Every finding on record at Morningside Center

Based on observation, interview and record review the facility failed ensure professional standards of quality of care and all services are provided according to accepted standards of clinical practice when licensed nursing staff administered medications without verification of the order prior to administration for two residents (Resident #1 and Resident #34) and when not maintaining proper nursing techniques and infection control measures for the removal and insertion of an indwelling urinary catheter for two residents (Resident #25 and Resident #5). The affected four residents out of the 14 sampled residents. The facility census was 56.Review of the facility's undated Catheter Insertion and Removal Policy showed: -After donning sterile gloves, use one hand to expose urinary meatus, with the other hand, cleanse resident using one stroke downward and discarding cleanser, repeat the same procedure with other side of meatus; -Cleanse directly over the urinary meatus with a clean wipe, one stroke downward and discard;-Insert catheter into meatus at an upward angle; -Give peri-care and leave resident clean and comfortable; -Always keep drainage bag off the floor. Review of the Journal of Infection Control and Epidemiology article titled Guideline for Prevention of Catheter Associated Urinary Tract Infections dated 01/02/2019, showed: -Do not allow the drainage bag to touch or rest on the floor; -Maintain unobstructed urine flow by keeping the drainage tube above the collection bag and free of kinks; -Avoid dependent loops. 1. Review of Resident #1's admission care plan showed the resident was alert and oriented with cognition intact and a recent re-admission to the facility. The resident was an insulin dependent diabetic and took insulin with all meals. Resident was dependent on nursing staff to administer medications per physician orders. Record review showed the resident had a current physician's order dated 01/16/2026 for Lispro Insulin injection of 100 units per milliliter (ml) and orders to have 3ml subcutaneous (fatty layer of tissue between the skin and muscle) with meals. Observation on March 19, 2026 at 11:56 A.M., showed RN B at the medication cart, with computer screen closed preparing supplies to administer the resident's lispro insulin, dose was dialed to 3 ml and the medication was administered to the resident. The order was not verified in the electronic medical record at any time by RN B prior to administration of the insulin, and it was not observed that the insulin was documented as given at the time it was observed being administered by RN B from memory. 2. Review of Resident #34's Quarterly MDS (Minimum Data Set), a federally required assessment completed by facility staff, was completed on 11/6/2025 and showed the resident was cognitively intact and was being treated for pain. Record review showed the resident had a current physician's order dated 01/05/26 for Hydrocodone/APAP 10/325mg 1 tablet to be administered four times a day for pain. Observation on March 19, 2026, at 12:11 P.M. showed RN B at the medication cart, opened the locked medication box and removed one tablet from the bubble-packed narcotic card (a cardboard piece of paper containing multiple pills) of Hydrocodone/APA P 10/325mg pills and administered the medication to the resident. RN B did not look at the order on the electronic medical records to verify if there had been any changes to this medication. The medication was given from RN B's memory. During an interview on March 19, 2026, at 3:10 P.M. RN B said he/she knew what medications to give, did not verify the physician's medication orders prior to administering the medications to both residents, but should have and should always verify an order prior to giving any medications. During an interview on March 19, 2026, at 3:45 P.M, the Administrator and Director of Nursing said it is the expectation that all physician orders should be verified and reviewed prior to the administration to any resident and then documented immediately when given. It was also the expectation that as an RN he/she should always ensure that this was done properly and according to the facility policy and best nursing practice. 3. Review of Resident #25's Quarterly MDS, dated [DATE] showed: -Cognition not intact -Required assistance with all personal hygiene, grooming, transfers, and indwelling urinary catheter care. -Diagnoses: disease of the prostate with ongoing urinary tract symptoms, high blood pressure, dementia. Review of physician orders dated 1/30/26 showed change indwelling urinary catheter monthly on the 19th and as needed for nodular prostrate. Observation and interview with RN B during an indwelling urinary catheter removal and insertion of new indwelling urinary catheter on 3/19/26 at 1:40 P.M., showed: -Resident was assisted to the bed to lay down. -RN B with gloved hands, took a pair of used scissors and cut the port to catheter balloon port, with zero return of any fluid in to collecting container. RN B stated I am old school and this is the way I do it -RN B through away removed catheter, and gloves and washed hands. -RN B laid down a clean towel and sat urinary catheter insertion tray on top of towel, dropped the insertion tray on the floor picked up and placed back on top of the clean towel. Opened the sterile insertion tray, applied sterile gloves, and opened the cleansing swabs, used one swab at a time, and cleaned the urinary opening in a circular motion and did not cleanse away from the urinary opening. Catheter tubing was inserted into the urinary opening with a 20-cc balloon bulb inflated to secure inside the placement. No immediate return of urine was noted, with sterile gloves dropped the leg secure strap on the floor then bent over and picked it up and then with contaminated glove attempted to advance the urinary catheter further into the resident's urinary opening. 4.Review of Resident #5's MDS dated [DATE], showed: -Severe cognitive impairment; -Dependent in all care areas including eating, mobility, toileting and hygiene; -Diagnoses included Non-Alzheimer's Dementia, pain and Urinary Tract Infection (UTI). Review of care plan dated 11/13/2025, showed: -Dependent on staff for Activities of Daily Living (ADLs); -Staff to provide catheter care every shift and as needed; -At risk for UTI's and skin breakdown. Observation on 03/19/2026 at12:20P.M. showed: -RN A removed sterile catheter from kit, tore the plastic packaging of the catheter, approximately 3-4 inches from tip of catheter, and handed catheter to CNA A; -RN A open and applied sterile gloves; -RN A placed each of his/her hands on inner thighs of each of Resident's legs, breaking one hand sterile technique of catheter insertion; -RN A used his/her left hand to stabilize resident's genitals, removed an antiseptic swab from packaging with his/her right hand; -RN A wiped antiseptic swab in a circular motion, then placed used swab into catheter kit packaging; -RN A obtained another antiseptic swab and wiped resident's genitals with swab in a circular motion, placed used swab into catheter kit and then repeated same process with remaining antiseptic swab; this should be done in one motion in a downward swipe and then discarded to ensure antisepsis (the application of antimicrobial chemicals to living tissue to destroy pathogens and prevent infection.) -RN A removed the lubricant packaging from catheter and obtained catheter from CNA A; -RN A inserted the catheter into resident's urethra, slightly removed catheter and then re-inserted catheter until urine was seen flowing from catheter; -RN A removed gloves, while applying a new sterile glove to his/her right hand, experienced difficulties, used his/her ungloved left hand to manipulate fingers of glove on to his/her right hand; -RN A used contaminated sterile gloved hand to further advance catheter into urethral opening; -RN A used both contaminated gloved hands to fill internal catheter stabilizing balloon through provided port on catheter tubing; -CNA A attached drainage bag and tubing to bed frame; -CNA A then lowered resident's bed causing a dependent loop in tubing and the drainage bag to lay directly on the floor. During an interview on 03/20/2026 at 10:00A.M., RN C said: there should be no dependent loop or coiling in tubing as this stops flow of urine and can lead to infection and Resident #5 is prone to frequent UTI's; During an interview on 03/19/2026 at 4:00P.M., RN A said: -He/She was not used to working with CNA C and that messed up the flow of the process; -He/She uses a circular motion to cleanse genitals instead of using a downward stroke; -He/She should have cleansed peri area of resident after inserting new catheter. During an interview on 03/20/2026 at 12:00P.M., the DON said: -Sterile procedure to be maintained during catheter insertion; -Staff should provide perineal care after insertion of catheter; -Staff should provide catheter care each shift and as needed for soiling.

Based on interview and record review, the facility failed to ensure the Do Not Resuscitate Order's (DNR, medical order that instructs the health care provider not to do resuscitative measures if a person's heart stops) for Resident #29, Resident #13 and Resident #21 were correct when the Durable Power of Attorney's (DPOA) a legal document that authorizes a designee to manage financial or medical affairs if the person became incapacitated, name was printed on the DNR instead of the name of the resident on Resident #29's DNR, and when the facility failed to ensure that two residents (Resident #13 and Resident #21) had physician letters of incapacitation prior to the Power of Attorney designee making decisions for him/her. This affected three of 14 sampled residents (Resident #29, Resident #13 and Resident #21). The facility census was 56. The facility did not provide the requested code status policy.1. Review of Resident #29's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/17/26 showed:-Severe cognitive impairment;-Partial assistance from staff for Activities of Daily Living (ADL)s;-Incontinent of bowel and bladder;-Diagnoses included dementia, high blood pressure and coronary artery disease. Review of the resident's care plan dated 03/22/26 showed the resident had a code status of DNR.Review of the resident's medical record showed:- On 11/17/25 a physician's order for Do Not Resuscitate;- DNR showed the name of the resident's DPOA printed on the line reserved for the name of the resident;- The DNR form was signed by the resident's DPOA on 11/14/25 and by the physician on 11/25/25.During an interview on 03/20/2026 at 9:40 A.M., the Social Services Director (SSD) said: - She was responsible for ensuring the code status was correct for each resident;- She was responsible for ensuring DPOA paperwork was in place if needed and incapacitation letters if the resident had been deemed incapacitated; -The resident's name should be on the top of the DNR not the DPOA's name;-The resident should be the one to sign the DNR if they have not been deemed incapacitated.2.Review of Resident #13's admission MDS dated [DATE] showed:-Moderate cognitive impairment;-Partial assistance from staff for ADLs;-Incontinent of bowel and bladder;-Diagnoses included Parkinson's Disease and depression.Review of the resident's care plan dated 02/12/26 showed:-The resident had a code status of DNR.Review of the resident's medical record showed:-On 05/02/25 a physician's order for Do Not Resuscitate;-The DNR signed by DPOA on 05/02/25;-No letter of incapacitation was found that deemed the resident to incapacitated.3.Review of Resident #21's Annual MDS dated [DATE] showed:-Severe cognitive impairment;-Substantial assistance with ADLs;-Incontinent of bowel and bladder-Diagnoses included Atrial fibrillation (an irregular heartbeat), kidney disease and dementia. Review of the resident's care plan dated 03/18/26 showed the resident had a code status of DNR.Review of the resident's medical record showed:-The DNR signed by DPOA on 01/15/25;-02/26/25 a physician's order for Do Not Resuscitate;-No letter of incapacitation was found that deemed the resident incapacitated.During an interview on 03/20/2026 at 9:40 A.M., the SSD said:-There were not letters for incapacity for resident #13 or #21;-She should have ensured resident #13 and resident #21 had incapacity verifications on file before the DPOAs signed the DNRs. During an interview on 03/20/2026 at 10:12 A.M., the Director of Nursing (DON) said:-The resident's name should be printed on their DNR not the name of the responsible party;-She expects the DNRs to be correct;-SSD in charge of making sure the DNRs are correct.During an interview on 03/20/2026 at 10:46 A.M., the Administrator said:-The name of the DPOA should not be printed on the line designated for the resident;-The DNR for resident #13 and resident #21 are not correct;-There were no incapacitation letters for resident #13 and resident #21 on file;-The facility is responsible for ensuring incapacitation letters are in the resident's medical record;-She expected the DNRs for Resident #13 and Resident #21 to be correct.

Based on interview and record review, the facility failed to ensure resident assessments were completed accurately for two of 14 sampled residents (Resident #1 and Resident #7) when the facility failed to accurately document a diagnosis of Resident #1 and failed to accurately document a Urinary Tract Infection (UTI) for Resident #7. The facility census was 56.The facility did not provide a resident assessment or Minimum Data Set (MDS) policy. MDS is a federally mandated assessment completed by facility staff in accordance with specified formats and timelines in conducting comprehensive assessments as part of an ongoing process through which the facility identifies preferences and goals of care, functional and health status, strengths and needs. 1. Review of Resident #1's Quarterly MDS, a federally mandated assessment completed by facility staff, dated 02/03/26, showed:-Resident had no cognitive impairment;-Diagnoses included high blood pressure and kidney failure;-Chronic Obstructive Pulmonary Disease (COPD) was not selected as a diagnosis. Review of Physician Order Set (POS) showed:-An order dated 12/30/2025 for Azithromycin (an antibiotic) 250mg orally, daily for four days for an Upper Respiratory Infection;-An order dated 12/29/2025 for Mucinex (a medication used to thin and loosen mucus), twice daily for seven days for an Upper Respiratory Infection;-Orders dated 05/02/2025 for cough syrup as needed and supplemental oxygen as needed. Review of Electronic Medical Record (EMR) dated 01/13/2026, showed an emergent transport to the emergency room for low blood oxygen levels, shortness of breath and tachycardia (abnormally fast resting heart rate). Review of EMR dated 01/16/2026 showed resident had been admitted to the hospital with diagnosis of COPD exacerbation and Pneumonia. Review of resident's care plan dated 02/25/2026, showed:-Resident required Enhanced Barrier Precautions (EBP- an infection control strategy in nursing homes requiring the use of gowns and gloves during high-contact care for residents at risk of multidrug-resistant organisms (MDROs)) related to a chronic wound;-Poor safety awareness and confusion, both can be symptoms of low blood oxygen levels, a known complication of COPD;-No mention of any use of supplemental oxygen, or goals and interventions to prevent recurrent Upper Respiratory Infections (URI). During an Interview on 03/20/2026 at 12:00P.M., the MDS coordinator said that if a resident was admitted to facility with a diagnosis of COPD, then that diagnosis should be reflected on the MDS assessment after admission and that he/she often is not able to update care plans and MDS assessments as quickly as he/she should. 2. Review of Resident #7's Quarterly MDS dated [DATE], showed:-Resident had severe cognitive impairment;-Incontinent of bowel and bladder; total assist of nursing care;-Diagnoses included heart disease, osteoarthritis and failure to thrive;-Urinary Tract Infection (UTI) in last 30 days was not selected. Review of Resident's care plan dated 11/12/2025, showed:-He/She required assistance with dressing, toileting, transfers, and locomotion;-He/She had urinary incontinence and was at risk for UTI'S and skin breakdown;-Resident to have any UTI's detected and treated promptly;-At risk for not having needs met. Review of Resident's Physician Order Sheet (POS) showed an order for urinary analysis (UA) dated 03/10/2026; and a subsequent order for Keflex (an antibiotic) 500mg orally twice daily for 7 days for a UTI after a positive result on UA. During an Interview on 03/20/2026 at 12:00P.M., the MDS coordinator said:-If a resident was admitted to facility with a diagnosis of UTI and is on antibiotics, then that diagnosis should be reflected on the MDS assessment after admission;-He/she often is not able to update care plans and MDS assessments as quickly as he/she should;-Most information is obtained from electronic medical record and facility staff charting. During an interview on 03/20/2026, at 12:19P.M., the DON stated that all MDS assessments should be accurate and completed in a timely manner per CMS requirements.

Based on interview and record review the facility failed 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 and psychosocial needs that are identified in the comprehensive assessment. When facility staff did not address UTI (urinary tract infection) with antibiotic usage for two residents (Resident #25 and Resident #14), did not address use of anticoagulant medication or therapeutic activities for one resident (Resident #52) and when dementia care had not been cared planned for one resident (Resident #29 & Resident #52). This affected four of the 14 sampled residents. The facility census was 56.Review of the facility's care plan policy, updated 8/2024 showed a comprehensive, person-centered care plan will include measurable objectives and timetables to [NAME] the resident's physical, psychosocial and functional needs is developed and implemented for reach resident. This includes services that will attain or maintain the resident's highest practicable self. Care plan will be completed by qualified persons, culturally competent and have careful consideration of the resident's problems and needs. Care plans are to be revised and updated according to the resident's needs and ongoing. 1.Review of Resident #25's Quarterly MDS, (minimum data set) A federally mandated assessment completed by facility staff., dated 2/24/26 showed: -Cognition not intact -Required assistance with all personal hygiene, grooming, transfers, and indwelling urinary catheter care. -Diagnoses: disease of the prostate with ongoing urinary tract symptoms, high blood pressure, dementia, and reoccurring antibiotic use for urinary infections. Review of the resident's care plan dated 3/11/26 showed no indication of antibiotic use for UTI or history of UTIs. During an interview on 3/19/26 at 1:45 P.M. the family member said the resident had problems with infections and frequent needs of antibiotics because of the catheter and was involved in the care planning for the resident. He/she expected that all needs regarding antibiotics and care of the UTI would be addressed so all staff know how to best care for the resident. During an interview on 3/19/26 at 2;45 P.M RN B said the resident's use of antibiotics should be care planned, and all care associated with the urinary catheter should be care planned. 2.Review of Resident #14's Quarterly MDS, dated [DATE] showed: -Cognition not intact -Behaviors associated with dementia -Total assist of personal hygiene, grooming and care. -Urinary incontinence with UTIs Review of care plan dated 1/15/2026 and reviewed again on 3/3/26 did not address frequent UTI and use of antibiotics to manage UTI or staff intervention to help manage UTI prevention. Behavioral monitoring on the care plan did not address the possibility of an active UTI as probable cause of behaviors. Review of lab results for urinalysis dated 3/18/26 showed active UTI and new antibiotics ordered for the treatment included Keflex 250mg daily with no stop date. During an interview on 3/19/26 RN A said that resident's with UTIs, history of UTI, and use of antibiotics should be care planned and was not sure why it was not listed on the resident's current care plan. 3.Review of Resident #52's Quarterly MDS, dated [DATE]., showed -Not Cognitively Intact related to Dementia; -Total assist of all personal care, hygiene, transfers, medication administration; -Used anticoagulants (a medication to keep blood from forming a clot) to prevent blood clots. Review of physician's orders showed the resident was prescribed Eliquis 5mg twice a day to prevent blood clots. Review of the resident's care plan completed on 3/18/25 and reviewed on 3/5/26 showed the resident's care plan did not address the resident's use of the blood thinner Eliquis or interventions needed for the monitoring of the resident while on this medication. The care plan additionally did not address any activity interests or dementia care with resident centered interventions to address psychosocial needs of the resident or staff interventions to help with behaviors when occur. During an interview on 3/19/26 at 3:30 P.M RN B said the resident takes a blood thinner twice a day and was not sure why it was not addressed on the care plan but should be. RN B was not sure who was responsible for doing this but did not think it was his/her responsibility to do that. RN B did not know the interests of the residents, other than sitting in his/her room when spouse visits. During an interview on 3/19/26 at 3:50 P.M. the MDS coordinator said she does her best to update care plans related to changes in the resident's needs when she can and when the information is provided to her. During an interview on 3/20/26 at 12:15 P.M the Director of Nursing said- Residents on antibiotics, blood thinners, infections, dementia care, and activity interest showed be care planned and updated as needed. 4.Review of Resident #7's Quarterly MDS dated [DATE], showed: -Severe cognitive impairment; -Incontinent of bowel and bladder; -Two or more falls since previous MDS assessment; -Requires maximum assistance with eating, toileting, mobility and transfers; -Diagnoses included heart disease, osteoarthritis and failure to thrive. Review of Resident's care plan dated 11/12/2025, showed: -He/She requires assistance with dressing, toileting, ambulation with walker at times, transfers, and locomotion; -Protection sleeves to both arms and legs to prevent skin tears; -He/She is at risk for skin breakdown due to thin skin, poor nutrition, incontinence, and decreased activity level; -Skin integrity problem start date of 01/13/2025 with no updated goals, interventions or approaches since initiation. During an interview on 03/18/2026 at 1:43P.M., CNA B said: -Resident previously ambulated and went to restroom; -Resident now dependent in all cares, including eating, toileting, ADL's and mobility; -Resident is a mechanical lift transfer with two staff members; During an interview on 03/20/2026 at 12:00P.M., the MDS Coordinator said: -Care plans are updated every quarter; -Information is obtained from charting; -If a resident is a mechanical lift transfer, the resident should be listed as dependent not maximum assist; -It is not reasonable for a resident that has gone from continent and ambulatory to dependent with all cares and incontinent to not have skin integrity care plan updated or adjusted. During an interview on 03/20/2026 at 12:40P.M., the DON said that care plans are updated quarterly and should be accurate to ensure proper care of residents. 5. Review of Resident #1's Quarterly MDS dated [DATE], showed: -No cognitive impairment; -Dependent with transfers, lower body tasks and toileting hygiene; -Participated in physical and occupational therapies; -Diagnoses included kidney failure, diabetes, high blood pressure and pain. Review of care plan dated 12/26/2025, showed: -He/She has a history of fall with hip fracture; -He/She is walking with a platform walker; -Mechanical lift for all transfers, currently non-weight bearing related to a wound. Review of Progress Notes showed: -11/04/2025 Resident chooses to use mechanical lift for transfer instead of pivot transfer or slide board transfers; -02/10/2026 Therapy discontinued mechanical lift, resident able to use sit to stand machine for transfers and toileting; -02/13/2026 Physician signed order to change transfer status; -02/26/2026 Discontinued sit to stand transfer and returning to mechanical lift due to inability to stand with staff. Review of activity order for Resident #1 showed: -Activity as tolerated ordered on 06/05/2024; -Activity order discontinued on 09/09/2024; -No additional activity or weight bearing order initiated. Review of Referral Form from Podiatrist dated 01/09/2026, showed resident may progress weight-bearing activity and has been cleared to stand and bear weight on both feet. Review of Referral Form from Podiatrist dated 02/19/2026, showed resident now full weight-bearing. 6.Review of Resident #5's Quarterly MDS dated [DATE], showed: -Severe cognitive impairment; -Dependent in all care areas including eating, mobility, toileting and hygiene; -Diagnoses included Non-Alzheimer's Dementia, pain and Urinary Tract Infection (UTI). Review of care plan dated 11/13/2025, showed: -Dependent on staff for Activities of Daily Living (ADLs); -Flat call light to be at Resident's side where it will activate if he/she attempts to get out of bed without assistance. -At risk for UTI's and skin breakdown. During an interview on 03/20/2026 at 12:00P.M., the MDS Coordinator said: -If an MDS is submitted 03/05/2026, there are 14 days to update comprehensive care plan; -All nursing staff is able to access each resident's care plan in Electronic Medical Record (EMR) system; -Nursing staff work all units and are responsible to ensure they are looking at care plans to provide appropriate care.

Based on observation, interview, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff failed to provide complete perineal care for Residents #13, #5, #7, #50 after an incontinence episode. This affected four of 14 sampled residents. The facility census was 56. Review of the facility's Perineal Care policy dated 2024 showed:-This procedure provides cleanliness and comfort to the resident and prevents infections;-Review the resident's care plan for any special needs of the resident;-Assemble any special supplies that are needed;-Use personal protective equipment;-Wipe from front to back cleaning all areas that urine and feces have touched;-Document how the resident tolerated the procedure and if the resident refused care;-Report any other information in accordance with facility policy and professional standards of practice. 1. Review of Resident #13's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 01/27/26 showed:-Moderate cognitive impairment;-Partial assistance from staff for activities of daily living (ADL)s;-Incontinent of bowel and bladder;-Diagnoses included Parkinson's Disease and depression. Review of the resident's care plan dated 02/12/26 showed:- Assistance of one staff for toileting;- Incontinent of urine;- Observe for signs and symptoms of a urinary tract infection (UTI) a common bacterial infection of the bladder or kidneys causing pain and burning. Review of the resident's Physician's Order Sheet (POS) dated February 2026 showed:-3/9/26 order for urinalysis (a test that can detect a urinary tract infection);-Order start date: 3/11/26, Bactrim DS (an antibiotic used to treat infections) 800 milligram (mg) /160 mg, give twice daily for UTI;-Order start date: 3/17/26, Amoxicillin (an antibiotic used to treat infections) 500 mg, give one tablet every 8 hours. Review of the resident's medical record showed:-3/11/26 lab results showed the resident's urine contained bacteria;-3/18/26 progress note, continued on Amoxicillin (antibiotic used to treat infection) for UTI. The resident was incontinent of urine and required assistance with perineal care;-03/16/2026 new order received to discontinue Bactrim DS and start Amoxicillin. Observation on 03/19/2026 at 08:43 A.M., showed:-Nurse's Aide (NA) A entered the resident's room;-The resident sat on the toilet;-There were droplets of yellow liquid on the top of the resident's upper thighs and in between his/her legs;-NA A washed his/her hands and applied gloves;-NA A removed the resident's wet brief while he/she sat on the toilet;-NA A placed a clean brief on the resident;-NA A cleaned the back of the resident using one wipe for each cleansing;-NA A assisted the resident to his/her feet and pulled the resident's clean brief and pants up;-NA A did not offer or attempt to clean the front of the resident where urine and/or feces had touched. During an interview on 03/19/2026 at 09:05 A.M., NA A said:-He/She had not been on the resident's hall very often;-He/She should have asked or offered to do perineal care on the resident's front side but he/she did not;-When doing perineal care he/she should have cleaned all areas that urine or feces had touched or offer to do so. During an interview on 03/19/2026 at 09:24 A.M., Registered Nurse (RN) A said:-The resident required assistance of one staff for toileting;-The resident could get himself/herself to the toilet but needed help with cleaning up;-The resident refused cares at times but he/she expected NA A to offer to clean all areas that urine or feces had touched;-The resident was on an antibiotic for a UTI;-Failing to clean all areas that urine and feces had touched can contribute to a uti. During an interview on 03/20/2026 at 10:12 A.M., the Director of Nursing (DON) said:-She expected staff to clean all areas where urine or feces had touched;-She expected NA A to offer to do perineal care on the resident's front side;-The resident was on an antibiotic for a UTI;-Incomplete perineal care was an important step to prevent infections. During an interview on 03/19/2026 at 10:38 A.M., the Administrator said:-She expected care to be given to prevent infections and provide comfort to the residents. 2.Review of Resident #5's MDS dated [DATE], showed: -Severe cognitive impairment; -Dependent in all care areas including eating, mobility, toileting and hygiene; -Diagnoses included Non-Alzheimer's Dementia, pain and Urinary Tract Infection (UTI). Review of care plan dated 11/13/2025, showed: -Dependent on staff for Activities of Daily Living (ADLs); -Staff to provide catheter care every shift and as needed; -Requires enhanced barrier precautions to help prevent resident from infection; -At risk for UTI's and skin breakdown. Observation of evening ADLs on 03/17/2026 at 07:43P.M., showed: -LPN A reminded MDS to apply Personal Protection Equipment (PPE) prior to providing cares; -During incontinence cares, LPN A wiped buttocks and coccyx four times with the same disposable wipe before discarding; -External catheter stabilizing device not properly attached, which can cause internal tension and injury; -Neither staff member provided a drink to dependent resident; -No oral care or hair care provided to resident. During an interview on 03/19/2026 at 03:30P.M., LPN A said that disposable wipes should not be folded and reused, after a wipe is used, it must be discarded. During an interview on 03/20/2026 at 12:00P.M., the DON said: -Incontinent residents to be checked for incontinence and changed every two hours and as needed; -Dependent residents should be assisted with oral care and ADLs twice daily; -Staff should offer a drink to dependent resident when in the room and when providing cares. 3.Review of Resident #7's Quarterly MDS dated [DATE], showed: -Severe cognitive impairment; -Incontinent of bowel and bladder; -Requires maximum assistance with eating, toileting, mobility and transfers; -Diagnoses included heart disease, osteoarthritis and failure to thrive. Review of Resident's care plan dated 11/12/2025, showed: -He/She requires assistance with dressing, toileting, ambulation with walker at times, transfers, and locomotion; -Protection sleeves to both arms and legs to prevent skin tears; -He/She is at risk for skin breakdown due to thin skin, poor nutrition, incontinence, and decreased activity level; An observation during evening cares on 03/17/2026 at 06:48P.M., showed: -LPN A and MDS transferred resident to bed using a mechanical lift, revealing resident's saturated pants; -Incontinence brief is dated and timed as 03/17/26 at 02:07P.M; -LPN A placed clean brief underneath soiled brief during incontinence cares; LPN A wiped bowel with disposable wipe twice, not disposing after first use; -LPN A wiped resident's genitals with disposable wipe, folded wipe and wiped three more times before disposing of used wipe; LPN A repeated this action two additional times before disposing of wipe; -No barrier cream was applied; -Resident was heard telling staff that his/her tailbone was hurting. An observation on 03/18/2026 at 1:43P.M., showed: -CNA C and CNA D transferred resident to bed utilizing a mechanical lift, revealing saturated pants; -Brief is timed and dated 03/18/2026 at 08:07A.M.; -During incontinence cares, CNA D wiped resident's coccyx and buttocks with a disposable wipe, folded and re-used wipe three times; -Staff did not provide oral care or hydration during cares. An observation of morning cares on 03/19/2026 at 09:29A.M., showed: -Incontinence brief was saturated, timed and dated for 03/19/2026 at 06:25A.M.; -CNA A wiped resident's genitals and tucked used disposable wipe in between legs; -CNA A obtained a new wipe, wiped resident and tucked used wipe in between resident's legs; CNA A repeated this action two additional times, tucking used wipe in between resident's legs; -Resident was rolled on to side, CNA A removed soiled brief, rolled and placed on resident's bed; -CNA A and ADON did not perform hand hygiene or use ABHR between dirty and clean tasks; -No oral care or hydration provided to resident. During an observation on 03/20/2026 at 9:06A.M., showed: -CNA B and CNA C provided incontinence cares to resident, brief not timed or dated and is saturated; -Resident is wearing same clothing as previous day; -No oral care or hydration provided to resident. 4.Review of Resident #50's Comprehensive MDS dated [DATE], showed: -Resident has severe cognitive impairment; -Incontinent of bowel and bladder; -Dependent on facility staff for ADL's toileting, hygiene and eating; -Diagnoses included reflux, thyroid disorder and Alzheimer's Dementia. Review of care plan dated 01/08/2026, showed: - Requires assistance with ADLs due to poor cognition; - Staff must anticipate needs; -Assist with oral care to keep mouth clean; -At risk for skin breakdown due to incontinence and immobility. Observation on 03/17/2026 at 7:33P.M., showed: -Resident has no bedside table, water pitcher on dresser, resident unable to reach when in bed; -Resident was assisted via mechanical lift to bed, revealing a saturated pants; -Brief was timed and dated 03/17/2026 at 4:00P.M.; -Brief and pants were soiled and saturated; -LPN A wiped resident with disposable wipe, folded wipe and wiped groin again; -LPN A removed lift sling from underneath resident by pulling material, shearing across back, instead of rolling resident to remove; -No drink was offered to resident or oral care provided. During an interview on 03/20/2026 at 9:15A.M., CNA B said: -Incontinent residents should be checked every 2 hours and changed as needed; -If a brief is checked and is dry, staff will indicate that on brief and put new time and date on brief; -Barrier cream should be applied to incontinent residents with each brief change. During an interview on 03/20/2026 at 11:15A.M., CNA A said: -Residents should not be left in wheelchair long enough to saturate brief and pants; -Incontinent residents should have their brief checked every two hours and changed as needed; -He/She doesn't apply barrier cream as often as he/she should. During an interview on 03/20/2026 at 10:00A.M., RN C said: -If a brief is checked and is dry, it is best practice to change brief anyway; -Barrier cream should be applied with each brief change; -Drinks should be offered to residents when in room; -Oral care should be completed upon rising, after meals and before going to bed in evening; -Used disposable wipes should no be tucked in between resident's legs after use as this can lead to infection. During an interview on 03/20/2026 at 12:00P.M., the DON said: -Each incontinent resident should have brief checked every two hours and changed as needed; -Barrier cream to be applied to incontinent residents with each incontinent episode; -Resident's should not be left in a brief long enough to saturate brief and pants; -Staff complete yearly skills check-offs for resident cares.

Based on observation, interview, and record review the facility failed to ensure that two residents (Resident #5 & #25) who had urinary catheter (a tube inserted into the bladder to drain urine from the body), received appropriate treatment and services to prevent urinary tract infections when the facility failed to provide proper catheter care management. The affected two of the sampled 14 residents. The facility census was 56Review of the facility's undated Catheter Insertion and Removal Policy showed: -To remove catheter: put on disposable gloves, attach syringe to balloon port of catheter and aspirate entire amount of sterile water in balloon; -Pinch catheter and withdraw gently and slowly; -After donning sterile gloves, use one hand to expose urinary meatus, with the other hand, cleanse resident using one stroke downward and discarding cleanser, repeat the same procedure with other side of urinary opening; -Cleanse directly over the urinary meatus with a clean wipe, one stroke downward and discard;-Insert catheter into urinary opening at an upward angle; -Secure catheter tubing to leg; -Give peri-care and leave resident clean and comfortable; -Always keep drainage bag off the floor. Review of the facility's undated Indwelling Catheter Care Policy showed: -Pour warm water over perineal area; -Wash perineum well with soap and warm water, taking care to wash from front to back; -Cleanse well at catheter insertion, taking care not to pull on catheter or advance further into urinary opening; -Rinse well with warm water and pat dry gently with clean towel. Review of the Journal of Infection Control and Epidemiology article titled Guideline for Prevention of Catheter Associated Urinary Tract Infections dated 01/02/2019, showed: -Do not allow the drainage bag to touch or rest on the floor; -Maintain unobstructed urine flow by keeping the drainage tube above the collection bag and free of kinks; -Avoid dependent loops. 1.Review of Resident #5's MDS dated [DATE], showed: -Severe cognitive impairment; -Dependent in all care areas including eating, mobility, toileting and hygiene; -Recent admission to hospice services; -Diagnoses included Non-Alzheimer's Dementia, pain and Urinary Tract Infection (UTI). Review of care plan dated 11/13/2025, showed: -Dependent on staff for Activities of Daily Living (ADLs); -Staff to provide catheter care every shift and as needed; -At risk for UTI's and skin breakdown. Review of the Physician Order Sheet (POS) dated 03/18/2026 showed an order for Macrobid (an antibiotic) 100mg orally twice daily for seven days for a UTI. Review of Electronic Medical Record (EMR) showed resident hospitalized [DATE]-[DATE] with a UTI; a new urinary catheter was placed during hospital admission. Observation of removal of previous catheter and insertion of new indwelling catheter change on 03/19/2026 at12:20P.M. showed: -RN A placed a clean towel at foot of bed and a clean towel between him/her and Resident. RN A opened dependent drainage bag with attached tubing, handing it to CNA A instructing him/her to hold it in his/her hand; -RN A used scissors to cut the internal catheter stabilizing device port on catheter tubing, draining clear fluid into a 1000mL graduate. When the fluid stopped draining from tubing, RN A did not look at graduate to determine amount collected; sat graduate down on Resident's bed, it became disturbed, the graduate fell over, spilling fluid on Resident's bed and bedsheets. RN A did not follow the facility policy or appropriate nursing techniques when removing the indwelling catheter. -ADON removed the graduate, used catheter, used tubing with drainage bag and disposed of them in the garbage; -RN A and ADON washed hands and applied new gloves. -RN A placed gathered supplies in between Resident's calves. He/She opened manufacturer prepared sterile Catheter kit, removing packaged lubricant and packaged sterile gloves and placing on the towel between him/her and the Resident. -RN A opened packaged sterile antiseptic swabs and then returned swabs contained in original packaging into the catheter kit. -RN A removed sterile catheter from kit, tore the plastic packaging of the catheter, approximately 3-4 inches from tip of catheter, and handed catheter to CNA A, instructing her to hold the catheter with his/her left hand and not to touch the exposed catheter or move it. -RN A tore open the lubricant package he/she obtained from towel and instructed CNA A to guide foley into opening on lubricant packaging; when this was completed, CNA A continued to hold catheter tubing wrapped in remaining plastic packaging; -RN A opened and applied sterile gloves, explained remaining procedure steps to the resident and asked him/her to open and relax his/her legs; -RN A placed each of his/her hands on inner thighs of each of Resident's legs, breaking one hand sterile technique of catheter insertion; -RN A used his/her left hand to stabilize resident's genitals, removed an antiseptic swab from packaging with his/her right hand; -RN A wiped antiseptic swab in a circular motion, then placed used swab into catheter kit packaging; -RN A obtained another antiseptic swab and wiped resident's genitals with swab in a circular motion, placed used swab into catheter kit and then repeated same process with remaining antiseptic swab; Did not clean away from the resident's urinary opening. -RN A removed the lubricant packaging from catheter and obtained catheter from CNA A; -RN A inserted the catheter into resident's urethra, slightly removed catheter and then re-inserted catheter until urine was seen flowing from catheter, RN clamped catheter by pinching tubing, stopping flow of urine; -RN A instructed CNA A to remove protective cap from tubing and drainage bag and connect tubing to catheter; -RN A removed gloves, applied a glove to his/her right hand, experienced difficulties, used his/her ungloved left hand to manipulate fingers of glove on to his/her right hand; -RN A applied left glove; -RN A used his/her right hand to further advance catheter into urethral opening without maintaining sterile technique. -RN A used both his/her hands to fill internal catheter stabilizing balloon through provided port on catheter tubing; -CNA A attached drainage bag and tubing to bed frame, RN A gathered and disposed of used supplies, removed gloves, washed hands and applied new pair; -CNA A removed gloves and applied a new pair; -RN A returned to resident's bedside, used alcohol pads to remove sticker from external catheter stabilizing device on resident's left inner thigh and then placed new external catheter stabilizing device to same location on resident's left inner thigh; -CNA A then lowered resident's bed causing a dependent loop in tubing and the drainage bag to lay directly on the floor. During an observation on 03/20/2026 at 09:30A.M., -CNA B did not anchor catheter tubing at insertion prior to cleaning tubing; -Resident's external catheter stabilizing device not secured properly; -CNA B asked surveyor if drainage bag should lay on floor; -CNA C said that resident likely had a UTI based on apple juice colored urine. During an interview on 03/20/2026 at 09:30A.M., CNA C stated that catheter tubing should be anchored at insertion prior to cleansing. During an interview on 03/20/2026 at 10:00A.M., RN C said: -There should be no dependent loop or coiling in tubing as this stops flow of urine and can lead to infection and Resident is prone to frequent UTI's; -The catheter tubing should be attached to external stabilizing device by groove in tubing, not allowed to move freely in stabilizing device; -Staff has been trained in proper placement of external catheter stabilizing devices. During an interview on 03/19/2026 at 4:00P.M., RN A said: -He/She has always cut the balloon port because he/she is old school; -Cannot be sure how much fluid was removed from internal stabilizing balloon as fluid spilled on bed; -He/She uses a circular motion to cleanse genitals instead of a front to back swipe; -He/She should have cleansed peri area of resident after inserting new catheter. 2.Review of Resident #25's Quarterly MDS, dated [DATE] showed: -Cognition not intact -Required assistance with all personal hygiene, grooming, transfers, and indwelling urinary catheter care. -Diagnoses: disease of the prostate with ongoing urinary tract symptoms, high blood pressure, dementia. Review of physician orders, dated 1/30/26 showed change indwelling urinary catheter monthly on the 19th and as needed for nodular prostrate. Observation and interview with RN B during a indwelling urinary catheter removal and insertion of new indwelling urinary catheter on 3/19/26 at 1:40 P.M., showed: -Resident was assisted to the bed to lay down. -RN B with gloved hands, took a pair of used scissors and cut the port to catheter balloon port, with zero return of any fluid in to collecting container. RN B stated I am old school and this is the way I do it -RN B through away removed catheter, and gloves and washed hands. -RN B laid down a clean towel and sat urinary catheter insertion tray on top of towel, dropped the insertion tray on the floor picked up and placed back on top of the clean towel. Opened the sterile insertion tray, applied sterile gloves, and opened the cleansing swabs, used one swab at a time, and cleaned the urinary opening in a circular motion and did not cleanse away from the urinary opening. Catheter tubing was inserted into the urinary opening with a 20 cc balloon bulb inflated to secure inside the placement. No immediate return of urine was noted, with sterile gloves dropped the leg secure strap on the floor then bent over and picked it up and then with contaminated glove attempted to advance the urinary catheter further into the resident's urinary opening. During an interview on 03/19/2026 at 4:00P.M., RN A said: -He/She has always cut the balloon port because he/she is old school; -Cannot be sure how much fluid was removed from internal stabilizing balloon as fluid spilled on bed; -He/She uses a circular motion to cleanse genitals instead of a front to back swipe; -He/She should have cleansed peri area of resident after inserting new catheter. During an interview on 03/20/2026 at 12:00P.M., the DON said: -Staff should provide catheter care each shift and as needed for soiling; -Catheter tubing should be anchored at insertion site prior to cleaning; -Staff should not fold and re-use wipes; -There should be coiling and a dependent loop in catheter tubing when hanging below level of resident's bladder.

Based on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than five percent (5%). When staff failed to verify a physician's order prior to the administration of insulin and narcotic medications resulting in two errors out of 25 opportunities for error, which resulted in an error rate of 8%. This affected two of the 14 sampled residents, (Resident #1 and #34). The facility census was 56.Review of the facility's policy titled, Medication administration-general guidelines, revised 8/16, showed: - Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so;- Personnel authorized to administer medications do so only after they have familiarized themselves with the medication;- Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR)/eMAR (electronic MAR) is compared with the medication label;- Information on the medication should be checked against the MAR/eMAR or treatment administration record (TAR)/electronic TAR (eTAR) at least three times during the med preparation and administration process;- If the label and MAR/eMAR or TAR/eTAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule prior to administering. 1. Review of Resident #1's admission baseline care plan showed the resident was alert and oriented with cognition intact and a recent re-admission to the facility. The resident was an insulin dependent diabetic and took insulin with all meals. Record review showed the resident had a current physician's order began on 1/16/2026 for Lispro Insulin injection of 100 units per milliliter (ml) and orders to have 3ml subcutaneous (fatty layer of tissue between the skin and muscle) with meals. Observation on March 19, 2026 at 11:56 A.M. , showed RN B at the medication cart, with computer screen closed preparing supplies to administer the resident's lispro insulin, dose was dialed to 3 ml and the medication was administered to the resident. The order was was not verified in the electronic medical record at any time by RN B prior to administration of the insulin, and it was not observed that the insulin was documented as given at the time it was observed being administered by RN B from memory. 2. Review of Resident #34's Quarterly MDS (Minimum Data Set), a federally required assessment completed by facility staff, was completed on 11/6/2025 and showed the resident was cognitively intact and was being treated for pain. Record review showed the resident had a physician's order Hydrocodone/APAP 10/325mg 1 tablet to be administered four times a day for pain and began on 1/5/2026 Observation on March 19, 2026 at 12:11 P.M. showed RN B at the medication cart, opened the locked medication box and removed one tablet from the bubble-packed narcotic card (a card board piece of paper containing multiple pills) of Hydrocodone/APA P 10/325mg pills and administered the medication to the resident. RN B did not look at the order on the electronic medical records to verify if their had been any changes to this medication. The medication was given from RN B's memory. During an interview on March 19, 2026 at 3:10 P.M. RN B said he/she knew what medications to give, did not verify the physician's medication orders prior to administering the medications to both resident, but should have and should always verify an order prior to giving any medications. During an interview on March 19, 2026 at 3:45 P.M, the Administrator and Director of Nursing said it is the expectation that all physician orders should be verified and reviewed prior to the administration to any resident, and then documented immediately when given. It was also the expectation that as an RN he/she should always ensure that this was done properly and according to the facility policy and best nursing practice.

Based on observation and interview the facility failed to ensure that two residents (Resident #1, and Resident # 34) were free from significant medication errors when RN B failed to verify an insulin and narcotic order prior to the administration of both, placing both residents at risk for negative outcome to their health and safety. This affected two residents out of 25 possibilities for a significant medication order. The facility census was 56. The facility was unable to provide any policy regarding a significant medication error. 1. Review of Resident #1's admission baseline care plan showed the resident was alert and oriented with cognition intact and a recent re-admission to the facility. The resident was an insulin dependent diabetic and took insulin with all meals. Record review showed the resident had a current physician's order for Lispro Insulin injection of 100 units per milliliter (ml) and orders to have 3ml subcutaneous (fatty layer of tissue between the skin and muscle) with meals. Order began on 1/16/2026 Observation on March 19, 2026 at 11:56 A.M. , showed RN B at the medication cart, with computer screen closed preparing supplies to administer the resident's lispro insulin, dose was dialed to 3 ml and the medication was administered to the resident. The order was was not verified in the electronic medical record at any time by RN B prior to administration of the insulin, and it was not observed that the insulin was documented as given at the time it was observed being administered by RN B from memory. 2. Review of Resident #34's Quarterly MDS (Minimum Data Set), a federally required assessment completed by facility staff, was completed on 11/6/2025 and showed the resident was cognitively intact and was being treated for pain. Record review showed the resident had a current physician's order for Hydrocodone/APAP 10/325mg 1 tablet to be administered four times a day for pain. Order began on 1/5/2026 Observation on March 19, 2026 at 12:11 P.M. showed RN B at the medication cart, opened the locked medication box and removed one tablet from the bubble-packed narcotic card (a card board piece of paper containing multiple pills) of Hydrocodone/APA P 10/325mg pills and administered the medication to the resident. RN B did not look at the order on the electronic medical records to verify if their had been any changes to this medication. The medication was given from RN B's memory. During an interview on March 19, 2026 at 3:10 P.M. RN B said he/she knew what medications to give, did not verify the physician's medication orders prior to administering the medications to both resident, but should have and should always verify an order prior to giving any medications. RN B said not verifying an order prior to the administration of a medication is a significant medication error. During an interview on March 19, 2026 at 3:45 P.M, the Administrator and Director of Nursing said it is the expectation that all physician orders should be verified and reviewed prior to the administration to any resident, and then documented immediately when given. It was also the expectation that as an RN he/she should always ensure that medication orders are verified to prevent a significant medication error from occurring.

Based on observation, interview and record review the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when the facility staff failed to maintain sterile precautions when placing a urinary catheter (a tube placed in the bladder to drain urine) for one Residents (Residents #5) out of the 14 sampled residents, and additionally when dietary staff failed to wash hands when serving water on 300 hall without performing hand hygiene between dirty and clean tasks. The facility census was 56.Review of the facility's undated Catheter Insertion and Removal Policy showed: -After donning sterile gloves, use one hand to expose urinary meatus, with the other hand, cleanse resident using one stroke downward and discarding cleanser, repeat the same procedure with other side of meatus; -Cleanse directly over the urinary meatus with a clean wipe, one stroke downward and discard;-Insert catheter into meatus at an upward angle; -Give peri-care and leave resident clean and comfortable; -Always keep drainage bag off the floor. Review of the facility's Handwashing/Hand Hygiene Policy dated 08/2024, showed: -All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; -Hand hygiene is indicated after touching the resident's environment or contaminated surfaces; -An alcohol-based hand rub (ABHR) is sufficient for most clinical situations. 1.Review of Resident #5's MDS dated [DATE], showed: -Severe cognitive impairment; -Dependent in all care areas including eating, mobility, toileting and hygiene; -Diagnoses included Non-Alzheimer's Dementia, pain and Urinary Tract Infection (UTI). Review of care plan dated 11/13/2025, showed: -Dependent on staff for Activities of Daily Living (ADLs); -Staff to provide catheter care every shift and as needed; -At risk for UTI's and skin breakdown. Observation on 03/19/2026 at12:20P.M. showed: -RN A removed sterile catheter from kit, tore the plastic packaging of the catheter, approximately 3-4 inches from tip of catheter, and handed catheter to CNA A; -RN A open and applied sterile gloves; -RN A placed each of his/her hands on inner thighs of each of Resident's legs, breaking one hand sterile technique of catheter insertion; -RN A used his/her left hand to stabilize resident's genitals, removed an antiseptic swab from packaging with his/her right hand; -RN A wiped antiseptic swab in a circular motion, then placed used swab into catheter kit packaging; -RN A obtained another antiseptic swab and wiped resident's genitals with swab in a circular motion, placed used swab into catheter kit and then repeated same process with remaining antiseptic swab; this should be done in one motion in a downward swipe and then discarded to ensure antisepsis (the application of antimicrobial chemicals to living tissue to destroy pathogens and prevent infection.) -RN A removed the lubricant packaging from catheter and obtained catheter from CNA A; -RN A inserted the catheter into resident's urethra, slightly removed catheter and then re-inserted catheter until urine was seen flowing from catheter; -RN A removed gloves, while applying a new sterile glove to his/her right hand, experienced difficulties, used his/her ungloved left hand to manipulate fingers of glove on to his/her right hand; -RN A used contaminated sterile gloved hand to further advance catheter into urethral opening; -RN A used both contaminated gloved hands to fill internal catheter stabilizing balloon through provided port on catheter tubing; -CNA A attached drainage bag and tubing to bed frame; -CNA A then lowered resident's bed causing a dependent loop in tubing and the drainage bag to lay directly on the floor. During an interview on 03/20/2026 at 10:00A.M., RN C said there should be no dependent loop or coiling in tubing as this stops flow of urine. This can lead to infection and Resident #5 is prone to frequent UTI's. During an interview on 03/19/2026 at 4:00P.M., RN A said: -He/She was not used to working with CNA C and that messed up the flow of the process; -He/She uses a circular motion to cleanse genitals instead of using a downward stroke; -He/She should have cleansed peri area of resident after inserting new catheter. During an interview on 03/20/2026 at 12:00P.M., the DON said: -Sterile procedure to be maintained during catheter insertion; -Staff should provide perineal care after insertion of catheter; -Staff should provide catheter care each shift and as needed for soiling. 2. Observation of the 300 hall on 03/19/2026 at 08:49 A.M., showed: -Dietary Aid (DA) entered unit with two carts, one empty and one containing approximately 20 pitchers of water; -DA entered room [ROOM NUMBER] with two clean water pitchers obtained from cart, he/she exited the room with two different cups and placed them on a different cart; -DA did not wash hands or sanitize with ABHR; -DA obtained two new pitchers of water from cart, entered room [ROOM NUMBER], and exited room with two different pitchers of water and placed on soiled cart; -DA did not wash hands or sanitize with ABHR; -DA repeated this going into rooms: 302, 304, 305, 306, 308 without performing any hand washing or using ABHR; Observation of the 300 hall on 03/20/2026 at 08:48A.M., showed: -Dietary Aid (DA) entered unit with two carts, one empty and one containing approximately 20 pitchers of water; -DA entered room [ROOM NUMBER] with two clean water pitchers obtained from cart, he/she exited the room with two different cups and placed them on a different cart; -DA did not wash hands or sanitize with ABHR; -DA obtained two new pitchers of water from cart, entered room [ROOM NUMBER], and exited room with two different pitchers of water and placed on soiled cart; -DA did not wash hands or sanitize with ABHR; -DA repeated this going into rooms: 303, 304, 305, 306, 307, 308 without performing any hand washing or using ABHR; During an interview on 03/20/2026 at 08:54A.M., the DA said: -He/She passes fresh water each day they work; -Dietary staff responsible for passing fresh water multiple times each day; -He/She should use ABHR between resident rooms when passing fresh water. During an interview on 03/20/2026 at 12:00P.M., the DON said: all staff are frequently in-serviced and observed performing hand hygiene and should use ABHR or wash hands between dirty and clean tasks. Observation of the dining room on 3/18/26 at 11:55 A.M., showed:- Dietary Aide (B) pushed a salad cart from table to table serving residents made to order salads. Staff member was serving without gloves.- 12:08 P.M. Dietary Aide (B) did not wash hands between serving each resident. Dietary Aide (B) touched the back of a resident with bare hands and then proceeded to serve another resident a salad. The salad was made by Dietary Aide (B) using tongs to place various salad items into a small bowl which was then placed in front of the resident with a plastic fork.- 12:10 P.M. Staff member continued to touch various residents and then served them a salad with no hand washing between residents served. During an interview on 3/19/26 at 11:40 A.M., Dietary Aide (B) said:- He/she operates the salad cart in the dining room and serves the residents salads based on their preferences.- He/she should wash hands between residents if touching a non-food service clean surface. He/she should wash his/her hands between touching residents and serving another resident due to the spread of germs. During an interview on 3/20/26 at 10:45 A.M., the Administrator said that staff should wash or sanitize their hands after touching a resident when serving meals in the dining room.

Based on interview and record review, the facility failed to protect one resident's (Resident #2) right to be free from physical abuse when Resident #1 slapped Resident #2 on the cheek. The facility census was 52. Review of the facility's Abuse and Neglect Policy undated., showed:- The purpose is to ensure that the residents of Morningside Center are protected from any mistreatment, neglect or all types of abuse;- Alleged violation is defined as a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse;- Abusers may include facility staff, other residents;- Abuse is defined as any verbal, mental, sexual, physical mistreatment of a resident whether or not an actual injury occurs;- Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish;- The facility will identify, correct, and intervene in situations where abuse is more likely to occur.Review of the facility's Resident Rights policy, undated., showed:- Residents have a right to be free from abuse and restraint;- You shall not be subjected to physical, sexual, or emotional injury or harm. The Administrator was notified on 1/14/2026 of the past noncompliance which began on 12/21/2025. The facility administration immediately separated and protected the resident from further abuse by Resident #1. Residents #1 and #2 were assessed and resident representatives and physicians were notified. All staff were In-serviced on how to have a positive impact and redirect residents with wandering and behaviors including physical, emotional, and verbal abuse by 12/23/25. Each resident's plan of care was updated by 12/24/25. The noncompliance was corrected on 12/24/2025. Review of Resident #1's Annual MDS (Minimum Data Set), a federally mandated assessment tool completed by facility staff, dated 12/23/25., showed:- Cognition not intact;- He/she was dependent on nursing staff for showers, toileting, and transfers;- Diagnoses urinary tract infection, diabetes, and respiratory failure.Review of the resident's care plan, dated 1/9/26, showed:- The resident could be a threat to others and at times become physically and verbally aggressive had been added to the care plan on 12/24/25, after the incident;- The resident was to be moved to a quiet and calm place had been added to the care plan on 12/24/25, after the incident;- The resident had impaired cognition and safety awareness, and staff had been required to calm the resident if signs of distress developed.Review of the resident's nursing progress notes for the month of December 2025 showed:- On 12/17/25 at 11:01 P.M., Resident #1 refusing care while hitting, kicking and cursing at staff;- On 12/18/25 at 2:04 A.M., Resident #1 refusing cares and incontinence checks/changes at this time. Yelling get out of my house while swinging at staff;- On 12/20/25 at 3:25 A.M., Resident #1 yelling at staff and swinging at them when they get close to him/her;- On 12/21/25 at 6:02 P.M., Resident #1 sitting in common area, in wheelchair, when another resident approached him/her, began touching him/her, the resident became angry and slapped Resident #2 across the face. Review of Resident #2's Quarterly MDS, dated [DATE], showed;- Cognition was not intact;- The Resident required moderate assistance with Activities of Daily Living (ADL's) to include showering, toileting, and transfers;- Diagnoses included: dementia, bipolar disorder, insomnia.Review of the resident's care plan, dated 1/9/26, showed:- The staff were required to do regular one on ones with the resident;- The resident had socially inappropriate/disruptive behavioral symptoms as evidenced by removing clothing in common areas;- The resident has impaired decision making and disorganized thinking related diagnosis of dementia.Review of the resident's nursing progress notes for the month of December 2025, showed:- On 12/21/25 at 6:05 P.M., the residents had been witnessed next to one another by the television in the hallway. The resident was picking on another resident's chair and clothes. Resident #1 said go away and before the staff member and resident #2 could go, Resident #1 slapped Resident #2 across the left side of their face.- On 12/21/25 at 8:25 A.M.; The Director of Nursing (DON) documented the resident had no obvious signs of distress or pain and was at the beauty shop that day smiling and talking.Review of the facility's self-report, dated 12/22/25., showed:- Resident #2 had been picking at Resident #1's clothing and wheelchair;- Resident #1 had yelled get away and Licensed Practical Nurse (LPN) A had been nearby, heard the raised voice, but did not arrive in time to separate the residents;- Resident #1 slapped Resident #2 in the face area and grabbed Resident #2's face;- Upon examination, Resident #2's face was red and he/she could not communicate pain but did not appear to be in great distress;- The residents were separated and the Administrator, DON, and family member had been notified;- Staff had been educated to be aware of Resident #2's wandering, educated about Resident #1's aggressive behavior, and the facility began to look into a stay at a psychiatric hospital for Resident #1.During an interview on 1/14/26 at 8:24 A.M., Resident #1 said:- He/she had got mad; it was his/her fault;- He/She was just trying to get Resident #2 to leave him/her alone. Trying to get Resident #2 away from others. During an interview on 1/14/26 at 8:35 A.M., Housekeeper A said: - He/She had training regarding resident-to-resident incidents, and he/she might try to intervene but would definitely get help;- He/she believed a resident should be free from abuse or assault.During an interview on 1/14/26 at 9:00 A.M., LPN A said:- He/she had observed the residents by the nurses station;- Resident #2 was picking and touching at Resident #1s clothes and wheelchair;- Resident #2's right hand went up, and before LPN A could do anything, contacted Resident #1's left cheek;- Both residents were assessed and separated then notifications made to the family, the physician, and the Administrator;- Resident #2 wanted Resident #1 out of his/her space, to leave him/her alone.During an interview on 1/14/26 at 10:10 A.M., Registered Nurse (RN) A said:- All of the staff keep track of Resident #2 who liked to wander. Resident #1 is immobile and can't get around and get to other residents;- A resident should definitely be free from abuse or assault.During an interview on 1/14/26 at 11:33 A.M., the Assistant Administrator said:- Resident #1 didn't have care planned interventions for aggressive behaviors towards others at the time of the incident because Resident #1 was kind of new and the facility was not aware of the Resident's history;- He/she acknowledged the resident had been aggressive many times towards staff and no interventions had been care planned prior to the incident;- During one of Resident #1's hospital visits, the hospital had decreased some of the resident's medications and that may have caused some aggression;- Going forward Resident #1 had been monitored more often and had undergone another hospitalization;- The staff from Resident #1's previous nursing home had said there had been no behaviors;- The staff were monitoring Resident #2 more often and were trying to develop an activity program including making rummage boxes, playing more music, and dancing;- Resident #2 had a red area for a bit, but no bruising afterwards;- Residents have the right to not be assaulted or abused;- The staff abuse/neglect training had been in November. Intake 2699220

Based on observations, interviews and record review, the facility failed to assure staff treated residents in a manner that maintained their dignity when staff failed to respond to call lights in a timely manner which affected six of the 13 sampled residents, (Resident #15, #47, #45, #1, #27 and #53. The facility census was 52. Review of the facility's policy titled, Residents Call System, revised September 2022, showed:- Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station; - Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor; - Calls for assistance are answered as soon as possible, but no later than five minutes; - Urgent requests for assistance are addressed immediately. Review of the facility's policy titles, Answering the Call light, dated 2001, showed: - The purpose of this procedure is to ensure timely responses tot he resident's requests and needs; - Upon admission and periodically as needed, explain and demonstrate use of the call light to the resident; - Explain to the resident that a call system is also located in his/her bathroom; - Answer the resident call system immediately. 1. Review of Resident #15's quarterly Minimum Data Set (MDS), dated [DATE], showed: - Moderately impaired cognition; - Required substantial assistance with toileting, bathing, lower body dressing, and putting on shoes; - Required set up or clean up assistance with personal hygiene and oral hygiene; - Required partial assistance for upper body dressing. Continuous observation on 01/15/25 from 07:46 A.M. to 01/15/25 08:13 A.M. showed: - Resident #15's call light was on; - No staff responded to the call light or entered residents room during the continuous observation; - It took 27 minutes for Resident #15's call light to be answered at 8:13 A.M. During an interview on 01/15/25 at 10:30 A.M., resident #15 said when He/She had to wait a long time for the call light to be answered, He/She peed my pants and it floods, then my clothes have to be changed. He/She said it is cold, wet and I don't like it. Review of call light logs dated 12/1/24 - 1/14/25 for Resident #15 showed: - On 12/5/24 at 7:17 A.M., it took one hour and four minutes for the call light to be answered; - On 12/11/24 at 7:46 A.M., it took one hour and one minute for the call light to be answered; - On 12/12/224 at 8:06 A.M., it took 57 minutes for the call light to be answered; - On 12/14/24 at 7:33 A.M., it took 27 minutes for the call light to be answered; - On 12/21/24 at 8:58 A.M., it took 49 minutes for the call light to be answered. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/17/24 showed: - Cognitive skills intact; - Independent with eating, oral hygiene, toilet use, dressing, personal hygiene and transfers; - Required substantial to maximum assistance with showers; - Diagnoses included stroke, depression, bipolar (a mental health condition that causes extreme mood swings) and multiple sclerosis (MS, a chronic disease that affects the brain and spinal cord). Review of the Resident's call light record for December 2024, showed the following dates and times were over 15 minutes: - 12/1/24 at 3:50 P.M., - one hour and 57 seconds; - 12/7/24 at 3:11 P.M., - one hour and thirteen minutes; - 12/13/24 at 7:59 A.M., - 59 minutes; - 12/14/24 at 10:34 A.M., - one hour and six minutes; - 12/14/24 at 1:08 P.M., - one hour and nine minutes; - 12/19/24 at 10:19 A.M., - one hour and ten minutes; - 12/26/24 at 6:24 P.M., - one hour and seven minutes; During an interview on 1/13/25 at 11:00 A.M., the resident said: - It varies on how long it takes for the call lights to get answered; - It depends on who is working and where they are located; - He/she has had to wait over 20 - 30 minutes before and it did not make him/her feel very good, especially if he/she needed something for pain. Review of the resident's care plan, revised 1/14/25, showed: - The resident required assistance with bathing and shaving; - The resident had MS flare ups (a period of new or worsening MS symptoms) at times that caused increased weakness. Review of the Resident's call light record for January 2025, showed the following dates and times were over 15 minutes: - 1/1/25 at 5:12 A.M., - one hour and 12 minutes; - 1/5/25 at 11:46 A.M., - 44 minutes; - 1/6/25 at 9:42 P.M., - 43 minutes; - 1/8/25 at 6:01 P.M., - 30 minutes; - 1/10/25 at 9:08 A.M., - 45 minutes; - 1/10/25 at 10:22 A.M., - 25 minutes; - 1/10/25 at 2:06 P.M., - 27 minutes; - 1/11/25 at 3:20 P.M., - 48 minutes; - 1/13/25 at 1:42 P.M., - 25 minutes; - 1/14/25 at 5:46 A.M., - 20 minutes. 3. Review of Resident #27's care plan, revised 11/7/24, showed the resident received extensive assistance from staff with all of his/her cares. Review of the resident's Quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Lower extremities impaired on both sides; - Dependent on the assistance of staff for toilet use, showers, dressing, personal hygiene, and transfers; - Always incontinent of bowel and bladder; - Diagnoses included congestive heart failure (CHF, accumulation of fluid in the lungs and other areas of the body), high blood pressure, urinary tract infection (UTI, an infection in any part of the urinary system), hemiparesis (muscle weakness or paralysis on one side of the body), and hemiplegia (paralysis affecting one side of the body). Review of the Resident's call light record for December 2024, showed the following dates and times were over 15 minutes: - 12/2/24 at 5:03 P.M., - 48 minutes; - 12/3/24 at 6:38 P.M., - one hour and seven minutes; - 12/5/24 at 1:46 P.M., - 29 minutes; - 12/9/24 at 4:55 P.M., - 27 minutes; - 12/9/24 at 7:06 P.M., - 28 minutes; - 12/10/24 at 7:22 A.M., - 29 minutes; - 12/10/24 at 1:40 P.M., - 30 minutes; - 12/12/24 at 11:42 A,M., - 40 minutes; - 12/13/24 at 7:59 P.M., - 36 minutes; - 12/14/24 at 10:35 A.M., - 29 minutes; - 12/15/24 at 6:27 A,M., - 22 minutes; - 12/15/24 at 4:19 P.M., - 26 minutes; - 12/15/24 at 6:26 P.M., - 47 minutes; - 12/16/24 at 1:32 P.M., - 34 minutes; - 12/16/24 at 6:44 P.M., - 55 minutes; - 12/18/24 at 3:49 P.M., - 33 minutes; - 12/21/24 at 10:26 A.M., - 35 minutes; - 12/22/24 at 3:30 P.M., - 20 minutes. During an interview on 1/14/25 at 9:04 A.M., the resident said:- He/she has waited over an hour for the call light to be answered; - Multiple times the resident has waited 20 - 30 minutes for staff to answer the call light; - The resident did not like waiting so long for the call light to be answered. Review of the Resident's call light record for January 2025, showed the following dates and times were over 15 minutes: - 1/1/25 at 9:55 A.M., - 25 minutes; - 1/1/25 at 6:41 P.M., - 17 minutes; - 1/4/25 at 9:53 A.M., - 20 minutes; - 1/4/25 at 7:11 P.M., - 31 minutes; - 1/5/25 at 1:42 P.M., - 23 minutes. 4. Review of Resident #53's Admission MDS, dated [DATE], showed: - Cognitive skills moderately impaired; - Required partial to moderate assistance with showers and transfers; - Supervision with toilet use, personal hygiene and dressing; - Had urinary catheter (sterile tube inserted into the bladder to drain urine); - Occasionally incontinent of bowel; - Diagnoses included rhabdomyolysis (a rare, potentially life-threatening condition that occurs when muscle tissue breaks down and releases its contents into the blood), cancer, anxiety, UTI in the last 30 days, diabetes mellitus, and coronary artery disease (CAD, narrowing or blockage of the coronary arteries). Review of the resident's care plan, revised 12/19/24, showed the resident required assistance with activities of daily living (ADLs) due to increased weakness following recent hospitalization with rhabdomyolysis. Review of the Resident's call light record for December 2024, showed the following dates and times were over 15 minutes: - 12/1/24 at 7:10 A.M., - 43 minutes; - 12/2/24 at 7:18 A.M., - 43 minutes; - 12/2/24 at 6:43 P.M., - 26 minutes; - 12/3/24 at 7:18 A.M., - 29 minutes; - 12/3/24 at 5:53 P.M., - 33 minutes; - 12/4/24 at 8:37 A.M., - 33 minutes; - 12/5/24 at 7:23 A.M., - 57 minutes; - 12/5/24 at 5:53 P.M., - 47 minutes; - 12/6/24 at 12:33 A.M., - 37 minutes; - 12/6/24 at 6:22 A.M., - 41 minutes; - 12/8/24 at 5:35 P.M., - 31 minutes; - 12/9/24 at 5:56 P.M., - 35 minutes; - 12/9/24 at 7:22 P.M., - 20 minutes; - 12/11/24 at 6:08 P.M., - one hour and 33 minutes; - 12/13/24 at 6:28 P.M., - 38 minutes; - 12/13/24 at 9:36 P.M., - 30 minutes; - 12/15/24 at 6:45 P.M., - 36 minutes; - 12/15/24 at 8:47 P.M., - 37 minutes; - 12/16/24 at 10:46 A.M., - 39 minutes; - 12/16/24 at 2:11 P.M., - 29 minutes; - 12/16/24 at 5:57 P.M., - 33 minutes; - 12/17/24 at 6:08 P.M., - 33 minutes; - 12/18/24 at 9:05 P.M., - 31 minutes; - 12/19/24 at 6:13 P.M., - 37 minutes; - 12/20/24 at 9:55 A.M., - 33 minutes; - 12/20/24 at 5:54 P.M., - 46 minutes; - 12/20/24 at 7:12 P.M., - 45 minutes; - 12/25/24 at 10:30 P.M., - 48 minutes; - 12/27/24 at 7:18 P.M., - 42 minutes; - 12/27/24 at 8:25 P.M., - 38 minutes; During an interview on 1/14/25 at 8:00 A.M., the resident said the call lights take longer to get answered in the mornings and in the evenings, about 15 - 20 minutes. Review of the Resident's call light record for January 2025, showed the following dates and times were over 15 minutes: - 1/1/25 at 5:17 A.M., - 29 minutes; - 1/1/25 at 5:57 A.M., - one hour and ten minutes; - 1/1/25 at 9:00 A.M., - 26 minutes; - 1/1/25 at 7:28 P.M., - 24 minutes; - 1/2/25 at 6:51 A.M., - one hour and 16 minutes; - 1/3/25 at 5:15 A.M., - 27 minutes; - 1/3/25 at 9:12 A.M., - 26 minutes; - 1/3/25 at 4:50 P.M., - 22 minutes; - 1/5/25 at 8:13 A.M., - 23 minutes; - 1/5/25 at 11:23 P.M., - 46 minutes; - 1/8/25 at 5:58 A.M., - 35 minutes; - 1/9/25 at 7:44 A.M., - 46 minutes; - 1/10/25 at 7:37 P.M., - 36 minutes; - 1/11/25 at 6:00 A.M., - 20 minutes; - 1/13/25 at 5:05 A.M., - 34 minutes; - 1/13/25 at 7:59 A.M., - 25 minutes; - 1/14/25 at 8:43 A.M., - 27 minutes. During an interview on 1/14/25 at 4:28 P.M., Registered Nurse (RN) B said: - All the staff should carry the call light phones; - The call lights do not make a noise, but they make a noise on the phones; - The call lights show up at the nurse's station; - He/she has had residents complain about how long it takes for the call lights to get answered; - He/she thought the policy said the call lights should be answered in ten minutes. During an interview on 1/15/25 at 7:45 A.M., RN A said: - The call lights should be answered within five minutes; - When the call light goes off, it lights up outside the resident's room, goes to the staff's call phone and to the monitor at both nurse's station; - He/she has had residents complain about the length of time it takes for the call lights to get answered. He/she tells the residents they will look into it and educate the staff. During an interview on 1/16/25 at 11:12 A.M., Certified Medication Technician (CMT) B said: - The call lights should be answered within 10 minutes; - If a resident or family member complained about the length of time it took for the call light to get answered, he/she assured the resident they would be there as soon as possible. and reported it to the charge nurse. During an interview on 1/16/25 at 2:10 P.M., the Director of Nursing (DON) said: - The bathroom call lights should be answered within five minutes; - The general call lights should be answered in no less than ten minutes; - They check the call light logs every day. 51166 5. Review of Resident #15's quarterly Minimum Data Set (MDS), dated [DATE], showed: - Moderately impaired cognition; - Required substantial assistance with toileting, bathing, lower body dressing, and putting on shoes; - Required set up or clean up assistance with personal hygiene and oral hygiene; - Required partial assistance for upper body dressing. Continuous observation on 01/15/25 from 07:46 A.M. to 01/15/25 08:13 A.M. showed: - Resident #15's call light was on; - No staff responded to the call light or entered residents room during the continuous observation; - It took 27 minutes for Resident #15's call light to be answered at 8:13 A.M. During an interview on 01/15/25 at 10:30 A.M., resident #15 said when He/She had to wait a long time for the call light to be answered, He/She peed my pants and it floods, then my clothes have to be changed. He/She said it is cold, wet and I don't like it. Review of call light logs dated 12/1/24 - 1/14/25 for Resident #15 showed: - On 12/5/24 at 7:17 A.M., it took one hour and four minutes for the call light to be answered; - On 12/11/24 at 7:46 A.M., it took one hour and one minute for the call light to be answered; - On 12/12/224 at 8:06 A.M., it took 57 minutes for the call light to be answered; - On 12/14/24 at 7:33 A.M., it took 27 minutes for the call light to be answered; - On 12/21/24 at 8:58 A.M., it took 49 minutes for the call light to be answered. 6. Review of Resident #47's annual Minimum Data Set (MDS), dated [DATE], showed: - Cognitive skills intact; - Upper extremity (shoulder, elbow, wrist, hand): impairment on both sides; - Lower extremity (hip, knee, ankle, foot): impairment on both sides; - Diagnoses included: debility (physical weakness), heart disease, lung disease, and pneumonia. Review of the resident's care plan, dated 12/11/23, showed, - The resident had an activities of daily living (ADL) self-care deficit related to a clubbed foot which caused difficulties with ambulation; - He/She requires staff assistance with all ADL's. During an interview on 01/14/25 at 04:36 P.M., resident #47 said it usually takes longer than 15 minutes for the call light to be answered. He/She said it makes Him/Her worried that staff won't make it in time for Him/Her to use the bathroom and it irritates the Hell out of me. Review of facility call light log for Resident #47, dated 12/1/24-1/14/25, showed: - On 12/1/24 at 7:27 A.M., it took 34 minutes for the call light to be answered; - On 12/5/24 at 7:17 A.M., it took one hour and four minutes for the call light to be answered; - On 12/11/224 at 7:46 A.M., it took one hour and one minute for the call light to be answered; - On 12/12/24 at 8:06 A.M., it took 57 minutes for the call light to be answered; - On 12/29/24 at 8:44 A.M., it took 28 minutes for the call light to be answered; - On 1/10/25 at 7:50 A.M., it took 45 minutes for the call light to be answered. During an interview on 01/15/25 at 02:07 P.M., CMT A said call lights are to be answered within 5 to 10 minutes. The facility provides a phone to staff that notifies them of which call lights need to be answered. The app on the phone displays the time that has lapsed since the resident pushed the call light. During an interview on 01/15/25 at 02:15 P.M., CNA B said there is an expectation that call lights should be answered within 15 minutes. During an interview on 01/15/25 at 03:19 P.M., RN B said call lights should be answered within 3-5 minutes. During an interview on 01/15/25 at 04:32 P.M., the Assistant Administrator said call lights should be answered within five to seven minutes, but that is too long if a resident needs to use the bathroom.

Based on interviews and record review, the facility failed to follow up with resident's grievances regarding quality of life and resident care or then they did not provide a rationale or response to resident council. This had the potential to affect all the residents at the facility. The facility census was 52. Review of the facility's Grievance Policy, dated 1/1/24 showed: -All grievances would be handled promptly and according to federal regulations; -Provide a written response to the complaint, including: a summary of findings, actions taken or planned to resolve the grievance; -Conduct follow-up with the complainant to ensure satisfaction with the resolution; -All staff will receive training on residents' grievance rights and this policy during orientation and annually thereafter. Review of resident council minutes dated 9/24/24, 10/29/24, and 12/31/24 showed: -No reference to prior months concerns; -No documented resolutions for residents' past concerns; -No documented explanation of why ongoing concerns were not be addressed. During a group interview on 1/14/25 at 2:11 P.M., resident council members said the facility doesn't follow-up with the resident council on the grievances and recommendations made by the council. During an interview on 1/15/25 at 02:36 P.M., Activity Director said: -They did not receive any formal training on coordinating resident council meetings; -When concerns were brought up by the resident council, they entered a report and then reviewed with administrative staff; -They were not aware of the process on how to address the concerns that were brought up by residents. During an interview on 1/15/25 at 4:08 P.M., Assistant Administrator said: -When residents brought up issues at resident council, the Activity Director took notes and sent to the administrative team; -Resident's concerns were discussed with the administrative team and addressed at the following, QA (quality assurance) meeting; -When the concern was addressed, staff would talk to the specific resident to see if the issue was resolved; - Sometimes issues were ongoing and there would not be an explanation for the resident council as to why the concern was not resolved. During an interview on 1/16/25 at 2:10 P.M., the Administrator said: -Concerns from resident council were reviewed by administrative staff and at QAPI (quality assurance and performance improvement); -They expected the resident council president to be informed about the status of the grievances or recommendations and the resident council president should provide the update to the resident council; -They had not provided documentation to the resident council regarding resolution to the residents' concerns.

Based on interviews and record review, the facility failed to obtain a physician's order for code status for four residents (Residents #26, #22, #51, and #16) out of the 13 sampled residents. The facility census was 52. A policy and procedure regarding the provisions of basic life support was requested, but not provided. The physician services policy, date 8/2024., shows once a resident is admitted to the facility, orders for the resident's immediate care and needs can by provided by a physician, physician assistant, nurse practitioner, or clinical nurse specialist. 1. Review of Resident #26's face sheet showed: -Readmission on 2/7/24; -Diagnoses: Dementia, heart disease, arthritis, fracture of right leg; -Code Status -Do Not Resuscitate (No life saving measures); -Assistance with all activities of daily living. Review of the care plan, last updated 8/14/24., showed there was no code status listed in the care plan. Review of the physician orders from readmitted [DATE] through January 2025., showed no physician order for the resident's code status. 2. Review of Resident #22's face sheet showed: -Readmission on 5/12/23; -Diagnoses: Stroke with deficit on the left side of body, heart disease, chest pain, artery disease; -Code Status-Full Code (All life saving measures are provided) listed; -Assistance with all activities of daily living. Review of the care plan, last updated 8/20/24., showed there was no code status listed in the care plan. Review of the physician orders from readmitted [DATE] through January 2025., showed: No physician order for the resident's code status. 3. Review of Resident #51's face sheet showed: -admitted [DATE] -Diagnoses: Fracture of the right leg, Stage 4 Pressure ulcer to coccyx (A full thickness wound to the muscle/bone area, over the boney area between the upper buttock cheeks), heart disease; -Code Status-Full Code; -Assistance with all activities of daily living. Review of the care plan, last updated 10/25/24., showed no indication of a code status listed in the care plan. Review of the physician orders from readmitted [DATE] through January 2025., showed: no physician order for the resident's code status. 52043 4. Review of Resident #16's face sheet showed: -The resident was admitted on [DATE]; -The Resident is responsible for self -Code status: Full Code -Diagnoses: Diabetes, high blood pressure, chronic kidney disease, heart failure, right above the knee amputation, and dysphagia (difficulty swallowing). Review of the resident's minimum data set (MDS) completed by facility staff on 1/14/25 showed: -Cognition intact. -Requires staff assistance of two and Hoyer lift with all transfers and activities of daily living. Review of the physician orders from September 2024 through January 2025 showed no order for a code status. Review of resident's undated care plan was without any indication of the resident's code status. An interview on 1/14/25 at 1:42 P.M., RN A said the code status is usually listed on the face sheet and is ordered by the physician. During an interview on 1/16/25, at 2:10 P.M, the DON (Director of Nursing) , when asked if there should be a physician order for code status, answered yes. During an interview on 1/16/25 at 2:32 P.M. the Administrator said all resident's should have an order from the physician for a code status.

Based on interview and record review the facility failed for follow infection control guidelines when they allowed four volunteers #1, #2, #3, and #4 to be around and provide services in the facility for residents before completing any TB skin testing. This had the potential to affect all residents. The facility census was 52. Review of the facility's undated TB (Tuberculosis) skin test., showed: -The purpose of a TB skin test is to determine if a resident or employee has been exposed to tuberculosis. -TB test will be done on all new employee at the time of hire and three weeks later. -The policy does not address TB skin testing for volunteers. Record Review of Volunteer #1., showed: - Hire date 4/24/24 -Completed criminal background checks 5/1/25 -Start date 5/1/25 -No TB skin testing was completed. Record Review of Volunteer #2., showed: -Hire date 11/4/24 -Completed criminal background checks 11/6/24 -Start date 11/6/24 -No TB skin test was completed. Record Review of Volunteer #3., showed: -Hire date 6/15/23 -Completed criminal background checks 7/14/23 -Start date 7/14/23 Record Review of Volunteer #4., showed: Hire date 7/31/23 Completed criminal background checks 7/31/23 -Start date 8/1/23 In a interview on 1/15/25 at 2:45P.M,, the Administrator and Director of Nursing said they were not aware TB checks were needed and they had not thought to include volunteers in the TB skin test surveillance process.

Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for one of 13 sampled residents, when they did not care plan the dialysis needs for Resident #106. The facility census was 52. Review of the facility's Care Plan policy, date 8/2024., showed: A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, physical, psychosocial and functional needs is developed and implemented for each resident. 31102 1. Review of Resident #106's face sheet showed and admitted [DATE]. Review of the resident's baseline care plan, dated 1/10/25, showed: - The resident was slightly confused; - History of falls prior to admission; - Required assistance of one staff for bed mobility, transfers, walking, toileting, and showers; - Continent of bowel and bladder; - Written summary of baseline care plan - evaluate after stroke, by therapy to restore function and potentially move to assisted living. - The baseline care plan did not address the issue of dialysis (a medical procedure that removes waste products and excess fluid from the blood when the kidneys are no longer able to function properly). Review of the resident's Physician Order Sheet (POS), dated January 2025, showed no orders for any assessments or vitals prior to or after dialysis. During an interview on 1/14/25 at 7:41 A.M., the resident said: - He/she did not think the staff went over his/her initial care plan with him/her; - He/she went to dialysis on Monday, Wednesday and Friday. During an interview on 1/15/25 at 4:06 P.M., the MDS/Care Plan Coordinator said the care plan should address the resident going to dialysis. During an interview on 1/15/25 at 4:27 P.M., the Social Services Designee (SSD) said: - Dialysis should be added to the resident's care plan; - He/she was not aware the resident was going to dialysis initially. During an interview on 1/16/25 at 10:49 A.M., Registered Nurse (RN) D said the care plan should address dialysis. During an interview on 1/16/25 at 2:10 P.M., the Director of Nursing (DON) said the care plan should address the resident going to dialysis.

Based on interviews and record reviews, the facility failed to ensure communication between the facility staff and dialysis (a medical procedure that removes waste products and excess fluid from the blood when the kidneys are no longer able to function properly) center followed standards of practice, when staff failed to document an assessment before and after dialysis. This affected one of the 13 sampled residents (Resident #106). The facility census was 52. Review of the facility's policy titled, Peritoneal Dialysis (a treatment for kidney failure that uses the lining of the abdomen to filter blood) (Continuous Ambulatory), revised October 2010, showed: - All dialysis procedures are administered outside of the facility under a contracted dialysis facility. 1. Review of Resident #106's face sheet showed: - admitted : 1/10/25. - Diagnoses included chronic kidney disease, Stage 3 (a moderate level of kidney damage where the kidneys are not filtering waste effectively, indicated by a decreased estimated glomerular filtration rate (eGFR) between 30 and 59 ml /min. (milliter/minute), signifying mild to moderate kidney function decline) and history of acute kidney failure (a history of a sudden decline in kidney function). Review of the resident's baseline care plan, dated 1/10/25, showed: - The resident was slightly confused; - Required assistance of one staff for activities of daily living; - Written summary of baseline care plan - evaluate after stroke, by therapy to restore function; - The baseline care plan did not address dialysis needs or care regarding dialysis. Review of the resident's Physician Order Sheet (POS), dated January 2025, showed; - No orders for any assessments or vitals prior to or after dialysis. - No orders regarding the monitoring of HD cath, or fistual care had been ordered. Review of the resident's progress notes, dated January 2025, showed: - 1/10/25 at 3:00 P.M., Hemodialysis port in right chest, clear dressing in place no redness or swelling noted, will have dialysis Mondays, Wednesdays and Fridays; - 1/13/25 at 5:05 A.M., resident departed with facility transporter for dialysis chair time. VS and weight obtained; - 1/13/25 at 5:10 A.M., the resident returned to facility- dialysis chair time has been moved to 1:00 P.M.; - 1/13/25 at 5:00 P.M., returned from dialysis, no concerns; - 1/15/25 at 1:45 P.M., out of facility for dialysis; - No documentation of assessments prior to leaving or returning from dialysis; - No documentation of communication with the dialysis center. During an interview on 1/14/25 at 7:41 A.M., the resident said: - He/she did not think the staff went over his/her initial care plan with him/her; - He/she went to dialysis on Mondays, Wednesdays and Fridays. During an interview on 1/15/25 at 7:45 A.M., Registered Nurse (RN) A said: - The staff do vital signs and weigh the resident before and after dialysis; - The staff do not send any paperwork with the resident to dialysis; - The dialysis center does not send any paperwork back with the resident after dialysis. During an interview on 1/16/25 at 11:30 A.M., RN C said: - The staff should do a full set of vital signs and weigh the resident before and after dialysis; - Staff are to monitor the site for infection; - They do not send any paperwork with the resident to dialysis and the dialysis center does not send any paperwork back to the facility. During an interview on 1/16/25 at 2:10 P.M., the Director of Nursing (DON) said: - There should be an order for the resident to go to dialysis; - The staff should get vital signs and weigh the resident; - Once a week they send paperwork and a report with the resident to dialysis.

Based on observation, interview and record review, the facility failed to complete a discharge summary for one of 13 sampled residents (Resident #55) and additionally failed to follow their own discharge planning policy. The facility census was 52. Review of the facility's Discharge Planning Policy, effective 1/11/24, showed, - The facility is committed to ensuring that all residents experience a person-centered, safe, and coordinated discharge process. Discharge planning will prioritize residents' needs, preferences, and post-discharge care requirements while adhering to regulatory standards. -Administrator is to ensure the necessary resources and staff training for effective discharge planning. - The Social Service Designee will: 1) Initiate discharge planning upon admission and update the plan throughout the residents' stay. 2) Ensure residents and their representatives are involved in the discharge planning process; receive education about discharge options and next steps. 3) Conduct a thorough assessment of residents' needs including physical, cognitive, and psychological status; home environment and support system; transportation needs; required medical equipment, supplies, or medications; follow-up care, including therapy, physician visits, and community resources. 4) Develop a written discharge plan that includes destination support services or caregivers involved post-discharge; specific instructions for medications, treatments, and follow-up appointments; contact information for caregivers and emergency resources; any risks associated with discharge and how they will be mitigated. 5) Maintain detailed records of discharge assessments, meetings with resident and family, final discharge plan, and communication with receiving care providers or facilities. 1. Review of Resident #55's Five Day Medicare scheduled assessment, A federally mandated assessment instrument completed by facility staff, dated 11/5/24 showed: - Cognitive skills intact; - Independent with eating, and oral hygiene; - Supervision or standby assist of one with toileting, lower body dressing, and putting on shoes; - Required set up and clean up with upper body dressing; - Substantial assistance with bathing. - Diagnoses included debility (physical weakness), anxiety disorder, heart disease, and lung disease. Review of the resident's electronic medical record on 01/15/25 01:39 P.M. showed: - No recapitulation of the resident's stay or that a copy of this was provided to the resident at discharge. - Resident was discharged on [DATE] During an interview on 1/16/25 at 2:10 P.M., the administrator said the facility should create a recapitulation of stay when a resident discharges from the facility and he/she will implement a new process to create them.

Based on observation, interview and record review, the facility failed to maintain the kitchen in a sanitary manner, failed to ensure food items were properly labeled and dated, failed to enter temperatures on the temperature logs and failed to ensure the walk in freezer did not have ice buildup. These all have the potential to affect all residents residing in the facility. The facility census was 55. The facility did not provide any policies. Record review of the walk in freezer temperature log showed: - No entries in the morning on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and no entries in the evening on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE]. Review of the produce/dessert refrigerator temperature log showed: - No entries in the morning on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and no entries in the evening on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and ,d+[DATE]. Review of the undated cleaning the refrigerator and freezers schedule showed: - Refrigerator: - Daily: Take anything out that has been opened and is older than 3 days out of the refrigerator and dispose of it; -Weekly: Take anything out that has been opened and is older than 3 days out of the refrigerator and dispose of it. - Freezers: - Daily: Label what you open with the date. - Walk-In Freezer: - Daily: Label what you open with the date; - Weekly: Make sure everything is labeled and dated and take any ice out of the freezer and dispose of it in the sink. Review of the facility's undated cleaning assignment schedule showed: - 11:30 A.M. to 7:30 P.M. shift: - Monday, Wednesday and Friday: Back store room - make sure items have dates; - Tuesday and Thursdays: Coordinate with evening cooks about cleaning ovens. - 8:00 A.M. to 4:00 P.M. shift: - Every day: Cappuccino machine; - Tuesday and Thursday: Stainless steel tables which includes cleaning the bottom shelf; - Saturday and Sunday: Coffee station. Review of Cook One's job duties showed: - Check and record temperatures; - Clean area as you work; - Put up left overs, dating and labeling them. Review of Cook Two's job duties showed: - Sanitize all surfaces; - Clean area as you work; - Clean steam table and dining room; - Check and record temperatures and ensure all job duties are completed. Review of Aide Two's job duties showed: - Daily cleaning schedule; - Put up left overs, dating and labeling them; - Help clean dining room and sanitize tables. Observation of the initial walk through of the kitchen on [DATE] at 9:45 A.M., showed: - A box of Buttermilk Mix opened, not dated; - Three gallons of chocolate ice cream opened, not dated; - One gallon container of Regal Code Worcestershire Sauce opened not dated; - Bag of lettuce opened, not dated; - [NAME] Farms box with an opened bag of cabbage with spots of browning, not dated; box had best used by date of [DATE] with another unopened bag in box; - Four drink pitcher containers of liquid, not labeled or dated; - Eight quart-sized containers of peaches with two quarts left, not dated; - Food debris on lower shelf with the weight scale and wax paper; - Coffee pot station in dining/serving area dirty; - Food debris on lower shelf of steam table. Observation of the walk in freezer on [DATE] at 9:00 A.M., showed: - Ice buildup on back coil with temperature of -4; - Winter Blend Broccoli opened, not dated; - Box of hamburger patties opened, not dated; - Box of Boneless Pork Pattie Ribs opened, not dated; - Box of Salted Caramel Chocolate chunk cookies opened, not dated. Observation and interview on [DATE] at 9:15 A.M., Dietary Cook A said: - When the delivery truck comes, he/she will put items in freezer and date/time them; - If items are taken out of the box, they should be dated/time; - If in a container, the container should be dated and timed; - Cooks are responsible for temperature logs for refrigerator and freezers and he/she logs them in the morning; - Staff should be checking daily for expired foods; - If some things needs fixed, they let the dietary supervisor know and then maintenance is notified. - The ice buildup in the walk-in freezer has been like that since he/she started over eight years ago; the maintenance company stated it has a slow leak; - Maintenance will come in and do preventative maintenance in the kitchen and will defrost freezer the freezer; - He/she saw the opened bag of cabbage not dated and saw spots of browning; he/she throws things away when he/she sees this. - He/she also observed the box the cabbage in saying best used by [DATE]; - Food debris in both ovens; - There should not be any debris in the ovens; they were last cleaned about two months ago. During an interview on [DATE] at 3:15 P.M., the Maintenance Coordinator said: - He/she has been with the facility since [DATE]; - The facility has a reporting log for staff to fill out for maintenance issues or they will call him/her to report something; - He does preventative maintenance in the kitchen; - He/she was made aware of the ice buildup in the walk in freezer as one of the cooks reported it to him/her; could not say when he/she was told; - The ice buildup occurs every so often, it does have an auto defrost but it does not get rid of it entirely; - The only thing he/she could think of is the line has a slow leak; they had another issue with a slow leak on another line but it was fixed. During an interview on [DATE] at 9:00 A.M., Dietary Cook B said: - He/she does not unload the delivery truck when it arrives; - He/she sometimes puts some of the dry goods away when the delivery truck arrives and will date them; - He/she will date/time the left overs as some are only good for three days, five days or seven days; - Everything should be labeled/dated; - When food products are taken out of a box, it should be dated and it should also be dated when opened; - The day cook normally looks for expired food; if he/she finds any him/herself, he/she will dispose of it; - He/she does not log temps for the refrigerator or freezers; - He/she does not clean oven but they should be clean and free of debris; - He/she tries to clean up work area as he/she goes. Observation on [DATE] at 9:40 A.M., showed ice buildup on pipe in back of walk in freezer. During an interview on [DATE] at 9:45 A.M., the Dietary Supervisor said: - When the delivery truck arrives, it is a team effort but typically the day cook, second cook and he/she unloads the truck; - Everything should have a receiving date; - Individual bags or any items removed out of boxes should be dated; - Cooks are responsible for checking for expired food daily; - Left overs should be tossed after three days but he/she has a rule, when in doubt, toss it out; - If foods are expired in dry storage, they should be tossed; - Lettuce/cabbage is supposed to be good for seven days once delivered; once it's opened, it's good for three days; - Food should be used by best by date; - He/she was made aware of the expired box/bags of cabbage and it has since been discarded; - Cooks are responsible for documenting the temperatures for the refrigerator, and freezer and there should not be any blank spots on the logs; - If staff notices any maintenance issues, they are to alert him/her and maintenance immediately by phone even if it is not an emergency; - He is not aware of a maintenance log; - He had not noticed the ice buildup in the walk in freezer; it does have a defrost daily but unsure of when it occurs; - Expectations is for kitchen to be clean; - Ovens should be clean and are when fully staffed; they have a cleaning schedule for this to be done on Tuesday's and Thursdays for one stove per day; - The stove should not have any food debris in it; During an interview on [DATE] at 3:38 P.M., the Administrator said: - Staff should label and date food in kitchen; - Food should be labeled and dated when opened; - Expired food should be thrown out, staff should be checking daily; - Refrigerator and freezer temperatures should be logged and there should not be any blank spots on the log; - If kitchen staff notice a maintenance issue, such as buildup of ice in the freezer, the maintenance director should be notified; - The kitchen should be cleaned; - The ovens should be cleaned weekly and should not have any food particles in it.

Based on observation, interview and record review, the facility failed to assess three residents (Resident's #4, #29, and #33) for entrapment and did not complete side rail assessments at least yearly. The facility census was 55. Review of the facilty's undated Physical Restraint policy showed: -Purpose: To prevent the resident from injuring himself or others; To improve the resident's mobility and independent functions; To treat the resident's medical symptoms. -Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. -Equipment includes side rails (bed rails). Procedure: 1: Assess resident's need for restraint use. 2: Obtain informed consent for restraint use. 3. Obtain physician's order for restraint. 4. Develop or review resident care plan for type of restraint, reason for use, alternate methods to be used and method application. 17. Side Rails: a. Determine the type of side rails to be used. b. Determine the medical symptoms to be treated with side rails c. Side rails extending less than the entire length of the bed may not be considered restraints if they do not prevent the resident from getting out of bed. d. Involve the resident and resident's representative in planning for side rail use. Many residents requests to have side rails up when in bed to improve bed mobility and provide a feeling of safety. 1. Review of Resident #29's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 3/31/23, showed: -The resident makes self understood and understands others. -Score of 3 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). The score of 3 indicates severely impaired cognition. -Diagnoses of major depressive disorder, malnutrition, anemia, history of left femur fracture. -The resident is independent with set up with activities of daily living, including bathing, dressing and personal hygiene. -He/She is occasionally incontinent of bladder and always continent of bowel. -He/She has had no falls during the review period. -He/She does not have bed rails. Observation of the resident's room on 5/20/23 at 1:33 P.M., showed: -There were cane rails (small rails) on each side of the head of the resident's bed. -The were bolsters (foam pads that run the length of the bed) near the head and foot of the bed. Observation of the resident's room on 5/31/23 at 3:17 P.M. showed: -There were cane rails on each side of the head of the resident's bed. -The are bolsters near the head and foot of the bed. -The resident was laying in the bed. Review of the resident's comprehensive care plan, dated 4/18/23, showed: -No interventions addressing the cane bed rails on the resident's bed. Review of the resident's electronic medical record on 5/31/23 showed: -No record of bed rail assessments for the resident. During an interview on 6/1/23 at 3:11 P.M. the Director of Nursing (DON) said: -He/She did not consider cane rails as bed rails. -If cane rails are to be considered bed rails, then residents should have bed rail assessments completed before the bed rails are added to the bed and periodically after. -Residents should also have entrapments assessments completed. During an interview on 6/1/23 at 3:38 P.M., the Administrator said: -All beds come with the cane rails attached unless a resident requests them be removed. -If residents have bed rails on the bed, then the resident should have bed rail assessments done before the bed rails are added to the bed. -Maintenance was supposed to assess the beds quarterly to evaluate the bed for an entrapment risk. -Bed rails should be included in the resident care plan. 46706 2. Review of Resident #4's quarterly MDS, dated [DATE], showed: - Moderate cognitive impairment; - Incontinent of bowel and bladder; - Assist of two for transfers; - Extensive assist of two for dressing; - Bed rails are not used; - Diagnoses included heart failure, stroke and high blood pressure. Review of the resident's care plan dated 4/3/23, did not address the use of side rails. Review of the resident's medical record on 6/1/23 showed: -No assessment for the use of bed rails was found; -No physician's order for the use of bed rails was found. Observation of the resident's room on 5/30/23, at 10:21 A.M., showed cane rails on the left and right side of the resident's bed. Observation of the resident's room on 5/31/23, at 2:13 P.M., showed cane rails on the left and right side of the resident's bed. 3. Review of Resident #33's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Incontinent of bowel and bladder; -Independent with transfers; -Assist of one for dressing; -Assist of one for toileting; -Bed rails are not used; -Diagnoses included diabetes (a disease that results in too excess sugar in the blood), anemia (a condition that leads to reduced oxygen flow to the body's organs) and high blood pressure. Review of the resident's care plan, dated 3/13/23, did not address the use of side rails. Observation of the resident's room on 5/30/23, at 11:16 A.M., showed cane rails on the left and right side of the resident's bed. Observation of the resident's room on 5/31/23, at 2:46 P.M., showed: - [NAME] rails on the left and right side of the resident's bed; - The resident was laying bed. Review of the resident's medical record on 6/1/23 showed: -No assessment for the use of bed rails was found; -No physician's order for the use of bed rails was found. During an interview on 6/1/23 at 3:11 P.M. the Director of Nursing (DON) said: -He/She did not consider cane rails as bed rails. -If cane rails are to be considered bed rails, then residents should have bed rail assessments completed before the bed rails are added to the bed and periodically after. -Residents should also have entrapments assessments completed. During an interview on 6/1/23 at 3:38 P.M., the Administrator said: -All beds come with the cane rails attached unless a resident requests them be removed. -If residents have bed rails on the bed, then the resident should have bed rail assessments done before the bed rails are added to the bed. -Maintenance was supposed to assess the beds quarterly to evaluate the bed for an entrapment risk. -Bed rails should be included in the resident care plan.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered plan of care consistent with the resident rights that include measurable objectives and timeframe to meet the resident's needs. This affected four sampled residents (Residents#4, #23, #29 and #33) The facility census was 55. The facility did not provide a policy regarding care planning. 1. Review of Resident #29's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 3/31/23, showed: -The resident makes self understood and understands others. -Score of 3 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). The score of 3 indicates severely impaired cognition. -Diagnoses of major depressive disorder, malnutrition, anemia, history of left femur fracture. -The resident was independent with set up with activities of daily living, including bathing, dressing and personal hygiene. -He/She was occasionally incontinent of bladder and always continent of bowel. -He/She has had no falls during the review period. -He/She did not have bed rails. Observation of the resident's room on 5/20/23 at 1:33 P.M., showed: -There were cane rails (small rails on the bed) on each side of the head of the resident's bed. -The were bolsters (a foam pad that lays at the sides of the residents bed length wise to prevent falls) near the head and foot of the bed. Observation of the resident's room on 5/31/23 at 3:17 P.M. showed: -There were cane rails on each side of the head of the resident's bed. -The are bolsters near the head and foot of the bed. Review of the resident's comprehensive care plan, dated 4/18/23, showed: -No interventions addressing the cane bed rails on the resident's bed. Review of the resident's electronic medical record on 5/31/23 showed: -No record of bed rail assessments for the resident. 2. Review of Resident #23's quarterly MDS, dated [DATE], showed: -The resident usually makes self understood and usually understands others. -Score of 6 on the BIMS. The score of 6 indicates severely impaired cognition. -Diagnoses of anemia, heart failure, depression, pain, osteoporosis. -The resident is totally dependent on staff for activities of daily living, including bathing, dressing and personal hygiene. -He/She was always incontinent of bowel and bladder. -The resident has had no falls during the review period. -The resident did not have bed rails. 46706 3. Review of Resident #4's quarterly MDS, dated [DATE], showed: - Moderate cognitive impairment; - Incontinent of bowel and bladder; - Assist of two staff for transfers; - Extensive assist of two staff for dressing; - Bed rails were not used; - Diagnoses included heart failure, stroke and high blood pressure. Review of the resident's care plan dated 4/3/23, did not address the use of side rails. Review of the resident's medical record on 6/1/23 showed: -No assessment for the use of bed rails was found; -No physician's order for the use of bed rails was found. Observation of the resident's room on 5/30/23, at 10:21 A.M., showed cane rails on the left and right side of the resident's bed. Observation of the resident's room on 5/31/23, at 2:13 P.M., showed cane rails on the left and right side of the resident's bed. 4. Review of Resident #33's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Incontinent of bowel and bladder; -Independent with transfers; -Assist of one staff for dressing; -Assist of one staff for toileting; -Bed rails were not used; -Diagnoses included diabetes (a disease that results in too much excess in the blood), anemia (a condition that leads to reduced oxygen flow to the body's organs) and high blood pressure. Review of the resident's care plan, dated 3/13/23, did not address the use of side rails. Observation of the resident's room on 5/30/23, at 11:16 A.M., showed cane rails on the left and right side of the resident's bed. Observation of the resident's room on 5/31/23, at 2:46 P.M., showed cane rails on the left and right side of the resident's bed. Review of the resident's medical record on 6/1/23 showed: -No assessment for the use of bed rails was found; -No physician's order for bed rails was found. 5. During an interview on 6/1/23 at 3:11 P.M., the Director of Nursing (DON) said: -He/she did not consider cane rails as bed rails; -If cane rails are to be considered bed rails, then residents should have bed rail assessments completed before the bed rails are added to the bed and periodically after; -Residents should also have entrapment assessments completed. During an interview on 6/1/23 at 3:38 P.M., the Administrator said: -All beds come with the cane rails attached unless a resident requests them to be removed; -If residents have bed rails on the bed, then the resident should have bed rail assessments done before the bed rails are added to the bed; -Maintenance assesses the beds quarterly to evaluated the bed for entrapment risk; -Bed rails should be included in the resident's care plan.