moxifloxacin HCI Opthmalic Solution 0.5%, Instill drop in left eye four times a day for cataract surgery, discontinue once bottle empty, start date 6/27/24, discharge date [DATE]. Resident #26 was not administered drops 14 of 66 times during period reviewed. -Prednisolone Acetate Opthalmic Suspension, Instill 1 drop in left eye four times a day for cataract surgery, start date 6/15/23, discharge date [DATE]. Resident #26 was not administered drops 11 out of 49 times during period reviewed. -Prednisolone Acetate Opthalmic Suspension, Instill 1 drop in left eye three times a day for cataract surgery for 7 days, start date 6/27/24. Resident #26 was not administered drops 7 out of 21 times during period reviewed. Interview on 9/12/24 at 1:40 p.m. with Staff N (Registered Nurse) confirmed the above findings. Staff N stated that he/she would notify the provider if a dose was missed. Interview on 9/12/24 at 11:42 p.m. with Staff K revealed that Staff K was never notified that Resident #26 missed the eye drops. Interview further revealed that his/her expectation would be that the eye drops would have been administered either prior to Resident #26 leaving the facility or once Resident #26 returned to ensure that the eye drops were administered the maximum amount in a day.

Based on observation and interview, it was determined that the facility failed to ensure resident's needs were accommodated by keeping their call bell within reach for 1 of 1 reviewed for environment in a final sample of 16 residents (Resident Identifier #12). Findings include: Observation on 9/10/24 at approximately 11:44 a.m. revealed Resident #12's call bell hanging over their roommates light fixture over their roommates bed. Interview on 9/10/24 at approximately 11:44 a.m. with Resident #12 revealed that he/she would yell for help if needed because he/she is unable to reach the call bell. Observation on 9/11/24 at approximately 10:29 a.m. of Resident #12 revealed the call bell hanging over their roommates light fixture over their roommates bed in the same spot as the day prior. Resident #12 was sitting in their wheel chair on a hoyer pad by their window. Resident #12 was unable to reach the call bell on the opposite side of his/her bed. Observation on 9/11/24 at approximately 3:18 p.m. of Resident #12 revealed the call bell hanging over their roommates light fixture over their roommates bed. Resident #12 was napping in bed and unable to reach the call bell.

Based on record review and interview, it was determined that the facility failed to ensure that a resident receiving anticoagulant (blood thinner) therapy received the necessary care and services for anticoagulation treatment for 5 days for 1 of 3 residents reviewed for anticoagulation therapy (Resident Identifier #1). Findings include: Record review on 5/30/24 of Resident #1's electronic medical record revealed a nurses note, dated 5/1/24 at 6:47 p.m. that stated Resident #1 was noted to have lips slightly cyanotic with vital signs as follows: Blood pressure of 124/87, heart rate of 163, respirations of 40, O2 [oxygen] saturation of 83% on 3 liters of oxygen and a temperature of 97.7 degrees Fahrenheit. Further review of the medical record revealed a note by Staff A (Nurse Practitioner) dated 5/1/24 and entered at 12:56 p.m., stating: The patient had not received [pronoun omitted] Coumadin since April 25 and was due for repeat INR [International Normalization Ratio] lab work however this appears to have not been done so the Coumadin was not re-dosed. The Nurse Practitioner's note also indicated that the resident agreed to go to the emergency room for further evaluation secondary to concerns of acute Pulmonary Embolism (PE). Review on 5/30/24 of Resident #1's April 2024 Medication Administration Record (MAR) revealed an order for Coumadin 2.5 milligrams (mg). The order read as follows: Give 1 tablet by mouth in the evening for a-fib [Atrial Fibrillation] until 4/25/24 recheck INR on 4/26/24 with a start date of 4/19/24 and an end date of 4/26/24. Further review of the April 2024 MAR revealed an order to Recheck INR on 4/26/2024 .contact the MD [Medical Doctor] or NP [Nurse Practitioner] with results for additional orders . This order was not signed off as completed in the MAR and no new orders to continue Coumadin were obtained. Interview on 5/30/24 at 11:00 a.m. with Staff B (Unit Manager) confirmed there was no results of INR testing being done on 4/26/24 as ordered for Resident #1. Interview on 5/30/24 at 1:00 p.m. with Staff C (Administrator) confirmed that the resident was sent to the hospital and admitted for bilateral pulmonary embolisms after not receiving Coumadin for 5 days.

Based on interview and record review, it was determined that the facility failed to monitor for side effects of hypothyroidism after discontinuing hypothyroid medication, which resulted in severe symptoms of hypothyroidism requiring multiple nights of hospitalization for 1 of 1 residents reviewed for hospitalization in a final sample of 20 residents (Resident identifier is #59). Findings include: Interview on 9/11/23 at approximately 9:22 a.m. with Resident #59 revealed that they had been sent to the hospital in July for multiple nights because he/she had an arrhythmia. Resident #59 also stated that while at the hospital it was discovered that he/she had not received their thyroid medication for several months. Review on 9/12/23 of Resident #59's Medication Administration Record (MAR) for March 2023 revealed an order for Levothyroxine 200 microgram (mcg) give once a day, dated 3/6/23. Further review of the MAR from March 2023 through July 2023, revealed their last dose of Levothyroxine before hospitalization was administered on 3/27/23. The resident had not received Levothyroxine for 15 total weeks. Review on 9/12/23 of Resident #59's physician's orders revealed the following order: Levothyroxine 200 mcg once a day for hypothyroidism discontinue to prevent contraindication with protonix, dated 3/27/23, and signed by Staff D (Nurse Practitioner) on 3/28/23. Further review of Resident #59's physicians orders revealed no orders to monitor for side effects of hypothyroidism or lab monitoring. Review on 9/12/23 of Resident #59's medical record revealed the following Nurse Practitioner note: 7/17/23- Plan: Hypothyroidism: Levothyroxine 200 mcg reinstituted. Inadvertent discontinuation on March 28, 2023. [pronoun omitted] has had significant fatigue Review on 9/12/23 of Resident #59's hospital discharge summary for 7/13/23-7/16/23 hospital stay revealed the following: .Patient was admitted with combination of fatigue, AKI [acute kidney injury], edema and elevated cardiac enzymes presumably secondary to renal insufficiency. Underlying etiology was felt to be hypothyroidism. Unfortunately the patient had not been given his Synthroid [levothyroxine] recently. He is previously on 200 mcg (micrograms) daily Further review of the discharge summary revealed the patient had a Thyroid Stimulating Hormone (TSH) of 96.680 on 7/13/23 when admitted . Interview on 9/13/23 at approximately 10:30 a.m. with Staff D confirmed the medication had been discontinued with no monitoring for side effects of hypothyroidism or monitoring of labs after the medication was discontinued. Staff D revealed that the nurse who wrote the discontinuation order no longer work at the facility since the end of March 2023. Staff D presumed the medication was discontinued with the intention of changing the time of administration due to contraindications with some other medications, but there was no new order with a new time of administration.

Based on record review, review of an incident report of an unusual occurrence involving resident injury, and staff interview the facility failed to prevent new pressure sores from developing in 1 of 17 residents in a standard survey sample. (Resident identifier is #1.) Findings include: Facility Policy and Procedure Review of the facility policy and procedure for "Skin Care & Pressure Ulcer Management Program" with a revision date of 1/10/11 reveals the following; - On page 3 under "Objectives" is written "1. Prevent pressure ulcers from developing in residents identified as being at risk." - On page 3 under "Objectives" is written "5. Provide standardized treatment and interventions that promote pressure ulcer healing.... ." - On page 5 under "Definition" is written "A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s)." - On page 18 under "Reducing Pressure" is written "As with all aspects of skin care, consider pressure redistribution treatment modalities specific to the pressure ulcer's classification. There are many pressure-reducing devices available which can be used based on the resident's specific needs." Resident #1. Medical record review conducted 12/11/12 through 12/13/12 revealed this resident was admitted [DATE]. The resident's current [DIAGNOSES REDACTED]. Review of the nursing notes revealed a note dated 10/9/12 indicating resident #1 was admitted to the hospital "for a surgical procedure." Review of a hospital "Operative Report" dated 10/10/12 reveals Resident #1 had a right femoral to anterior tibial (above ankle) bypass procedure done. Further review of nursing notes revealed a note dated 10/20/12 which indicates this resident was readmitted to the facility after a failed bypass procedure which required a "Right BKA on 10/16/12." This same nursing note indicates Resident #1 was having phantom pains on the right leg when readmitted and was receiving "[MEDICATION NAME] 5 mg (milligram) one - two tabs po (by mouth) prn (as needed) for pain. Resident able to make needs known." A nursing note dated 10/21/12 reveals this resident is "Alert/oriented. Makes her needs known. Hoyer transfer from bed to w/c (wheelchair). ...2 assist bed mobility and ADL's (Activities of Daily Living)." Review of the"Nursing Assessment" form completed on 10/20/12 when Resident #1 was readmitted revealed a "Total Norton Plus Score" for pressure ulcer risk was an 8. The form reads "Score 10 or less = High Risk" (for developing a pressure ulcer). Review of a nursing note dated 10/23/12 at 1200 states "Resident noted during am care to be on bedpan. ...Care was done at 9:30 am.....Large red ring noted around buttocks with deep indentation. 7.5 cm (centimeter) x 2 cm blistered pressure area noted with deep maroon/purplish color on L (left) buttocks. Sm (small) amt (amount) bleeding from area. ....Resident also noted to have Stage II ulcer on R (right) buttock 2 cm x 2 cm. Area superficial.....Md aware and daughter-in-law notified." (This pressure ulcer developed 7 days post op.) A physician note dated 10/25/12 reads " - Here to eval (evaluate) recent decubitus ulcer caused by being accidentally left on the bedpan.....Some confusion at night... ." Review of two facility "Pressure Ulcer Documentation Forms" both dated 10/23/12 revealed the following: - "Left Buttocks - 10/23/12 - U (unstageable) 7.5 cm length x 2 cm width (open blistered) area with deep maroon color with a small amount of blood and wound related pain." - "Right Buttocks - 10/23/12 - Stage 2 - 2 cm x 2 cm superficial area with wound related pain." During an interview with Staff F (RN/Wound Nurse) on 12/12/12 at 10:45 am, Staff F said the facility Pressure Ulcer Documentation Forms were filled out by this nurse (Staff F) after observing the wounds on Resident #1's buttocks. Staff F, during this same interview, confirmed Resident #1 was found on the bedpan and had been on it for an undetermined amount of time. Staff F also said during this same interview that Resident #1 had been able to move and reposition self in bed prior to this incident and had been able to make needs known (as documented in nursing notes). Staff F said the facility initiated a plan to reposition the resident every 2 hours after Resident #1 was found on the bedpan on 10/23/12. Review of the care plan in use at the time revealed it was updated on 10/23/12 and the intervention to reposition every 2 hours was added. Review of the October 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the physician orders revealed an order on 10/20/12 (the day Resident #1 returned from the hospital) for "Pressure reducing mattress to bed." On 10/26/12 another physician order was obtained for "Medtech 5000 air mattress to bed... ." During an interview with Staff F on 12/12/12 in the afternoon, the mattress specifications were reviewed. Staff F said during this interview that Resident #1 was on the house mattress from 10/20/12 to 10/26/12 when an air mattress was obtained. During an interview with Staff F on 12/13/12 in the morning, the mattress specifications were reviewed. Staff F stated the house mattress that Resident #1 was on from 10/20/12 through 10/26/12 was called a "Panacea Comfort Mattress." Review of the specifications with Staff F during this interview revealed this mattress is a foam mattress and has listed on the specifications as being used "For up to Stage II wounds." Staff F confirmed after review of the specifications that Resident #1 should have had an upgraded in the mattress being used based on the observation of the presence of an unstageable area resulting from a prolonged period on a bed pan (10/23/12). Staff F confirmed that Resident #1 was on the "Panacea Comfort Mattress" for three days, from 10/23/12 through 10/26/12, even though identified as having an unstageable area. Staff A confirmed the air mattress was not ordered by the physician or obtained until 10/26/12. Further review of the "Pressure Ulcer Documentation Form" for the left buttocks revealed it had worsened on 10/30/12 (from the 10/23/12 observation and documentation). On 10/30/12, Staff F measured and described this area on this form as unstageable - 11 cm in length x 3 cm in width and .1 cm in depth and wrote on the form that it was open with slough in the middle and was comprised of 50% granulation tissue and 50% slough. Further review of the "Pressure Ulcer Documentation Form" from the right buttocks revealed it had worsened on 10/30/12 (from the 10/23/12 observation and documentation). On 10/30/12, Staff F measured and described the area on this form as a Stage 2, measuring 10 cm in length x 2.5 cm in width and with superficial depth. It is written "Area larger due to blistered skin that sloughed off" and it is comprised of 100% epitheal tissue.

Based on record review, review of facility policy and procedure, and review of an incident report of an alleged occurrence and staff interview the facility failed to implement its policy and procedure to prevent neglect by not providing the services necessary to avoid physical harm for 1 of 17 residents in a standard survey sample. (Resident identifier is #1) Findings include: Policy and Procedure Review of the facility policy and procedure entitled "Abuse and Neglect Prohibition Program" with a revision date of 11/2010 reveals on page 6 the definition of neglect stating it "is the failure to provide goods and services that are necessary to avoid physical harm, mental anguish, or mental illness." On page 11 of this same policy is listed some signs and symptoms of potential neglect which include "lack of supervision and monitoring, ...inadequate help with hygiene ..., ...lack of access to the toilet or inadequate changing...which can lead to skin damage...and indignity, ...not attending to the resident... ." Resident #1. Medical record review conducted 12/11/12 through 12/13/12 revealed this resident was admitted [DATE]. The resident's current [DIAGNOSES REDACTED]. Review of the nursing notes revealed a note dated 10/9/12 indicating resident #1 was admitted to the hospital "for a surgical procedure." Review of a hospital "Operative Report" dated 10/10/12 revealed Resident #1 had a right femoral to anterior tibial (above ankle) bypass procedure done. Further review of nursing notes revealed a note dated 10/20/12 which indicates this resident was readmitted to the facility after a failed bypass procedure which required a "Right BKA on 10/16/12." This same nursing note indicates Resident #1 was having phantom pains on the right leg when readmitted and was receiving "[MEDICATION NAME] 5 mg (milligram) one - two tabs po (by mouth) prn (as needed) for pain. Resident able to make needs known." A nursing note dated 10/21/12 revealed this resident is "Alert/oriented. Makes her needs known. Hoyer transfer from bed to w/c (wheelchair). ...2 assist bed mobility and ADL's (Activities of Daily Living)." Review of the "Nursing Assessment" form completed on 10/20/12 when Resident #1 was readmitted revealed a "Total Norton Plus Score" for pressure ulcer risk was an 8. The form reads "Score 10 or less = High Risk" (for developing a pressure ulcer). Review of a nursing note dated 10/23/12 at 1200 states "Resident noted during am care to be on bedpan. ...Care was done at 9:30 am.....Large red ring noted around buttocks with deep indentation. 7.5 cm (centimeter) x 2 cm blistered pressure area noted with deep maroon/purplish color on L (left) buttocks. Sm (small) amt (amount) bleeding from area. ....Resident also noted to have Stage II ulcer on R (right) buttock 2 cm x 2 cm. Area superficial.....Md aware and daughter-in-law notified." A physician note dated 10/25/12 reads " - Here to eval (evaluate) recent decubitus ulcer caused by being accidentally left on the bedpan.....Some confusion at night... ." Review of two facility "Pressure Ulcer Documentation Forms" both dated 10/23/12 revealed the following: - "Left Buttocks - 10/23/12 - U (unstageable) 7.5 cm length x 2 cm width (open blistered) area with deep maroon color with a small amount of blood and wound related pain." - "Right Buttocks - 10/23/12 - Stage 2 - 2 cm x 2 cm superficial area with wound related pain." During an interview with Staff F (RN/Wound Nurse) on 12/12/12 at 10:45 am, Staff F said the facility Pressure Ulcer Documentation Forms were filled out by this nurse (Staff F) after observing the wounds on Resident #1's buttocks. Staff F, during this same interview, confirmed Resident #1 was found on the bedpan and had been on it for an undetermined amount of time. Staff F also said during this same interview that Resident #1 had been able to move and reposition self in bed prior to this incident and had been able to make needs known (as documented in nursing notes). Staff F said the facility initiated a plan to reposition the resident every 2 hours after Resident #1 was found on the bedpan on 10/23/12. Review of the care plan in use at the time revealed it was updated on 10/23/12 and the intervention to reposition every 2 hours was added. Review of the October 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].