Every finding on record at Munson Healthcare Otsego Memorial Hospital LTCU

This citation pertains to intake: 2614163Based on interview and record review, the facility failed to implement fall preventions for one Resident (R6) of two residents reviewed for falls. This deficient practice resulted in a fractured 5th digit for R6 when a fall mat and bed alarm were not in place and functioning. Findings include:Review of R6's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses including dementia. R6's 8/15/25 Minimum Data Set (MDS) assessment revealed she was unable to complete the Brief Interview for Mental Status (BIMS) score and was noted by staff to have severely impaired cognition.Review of the facility's reported fall incident for R6 dated 8/17/26 read, in part, On 8/17/26 at 10:10 PM, (R6) was found on the right side of her bed on her left side. Resident unaware of what happened. Resident noted with a hematoma to left forehead. Resident noted with ASA regimen (a daily prescription or recommendation of acetylsalicylic acid to reduce blood clot formation) in place and was sent to the Emergency Department (ED) for evaluation. While in the ED, (R6) noted with pain in her left hand. Xray completed and an indeterminate fracture of the left 5th digit was noted.Investigation.During investigation it was stated that Registered Nurse (RN) I had put (R6) to bed. After the fall it was noted that the fall mat was on the wrong side of the bed, and the bed alarm was not turned on. (R6's) fall care plan was reviewed, floor mat and bed alarm are on care plan to be in place at night when in bed.On 4/1/26 at 10:22 AM an interview was conducted with RN I. RN I stated she remembered the night with R6 stating R6's bed was not pushed up against the window like it normally was, but she thought she placed the fall mat on the correct side of the bed, not realizing it was the wrong side. RN I confirmed she did not turn R6's bed alarm on because she forgot.Review of R6's Care Plans read, in part, (R6) is a risk for falls r/t (related to) gait/balance problems, unaware of safety needs and dementia.interventions: anti-fatigue mat is to be placed next to bed (left side) to prevent injury if (R6) should fall/roll out of bed.(R6) uses a bed alarm. Ensure the devices is in place and functioning properly. Bed alarm mat to be used at all times while in bed.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:R6's Care Plan was reviewed and interventions updated to prevent further occurrence of fall-related injuries.Staff re-educated related to assuring care planned interventions are followed following care, and notification to nursing leadership when interventions are no longer appropriate and when new interventions are needed.Facility residents have had fall care plans reviewed to ensure appropriate and meaningful interventions are in place. Any identified equipment needs and assistive devices have been obtained and are in place. No further residents were noted with a fall-related injury in the last 30 days.Director of Nursing or designee completed observation and audits twice weekly for four weeks then weekly for four weeks and then monthly at the discretion of the facility Quality Assurance Performance Improvement Committee (QAPI) to ensure continued compliance.Audits reviewed with the Administrator as completed and presented by the Administrator to the monthly facility QAPI Committee.The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on interview and record review, the facility failed to:Implement an infection prevention and control program (IPCP) that included infection identification and surveillance to prevent the transmission of infectious organisms to all 24 residents in the facilityTrack and correlate a contagious and infectious organism for one Resident (R25) of five residents reviewed for infection prevention and control.Findings include:Resident #25 (R25) was transferred from the hospital to the facility on 2/14/26 with Clostridium difficile infection (CDI - a highly contagious bacterial infection that can be life-threatening). Infection control documentation for February 2026 and March 2026 were requested and reviewed on 4/1/26.The infection control program documents for February 2026 did not include the CDI of R25. The Infection mapping, line listings, logs, and documentation excluded the CDI.Several residents diagnosed with symptomatic infections were on the infection line listing but were not reflected in facility mapping or data analysis documentation.There was no infection documentation provided for the month of March 2026.During entrance conference on 3/30/26 at 1:03 PM, the Nursing Home Administrator (NHA) said the Infection Preventionist (IP) would not be available during the survey. The NHA said questions about the IPCP should be directed to Registered Nurse (RN) B or the NHA.RN B was interviewed on 4/1/26 at 1:12 PM. RN B was asked to review the infection control information for February 2026. RN B was asked the reason the CDI of R25 was not included for tracking, trending, and correlation of symptoms of infection. RN B said she did not know the reason the CDI wasn't included in the infection records. RN B reviewed the February 2026 information and confirmed the CDI for R25 was not documented in infection control information.RN B was asked how the facility monitored the CDI infection and how the facility was correlating other residents with gastrointestinal symptoms. RN B said she did not know how the facility was tracking or monitoring for CDI.When asked where the symptom monitoring information and infection documentation was located for the month of March 2026, RN B said, If it's not in here [infection control binder], we don't have it. RN B confirmed there was no infection control documentation for identifying or monitoring infections for the month of March 2026. RN B confirmed there were residents in the facility with symptomatic infections in March 2026.The NHA was interviewed on 4/1/26 at 1:19 PM. The NHA was queried regarding the exclusion of the CDI of R25 from the February 2026 infection control program documentation. The NHA reviewed the electronic documentation and said, I don't have it - it isn't here.The NHA confirmed there was missing documentation for infections in the infection control program documentation including the month of March 2026. The NHA said the IP was working to catch up on the infection control program. The NHA said, We have a lot of work to do [with the infection control program]. The NHA agreed that the IPCP wasn't in place.The policy Infection Prevention and Control Program dated as revised 7/21/25 read, in part: . This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. A system of surveillance is utilized for prevention, identifying, reporting, investigation, and controlling infections and communicable diseases for all residents.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety, resulting in the potential to spread food borne illness among all residents that consume food from the kitchen. Findings include:On 03/31/2026 at 2:45 PM the three-compartment sink was noted to not be properly air gapped and soap was bubbling up out of the floor drain. Kitchen staff had just emptied out the first compartment (wash) of the sink upon arrival. During this observation cook H, stated that happens all of the time, with other staff in the room agreeing with her. On 03/31/2026 at 3:00 PM observed the vegetable wash sink had an air-break and not an air gap between the food compartment drain-line and the floor drain.On 04/01/2026 at 10:05 AM in the Clean Storage Room observed the Symphony Plus ice machine drain extended down into the floor drain without an air gap.According to the 2022 FDA Food Code Section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. P On 03/31/2026 at 2:49 PM observed the floor and drain lines under the three-compartment sink and metal utensil storage rack were soiled with grease, grime and debris. According to the 2022 FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.On 03/31/2026 at 2:48 PM observed the insulation that was wrapping water lines running behind the storage shelving units to the left of the three-compartment sink, damaged, with clean utensils being stored on the shelving unit a couple inches away from the damaged insulation that covered the pipes.4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination

Based on interview and record review, the facility failed to ensure Medication Regimen Reviews (MRR) were addressed by the attending physician for three Residents (R16, R3, & R4) of five residents reviewed for MRR and unnecessary medications. Findings include:Resident #16 (R16) A Minimum Data Set (MDS) assessment dated [DATE] documented R16 was readmitted to the facility on [DATE] following a hospitalization. The MDS disclosed R16 had severely impaired cognition and displayed verbal and physical behaviors. The electronic medical record (EMR) of R16 documented a diagnosis of dementia with behavioral disturbance, and a physician's order for twice daily administrations of divalproex (a medication that reduces mood swings, impulsiveness and agitation). A pharmacist's monthly medication regimen review (MRR) dated 12/16/25 read, in part: See Report – GDR [Gradual Dose Reduction] and clarification requests. The pharmacist's report referenced in the MRR on 12/16/25 was not located in the EMR of R16. An MRR dated 1/14/26 read, in part: See Reports – GDR request. The pharmacist's report referenced in the MRR on 1/14/26 was not located in the EMR of R16. On 3/31/26 at approximately 2:00 PM, Social Worker A was asked to provide the pharmacist's reports to the physician and the physician's response to the pharmacist's recommendations for the MRRs conducted for R16 on 12/16/25 and 1/14/26. On 3/31/26 at 2:50 PM, Social Worker A provided an undated pharmacist's report addressed to R16's physician. The report read, in part: .Note to Attending Physician/Prescriber. Resident is currently due for a GDR evaluation on her divalproex. Please evaluate [R16's name redacted] to determine if she is ready for a reduction at this time. If you feel that no GDR should be attempted, please document your reasoning for clinical contraindication at the bottom of this form or in your next progress note. The undated pharmacist's report contained check boxes to agree or disagree with the recommendation. The disagree box was checked and the physician signed and dated the form on 1/22/26. The physician did not document clinical reasoning for declining the pharmacist's recommendation on the form. A review of the EMR of R16, including physician progress notes, which also did not reveal documentation from the physician regarding the rationale for rejecting the pharmacist's recommendation. The Nursing Home Administrator (NHA) was interviewed on 3/31/26 at 3:31 PM. The NHA was asked if the pharmacist's report for R16 that was signed by the physician on 1/22/26 was for the MRR conducted on 12/16/25 or 1/14/26. The NHA reviewed facility documents and the EMR of R16 and said he was unable to determine the date. The NHA was asked the location of the other MRR report. The NHA said he was unable to locate the additional MRR report. When asked if the physician documented the clinical rationale for declining the pharmacist's recommendation, the NHA said he and Social Worker A would look for the information. On 3/31/26 at 3:41 PM, Social Worker A reported they were unable to locate physician documentation regarding the reason for declining the pharmacist's recommendation for GDR of the divalproex. Social Worker A said the additional MRR report could not be located. Resident #3 (R3) An MDS dated [DATE] documented R3 was admitted to the facility on [DATE] with a primary medical condition of rheumatoid arthritis (a disease of the joints that can affect the organs). The MDS reflected R3 had moderately impaired cognition. The EMR of R3 documented a diagnosis of osteoporosis (a bone disease resulting in weak and fragile bones). A pharmacist's monthly MRR dated 10/15/25 read, in part: .Medication change recommendations. See Report – med addition request. The pharmacist's report for the MRR on 10/15/25 was not located in the EMR of R3. On 4/1/26 at 9:01 AM, Social Worker A provided an undated pharmacist's report addressed to R3's physician. The report read: Resident is taking alendronate [a medication to strengthen bones and reduce the risk of fractures] 70 mg [milligrams] q [every] week. Could consideration be given to adding a calcium/vitamin D supplement to her regimen to augment? . The physician wrote declined on the pharmacist's report and signed and dated the report on 10/23/25. There was no rationale written on the report or in the EMR of R3 indicating the rationale for declination of the pharmacist's recommendation. Social Worker A was queried on 4/1/26 at 9:06 AM regarding physician documentation regarding the reason for declining the pharmacist's recommendation. Social Worker A said, There is no documentation by the doctor. I don't know why he didn't take the recommendation. During an interview with the NHA on 4/1/26 at 1:32 PM, the NHA confirmed the missing pharmacist reports and lack of physician documentation on pharmacist recommendations were a concern. Resident R4 On 3/31/26 at 1:12 p.m., review of R4's MDS assessment, dated 2/18/26, revealed R4 was admitted to the facility on [DATE], with current active diagnoses that included the following, in part: Non-Alzheimer's dementia and anxiety disorder. The MDS assessment also revealed R4 received an antipsychotic medication on a routine basis and noted no gradual dose reduction (GDR) had been completed, with Contraindicated documented as No. R4 scored 12 of 15 on the Brief Interview for Mental Status (BIMS), reflective of moderately impaired cognition. On 3/31/26 at 1:58 p.m., review of R4's monthly MRRs revealed a 11/19/25 pharmacy recommendation for a GDR of an antipsychotic medication. The Note to Attending Physician/Prescriber was requested from Social Worker A, and provided on 3/31/26 at 2:50 p.m. Review of the Note to Attending Physician/Prescriber on 3/31/26 at 2:50 p.m., revealed the following, in part: .Resident is currently due for a GDR evaluation on [their] risperidone (antipsychotic medication) 1mg (milligram) qd (daily) for hallucinations. Please evaluate [R4] to determine if she is ready for a reduction at this time. If you feel that no GDR should be attempted, please document your reasoning for clinical contraindication at the bottom of this form or in your next progress note. The Physician/Prescriber Response area for physician notation included Decline see form with a signature that appeared to be a circle with a line drawn through it, similar to a zero, dated 12/5/25. During an interview on 4/1/25 at 8:15 a.m., when asked for any documentation showing the physicians declination rationale for R4's antipsychotic GDR, Social Worker A stated, I cannot find one (GDR declination rationale). No physician rationale was provided for the 11/19/25 GDR request declination. Review of the [Pharmacy Name] Skilled Nursing Facility Policy and Procedure Manual, received from the facility on 3/31/26 at 2:09 p.m., revealed the following, in part: Medication Regimen Review policy: The consultant pharmacist will review the drug regimen of all the residents at least monthly and report any observed irregularities in drug use and other drug therapy recommendations to the director of nursing and attending physician . The prescriber's response will be recorded on a copy of the MRR report that shall remain in the facility or in the individual resident's clinical record. Recommendations are acted upon and documented by the facility staff or prescriber .Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing . Nursing and physician responses to the consultant pharmacist's observations and recommendations should be recorded in the resident's clinical record or on the consultant's written report and filed in the facility for at least two (2) years.

Based on interview and record review, the facility failed to provide hospice documentation for two Residents (R2, and R22) out of two residents reviewed for hospice care services. This deficient practice resulted in incomplete documentation for services that were provided by hospice. Findings include: R2 Review of R2's Electronic Medical Record (EMR) revealed admission to the facility on 1/29/26 with diagnoses including congestive heart failure (CHF). R2's Minimum Data Set (MDS) assessment dated [DATE] revealed she scored a 15/15 on the Brief Interview for Mental Status (BIMS) score, indicative of cognitively intact status. The MDS assessment also documented R2's participation in Hospice care. Review of R2's Physician Orders read, in part, May sign on to hospice agency of choice .Order: Active .Start Date: 3/2/2026 Review of R2's Care Plans read, in part, (R2) has a terminal prognosis r/t (related to) heart disease. (R2) is on [Hospice Company Name] and will remain long term in facility .Interventions: Work cooperatively with hospice team to ensure (R2)'s spiritual, emotional, intellectual, physicial and social needs are met . On 3/31/26 at 12:00 PM, Review of R2's EMR revealed no documentation including visit notes, cares, or services provided by hospice during the course of her care starting on 3/2/26. The facility was unable to provide further documentation before the end of the survey on 4/1/26. Resident R22 Review of R22's MDS assessment, dated 1/30/26, revealed the Resident was admitted to the facility on [DATE], with active diagnoses that included the following, in part: coronary artery disease (CAD), vascular dementia, hemiplegia (paralysis of left side), chronic obstructive pulmonary disease (COPD), peripheral vascular disease (PVD) and encounter for palliative care. R22 scored 9 of 15 on the Brief Interview for Mental Status (BIMS) reflective of moderately impaired cognition. The MDS assessment also documented R22's participation in Hospice care. On 3/31/26 at 8:49 a.m., review of R22's electronic medical record (EMR) revealed a Hospice Election Statement, dated 10/13/2025. On 3/31/2026 at 11:28 a.m., review of R22's EMR revealed a [Hospice Agency] Hospice Care Plan created 10/14/25. Review of the MISC (miscellaneous) tab in the [Hospice Agency] binder found no Hospice visit notes pertaining to the care and services provided to R22 by the Hospice Agency during the course of his care since October of 2025. During an interview on 3/31/26 at 11:37 a.m., Clinical Care Coordinator (CCC) B was asked for documentation of Hospice visit notes for R22. CCC B said the daily Hospice visit notes should be in the miscellaneous tab in R22's EMR. When R22's miscellaneous tab was reviewed with CCC B they confirmed no visit notes completed by the Hospice Agency were found in R22's EMR. CCC B stated, When I get stuff from Hospice, I put it in the scanning bin. I am not sure of where the papers with the Hospice visit notes are. During an interview on 3/31/26 at 11:42 a.m., Social Worker (SW) A was asked for R22's Hospice visit notes detailing care and services provided to the Resident. SW A stated, They (Hospice visit notes) would not be scanned in. [Hospice Agency] signs the log and the notes are uploaded. We haven't uploaded any daily visit notes for hospice yet. They are going to have to start filling out daily visit notes . They will have to do daily collaboration sheets like [another Hospice Agency] does. During an interview on 3/31/26 at 11:58 a.m., a copy of the Hospice Policy was requested from SW A. Review of the Hospice Care policy, provided on 4/1/26 at approximately 11:30 a.m., revealed the following, in part: .The facility will initiate and maintain a medical record on each hospice resident. Hospice staff will document progress information on hospice forms, leaving a copy of such notes with the facility. The facility will retain these notes as a part of the resident's permanent record .

Based on interview and record review, the facility failed toEnsure a discharge summary included a reconciliation of pre-discharge medications with the resident's post-discharge medications, and;Issue written notification of transfer for two Residents (R32 and R30) of four residents reviewed for closed records.Findings include:Resident #32 (R32)R32 was discharged from the facility with home health care services on 2/27/26.A Discharge summary dated [DATE] was reviewed on 4/1/26. Section B number 14 of the discharge summary included the prompt Drug Therapy Required. The documented response read: Meds called into [name of drugstore pharmacy redacted].Section B number 14a of the discharge summary contained a selection box (a user interface element that allows users to select one or more options from a predefined list) that read: See Physician's Order Listing. The selection box was blank. There was no Physician's Order Listing included with the discharge summary.Section F of the Discharge Summary contained sections for the resident and/or resident representative signatures which were blank despite a date entry of 2/27/2026.Social Worker A was interviewed on 4/1/26 at 10:05 AM. Social Worker A said residents received the Discharge Summary when they are discharged from the facility. When asked about a list of medications or medication reconciliation, Social Worker A said all information regarding medications was contained in the Discharge Summary. When asked about the medication reconciliation or a list of discharge medications for R32, Social Worker A reviewed the electronic medical record (EMR) of R32 and said there was no documented indication, a list of discharge medications was provided to R32, or that a medication reconciliation had been completed.When asked if R32 and/or the resident representative of R32 had signed the discharge summary, Social Worker A said it was in the miscellaneous tab in the EMR of R32. Social Worker A reviewed the referenced portion of R32's EMR and verified a signed copy of the discharge summary was not in the EMR of R32.Social Worker A said the signed discharge summary may not have been uploaded into the EMR yet and said she would look for it. No discharge summary containing the resident and/or resident representative signature was provided by the end of survey.The policy Notice of Transfer and/or Discharge dated as revised 7/21/25 read, in part: .Anticipated Discharges. 3. The following items are addressed during the discharge conference: a. Discharge instructions are completed and reviewed b. Reconciliation of all pre-discharge medications with post-discharge medications.Resident #30 (R30)R30 was transferred from the facility to the hospital Emergency Department on 3/12/26.The EMR of R30 did not contain documentation indicating written notification of transfer was provided to R30 or the resident representative of R30.During an interview on 4/1/26 at 10:27 AM, Social Worker A was asked for the written notification of transfer that was provided to R30 and/or the resident representative of R30. Social Worker A said, We don't do that - all we've ever sent is the bed hold information.The policy Notice of Transfer and/or Discharge dated as revised 7/21/25 read, in part: .The facility will provide the resident, and/or resident's representative with the appropriate notice of transfer/discharge according to state and federal requirements. The resident and/or representative will be notified of the transfer/discharge and provided with the following information: 1. The reason for the transfer or discharge. 2. The effective date of the transfer or discharge. 3. The location to which the resident is being transferred or discharged . 4. The name, address, and telephone number of the state long-term care (LTC) ombudsman.6. The name, address, and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices.

Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee met at least once per quarter with the required committee members resulting in the potential for quality-of-care concerns for all 27 residents in the facility. Findings include: On 2/13/2025 at 2:00 p.m., a review of the available attendance documentation for QAPI meetings with the interim-Nursing Home Administrator (NHA) and the Director of Nursing (DON), revealed the following: Meeting held on 2/5/2025: The Medical Director or designee did not attend. Meeting held on 10/24/2024: No attendance record found. NHA reported she was unsure where the October 2024 attendance record was placed and confirmed the medical director or designee did not attend the February 2025 meeting. The missing attendance records were not provided by survey exit on 2/13/2025 at 3:00 p.m.

Based on interview and record review the facility failed to provide evidence of documented monthly pharmacy medication regimen reviews (MRRs) and failed to appropriately follow a pharmacy recommendation for four Residents (3, 10, 15, 21) out of five residents reviewed for medication review. This deficient practice resulted in the potential for adverse medication side effects. Findings include: Resident #10 (R10) Review of R10's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnosis including rheumatoid arthritis, dementia with behaviors, type 2 diabetes, depression and anxiety. R10 scored a 10/15 on the Brief Interview for Mental Status (BIMS) assessment dated [DATE] indicating moderate cognitive impairment. Review of document titled Consultant Pharmacist's Medication Regimen Review (MRR): for recommendations created between 1/1/25 and 1/31/25 read in part, .Please consider adding standing order labs for the following medications: 1. Clopidogrel (anticoagulant-blood thinner), Aspirin: CBC (complete blood count) every 12 months 2. Alendronate (calcium metabolism for bone structure): Calcium, Phosphate 3. Seroquel (antipsychotic): FLP (fasting lipid profile), A1C (blood sugar test-3 month average), BMP (basic metabolic panel) every 12 months 4. Vitamin D: Vitamin D levels every 12 months Review of the physician order recapitulation report did not reveal any labs ordered for the recommendations from pharmacy. Resident #15 (R15) Review of R15's EMR revealed admission to the facility on [DATE] with diagnosis including senile degeneration of brain, heart failure, dementia, depression, and anxiety. R15 scored a 3/15 on the BIMS assessment dated [DATE] indicating severe cognitive impairment. Review of document titled Consultant Pharmacist's Medication Regimen Review: for recommendations created between 1/1/25 and 1/31/25 read in part, .Please consider adding standing order labs for the following medications: 1. Ompeprazole (Stomach Acid Reducer): Magnesium every 12 months 2. Atorvastatin (Cholesterol reducer): FLP and LFT (liver function test) every 12 months 3. Eliquis (antiplatelet-blood thinner): CBC every 12 months 4. Lisinopril (blood pressure), Sertraline (antidepressant), Lasix (fluid balance): BMP every 12 months 5. Iron: HGB (hemoglobin), TIB (total iron binding capacity), Ferritin (iron test) every 12 months 6. Metformin (blood sugar contol): A1C Review of the physician order recapitulation report did not reveal any labs ordered for the recommendations from pharmacy. 49735 Resident #3 (R3) Review of R3's MDS assessment dated [DATE], revealed admission to the facility on [DATE] with active diagnoses that included: dementia, anxiety disorder and depression. R3 scored a 10 of 15 on the BIMS assessment reflective of moderate cognitive impairment. Review of document titled Consultant Pharmacist's Medication Regimen Review: for recommendations created between 1/1/25 and 1/31/25 read in part, .Please consider adding standing order labs for the following medications: 1. Atorvastatin: FLP, LFT every 12 months 2. Bumetanide (fluid balance) Lisinopril: BMP every 12 months 3. Vitamin D3: Vitamin D levels every 12 months 4. Iron: TIB, Ferritin, HGB levels every 12 months 5. Lantus (insulin): A1C 6. Levothyroxine (thyroid medication): Thyroid Stimulating Hormone (TSH) yearly Review of the physician order recapitulation report did not reveal any labs ordered for the recommendations from pharmacy. Resident #21 (R21) Review of R21's MDS assessment dated [DATE], revealed admission to the facility on [DATE] with active diagnoses that included dementia. Further review of the MDS revealed R3 rarely or never is understood and requires cues or supervision regarding daily decision making. Review of document titled Consultant Pharmacist Medication Regimen Review: for recommendations created between 1/1/25 and 1/31/25 read in part, .please consider adding standing order labs for the following medications: 1. Quetiapine: Orthostatic Blood pressure monthly, A1C, FLP every 12 months Review of the physician order recapitulation report did not reveal any labs ordered for the recommendations from pharmacy. During an interview on 2/12/25 at 3:47 p.m., the Medical Director E stated I have not seen all the recommendations on all the labs (from the pharmacy), I only get the recommendations regarding the medications . The Medical Director E acknowledged that the physician should see all the recommendations from the pharmacy. Review of facility policy titled Medication Regimen Review read in part, .The consultant pharmacists evaluation may include .reviewing are or evaluating .laboratory results, diagnostic, studies,, or other medication therapy measurements are obtained by staff/physician and acted upon . the prescriber's (physicians) response will be recorded on a copy of the Medication Regimen Review report that shall remain in the facility or in the individual residents clinical record

Based on observation, interview, and record review, the facility failed to ensure a functional call light for one Resident (#129) of 12 residents reviewed for operational call lights. This deficient practice resulted in dissatisfaction with the timeliness of the provision of care and fear that care needs may not be met in an emergency. Findings include: Resident #129 (R129) During an interview on 2/11/25 at 12:40 p.m., R129 said staff were slow to respond to care needs and added that the call light did not work. R129 said staff were notified and knew the call light was not working. R129 said they reported the non-functional call light to Certified Nurse Aides (CNAs), and Nurses. R129 stated, That is frustrating for me. I have never timed how long it takes them to respond. On 2/13/25 at 12:43 p.m., review of R129's Minimum Data Set (MDS) assessment, dated 9/26/24, revealed a Brief Interview for Mental Status (BIMS) score from his previous admission on 9/26/24, of 12 out of 15, indicative of moderate cognitive impairment. Resident 129 was able to answer all questions appropriately on 2/11/25 at 12:40 p.m., and cognitive impairment was not identified during the conversation. On 2/11/25 at 12:44 p.m., R129 was observed pressing the call light to signal staff of a care need. The indicator light on the call light box located on the wall, which shows when a call light is pressed did not turn on. The call light cord/button was observed connected to the call light box, and the indicator light above the door outside of R129's room was observed not triggered. On 2/11/25 at approximately 12:45 p.m., R129's roommate, R128 was asked to press their call light. Roommate R129's call light was observed functional both inside and outside of the room. Roommate R128 said they had been pushing their call light when their roommate (R129) needed assistance, since [R129's] call light didn't work. R129 stated, In an emergency it (a non-functional call light) would be a problem. Review of R129's Care Plans revealed the following, in part: Focus: [R129] has limited physical mobility r/t (related to) weakness, history of stroke with residual affecting . right side. Date Initiated: 2/7/25 . Interventions/Tasks: AMBULATION: Not at this time. Date Initiated: 2/7/25. Focus: [R129] is a for falls (sic) r/t deconditioning. Gait/balance problems. Date Initiated: 2/7/25 . Interventions/Tasks: Be sure [R129's] call light is within reach and encourage him to use it for assistance as needed. Date Initiated: 2/7/25. Review of Roommate R128's MDS assessment on 2/13/25 at 1:04 p.m., revealed R128 scored 15 of 15 on the BIMS, dated 2/6/25, reflective of intact cognition. R128 was lucid and answered all questions appropriately. During an interview on 2/11/25 at 12:56 p.m., CNA C confirmed R129 had a non-functional call light. CNA C stated, It (R129's call light) has been funky for a while and we put work orders in (to the facility maintenance department for repair). I am not sure when the last time it worked. The call light does not work, and I am going to put a call order in again today . I unplugged the call light and plugged it back in and it didn't work (at this time). It is just frustrating because I know that that there have been multiple work orders put in for the call light, but that is a maintenance thing, and they have not come to fix it (R129's call light). During an interview on 2/11/25 at 1:01 p.m., Registered Nurse (RN) B was asked about R129's call light. RN B stated, I am aware that [R129's] call light does not work. This morning, I had to give him an enema and I gave him [Roommate R128's call light] because [R128] was gone (out of the room) . There have been multiple work orders (put in to the maintenance department) for [R129's] call light, and they have not come to repair it. I don't know what is wrong with it. I have to do another work order (today). During an interview on 2/12/25 at 8:18 a.m., any and/or all work orders prepared or received by the facility maintenance department for R129's call light were requested from the Interim Nursing Home Administrator (NHA). The NHA said she would retrieve the requested information. During an interview on 2/12/25 at 8:24 a.m., Maintenance Director G was asked about work orders for R129's call light. Maintenance Director G said the nursing home did not put in work orders for call light repair into the hospital maintenance staff. Maintenance Director G said facility staff were supposed to call a third-party contractor to come and fix the call lights. On 2/12/25 at 8:40 a.m., an interview was conducted with both the NHA and the Director of Nursing (DON) . The NHA said they were working with the hospitals facilities department to get a copy of the work orders related to call lights. The DON stated, I want to tell you that they (maintenance department) do come here for call lights. They are supposed to come down and check the call light, and if it is something they can't fix then we are supposed to call [third party vendor for call lights.) The DON confirmed multiple work orders had been placed with the maintenance department for the call light in R129's room. During an interview on 2/12/25 at 10:40 a.m., Maintenance Director G acknowledged they did have all the work orders and asked why this Surveyor wanted to see them because they had a contract with a third party to repair the call lights in the facility. It was explained there were requested to review the work orders, to verify if they were closed out or attended to by maintenance staff. During an interview on 2/12/25 at 10:58 a.m., the NHA reported that they were unable to locate a call light policy, and they do not believe there is a policy regarding call lights. The NHA could not provide a third-party contractor agreement for call light repair at this time. During an interview on 2/12/25 at 3:18 p.m., the NHA reported they had contacted [the third-party contractor] and the facility does not have a contract with this company to come and repair the call lights. The third-party company said when they purchased the call light system, they (Company Name) agreed to service the call lights if they were called. The NHA said if the third-party company was called for a repair, they charge them $125 per hour to come out. When asked if facilities management provides other maintenance work within the facility, the NHA said Yes, they provide all of the other maintenance in the facility. The NHA expressed understanding of the concern related to R129's non-functional call light. Review of Work Orders for the call light in R129's room, entered into the electronic document submission program used during the survey on 2/12/25 at 3:23 p.m., revealed the following: 1. Work Order #351741 - Request Date 9/8/24 at 4:54 PM. Status: CLOSED. Problem: room [ROOM NUMBER] call light is not working properly. It will work once in a while but not all the time. Had a resident trying to get help for an hour and the light would not work.5 hours (1/2 hour) of Labor was documented on 9/11/24. 2. Work Order #364168 - Request Date 11/15/2024. Status: CLOSED. Problem: room [ROOM NUMBER] bed #2 . is having issues with call light. It is not working. Resident states someone came to fix it recently and they got it working however it appears to be broken again as of 11/15/24.5 hours (1/2 hour) of Labor was documented on 11/18/24. 3. Work Order #364297 - Request Date 11/18/24. Status: CLOSED. Problem: Call light in room [ROOM NUMBER]-2 is not working.5 hours (1.2 hour) of Labor was documented on 11/18/24. 4. Work Order #370113 - Request Date 12/20/24. Status: CLOSED. Problem: room [ROOM NUMBER] bed 2 both call lights not working correctly. Please fix asap.75 hours (3/4 hour) of Labor was documented on 12/23/24. 5. Work Order #380366 - Request Date 2/11/25. Status: OPEN. Problem: Call light does work in room [ROOM NUMBER]-2. Above Work Orders #1, #2, and #4 showed the call light in room [ROOM NUMBER]-2 was not repaired for three days after receiving notification of the non-functional call light.

Based on interview and record review, the facility failed to: 1. Indicate a specific end date for as needed (PRN) psychotropic (drug that affects brain activity) medication for Residents #21. 2. Conduct an Abnormal Involuntary Movement Scale (AIMS) assessment (measures side effects of medications, i.e. tardive dyskinesia) for two Residents (#3 and #10), from a total of five residents reviewed for unnecessary medications. Findings include. Resident #21 (R21) Review of R21's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE] with diagnoses including dementia. Section C of the MDS rated R21 as rarely or never is understood and requires cues or supervision regarding daily decision making. R21 was prescribed lorazepam (an antianxiety medication) every 12 hours PRN for anxiety. A review of the lorazepam order history revealed R21 was prescribed lorazepam PRN since 8/27/24, without a specific end date. Review of Physician notes in R21's medical record from 8/27/24 through 9/10/24 revealed no documented rationale by the physician for PRN lorazepam to continue, and no documentation was observed for rationale for continued use beyond the 14-day standard reevaluation criteria for PRN psychotropic medications. During an interview on 2/12/25 at 2:25 p.m., when asked about the PRN order for antipsychotics, the Director of Nursing (DON) stated, We can only write a PRN prescription for 14 days then the order would be stopped, and a new order would be written . Review of facility policy titled Chemical Restrains/Psychoactive Medications, last revised 4/22/24, read in part .antianxiety medications .as needed (PRN) orders not to exceed 14 days without physician documentation . Resident #3 (R3) Review of R3's MDS assessment dated [DATE], revealed admission to the facility on [DATE] with diagnoses including dementia, anxiety disorder, and depression. R3 scored a 10 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of moderate cognitive impairment. Review of R3's Electronic Medical Record (EMR) revealed a Doctors order for Seroquel 25 mg, with an original start date of 8/16/24. Seroquel is an antipsychotic medication and requires periodic AIMS assessments. No AIMS assessment could be located in the EMR for R3. During an observation and interview on 2/13/25 at 11:54, Social Worker D was observed reviewing the chart for R21 for an AIMS assessment and stated, Oh my God, I do not see one .I guess we have not done one. During an interview on 2/13/24 at 11:58 am, Registered Nurse (RN) A acknowledged the nurses are supposed to complete an AIMS assessments quarterly for residents who are prescribed antipsychotics. Review of facility policy titled Chemical Restraints/Psychoactive Medications, last revised 4/22/24, read in part . the purpose of monitoring the use of psychoactive mediations are to .detect adverse consequences/side effects .the nursing staff is responsible for initiating an Abnormal Involuntary Movement Scale (AIMS) assessment . 34568 Resident #10 (R10) Review of R10's EMR revealed admission to the facility on [DATE] with diagnosis including dementia with behaviors, depression and anxiety. R10 scored a 10/15 on the Brief Interview for Mental Status (BIMS) assessment dated [DATE] indicating moderate cognitive impairment. Review of R10's Physician Orders revealed the following medication: Seroquel 25 mg every day; start date 5/10/24. R10's last AIMS assessment was completed 8/27/24. An interview with Social Worker D on 2/13/25 at 1:30 p.m. confirmed R10 was missing the last two quarterly AIMS assessments which should have been completed in November 2024 and February 2024. Social Worker D stated AIMS assessments should be completed quarterly for residents on an antipsychotic medication.

Based on observation, interview, and record review the facility failed to provide timely Electronic Medical Record (EMR) access for their annual recertification survey. Findings include: On 3/25/24 at 9:55 AM, an entrance conference was conducted with the Nursing Home Administrator (NHA). The NHA was informed of the requirements on the Entrance Conference Worksheet, dated 10/2023, read in part, .INFORMATION NEEDED BY THE END OF THE FIRST DAY OF SURVEY .37. Provide each surveyor with access to all resident electronic health records - do not exclude any information that should be a part of the resident's medical record. Provide specific information on how surveyors can access the EHRs outside of the conference room. Please complete the attached form on page 4 which is titled Electronic Health Record Information . On 3/25/24 at 10:00 AM, the NHA was asked what kind of EMR system the facility had and replied that they utilize two different name brand EMRs. At that time the NHA was made aware and acknowledged understanding that each member of the survey team would need access to both systems to assist with the completion of the annual survey. On 3/26/24 at approximately 10:00 AM, an observation and record review was made of one the facilities EMR and lacked physician notes, physician orders, physical therapy notes, wound care notes, occupational therapy notes, and other required annual survey process records for review. On 3/26/24 at 10:30 AM, the survey team conducted a meeting and confirmed with the team coordinator that they had not received access to the second EMR which included the majority of the residents' medical records. On 3/26/24 at 10:31 AM, an interview was conducted with the NHA and a second request was made for full access to the facilities EMR. The NHA stated she would work on it, but that since there had been some changes with Information Technology (IT) she would see what she could do. On 3/26/24 at 12:30 PM, the NHA came to discuss her frustration with the survey team regarding access to one of the EMRs. At that time, she was unable to get the survey team access and stated that she needed to call an IT representative that she thought would be able to help. On 3/26/24 at 3:00 PM, an observation and record review were made and at that time it was discovered that one member had a username and password, but was unable to access the second EMR system and a second surveyor still had no access at all to the second EMR system. On 3/27/24 at 9:45 AM, an observation was made by Registered Nurse (RN) B of the EMR system and replied, You (surveyors) don't have the access that you need to pull up the medication list. On 3/27/24 at 10:20 AM, an interview was conducted with RN B and was asked if she had a miscellaneous tab in the EMR system and replied, Yes. RN B was made aware that the survey team did not have access to this tab. On 3/27/24 at 2:00 PM, the Medical Director came to be interviewed by a member of the survey team and stated, He realizes that the medical records are all over the place and they are located in multiple different systems. The Medical Director alluded to challenging efforts to accessing resident medical records. On 3/27/24 at 4:11 PM, an interview was conducted with the NHA, and she stated, It was difficult and frustrating to obtain access to the EMR for the survey team. It should not be that complicated. We are in the process of building one EMR system for our facility and it can not happen soon enough.

Based on observation, interview and record review, the facility failed to ensure one Resident (R22) with limited mobility was appropriately set up for meal service to maintain mobility out of three residents reviewed for Range of Motion (ROM). This deficient practice resulted in R22 appearing to experience not being able to feed himself easily and the potential for decreased mobility and ROM. Findings include: Review of R22's Admission Record revealed he was admitted to the facility on [DATE] with diagnosis including cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, and dysphagia. His 3/1/24 Minimum Data Set (MDS) assessment revealed he scored a 3/15 on the Brief Interview for Mental Status (BIMS) score, indicating he was severely cognitively impaired. Further review of his MDS assessment revealed he had impairment of one side for both upper and lower extremity and required set-up for eating. On 3/25/24 at 11:42 a.m. R22 was observed to be eating his lunch in the television room attached to the main dining room. R22 was in his wheelchair with a bed side table sitting overtop of his lap, with his meal placed in front of him and his silverware noted to be on his right side. R22 was noted to have a severe contracture of his right hand and was unable to use it. An attempted interview was conducted with R22 but was unable to answer questions appropriately. R22 was observed to slurp soup from the bowl by using his left hand. When asked if he was able to grab the silverware located on his right side, R22 stated, No. Two unidentified staff members were noted to be in and out of the television room and did not stop to assist R22. R22 then began to eat his cherry pie out of the plastic container with his hands. On 3/26/24 at 11:57 p.m., R22 was noted to be in the same television room as the day before with a bedside table across his lap. R22 was only given a fork to complete his meal and placed the fork down to eat his apple pie with his fingers. R22 was asked if he could reach his spoon on his right side and he again stated, No. An interview was conducted with the Director of Nursing (DON) on 3/27/24 at approximately 3:30 p.m. The DON confirmed that R22's care plan did not identify that silverware should be placed on his left side so he could reach and feed himself. The DON stated that this would be corrected immediately.

This citation pertains to intake: MI00143410 Based on interview and record review, the facility failed to prevent staff to resident verbal and physical abuse for three Residents (R3, R14, R19) of three residents reviewed for abuse. This deficient practice resulted in R19 expressing fear of exposure to continued rough treatment during cares and fear of retaliation and the likelihood of feeling degraded by derogatory and profane comments by R3 and R14 based on the reasonable person concept. Findings include: Review of the facility's Investigation Summary/[Facility Name] dated [DATE] read, in part, .On [DATE]th (Certified Nurse Aide (CNA) K) reported to the (Director of Nursing (DON)) that resident (R19) had told her (CNA J) was rough with him, yanking on his arms and legs. 'I asked her to stop she does for a bit then does it again. She's mean to me and pulls and tugs on my arms. I'm scared of her. I especially don't like when she gets me out of bed in the mornings. I feel like she's going to pull my arms out of their sockets.' When asked if he was afraid of CNA J, (R19) said yes. CNA K said he was tearful and said he showed distress in his facial expression .R19 scored a ,d+[DATE] on the BIMS (Brief Interview for Mental Status) .[DATE]th, 2024 interview with CNA L stated that CNA J works too many hours and is always tired .she's so worn out and treats others poorly .when asked for examples CNA L gave in room with (R3) with cares CNA J stated 'Come on, (R3), roll your fat over.' And with (R14) crying all the time, CNA J stated Stop your God D*** crying! (R14) also grips hands of employees tightly and CNA J will yank her hand away and say, 'Don't F******* dig into me with your nails.' Review of CNA K and CNA L written statements confirmed the facility's Investigation Summary. An interview was conducted with R19 on [DATE] at 9:44 a.m., R19 declined to answer questions regarding his care with CNA J. R3 was noted to have expired prior to the survey start date of [DATE]. Review of R14's Minimum Data Set (MDS) assessment dated [DATE] revealed she scored a 99 on the BIMS score and was unable to be interviewed. An interview was conducted with CNA J on [DATE] at 12:37 p.m. When asked if she ever becomes frustrated with caring for residents, including those with cognitive impairments CNA J stated, I got frustrated with one resident who constantly rings her call light, or cries. In regard to the incident with R19, CNA J stated, I have taken care of (R19) for three years, he is a two person assist and cannot help you with his cares. When asked if CNA J has experienced burnout, she replied, I have worked 103 hours every two weeks, I'm always picking up and working shifts because I'm American. When asked if she has ever sworn in front of resident's CNA J stated, It may slip here and there. An interview was conducted with the Nursing Home Administrator (NHA) on [DATE] at approximately 1:00 p.m. The NHA confirmed that CNA J was terminated from employment due to the nature of the statements given to her from staff. The NHA confirmed the allegations were substantiated by the facility. Review of the facility's Resident Abuse Identification and Prevention revised on [DATE] read, in part, .[Facility Name] strictly prohibits mistreatment, neglect and abuse of residents and misappropriation of resident property, and does not tolerate verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion for any reason .

This citation pertains to intake: MI00143410 Based on interview and record review, the facility failed to report staff to resident verbal abuse for two Residents (R3, R14) of three residents reviewed for abuse. Findings include: Review of the facility's Investigation Summary/[Facility Name] dated [DATE] read, in part, .[DATE]th, 2024 interview with CNA L stated that CNA J works too many hours and is always tired .she's so worn out and treats others poorly .when asked for examples CNA L gave in room with (R3) with cares CNA J stated 'Come on, (R3), roll your fat over.' And with (R14) crying all the time, CNA J stated Stop your God D*** crying! (R14) also grips hands of employees tightly and CNA J will yank her hand away and say, 'Don't F******* dig into me with your nails.' Review of CNA K and CNA L written statements confirmed the facility's Investigation Summary. R3 was noted to have expired prior to the survey start date of [DATE]. Review of R14's Minimum Data Set (MDS) assessment dated [DATE] revealed she scored a 99 on the BIMS score and was unable to be interviewed. An interview was conducted with CNA J on [DATE] at 12:37 p.m. When asked if she ever becomes frustrated with caring for residents, including those with cognitive impairments CNA J stated, I got frustrated with one resident who constantly rings her call light, or cries. In regard to the incident with R19, CNA J stated, I have taken care of (R19) for three years, he is a two person assist and cannot help you with his cares. When asked if CNA J has experienced burnout, she replied, I have worked 103 hours every two weeks, I'm always picking up and working shifts because I'm American. When asked if she has ever sworn in front of resident's CNA J stated, It may slip here and there. An interview was conducted with the Nursing Home Administrator (NHA) on [DATE] at approximately 1:00 p.m. The NHA confirmed that CNA J was terminated from employment due to the nature of the statements given to her from staff. The NHA confirmed the allegations were substantiated by the facility and she did not report these additional incidents involving R3 and R14 to the State Agency as they did not come to her knowledge until after the investigation into R19. When asked why staff did not report these incidents sooner, the NHA stated she did not know. Review of the facility's Resident Abuse Identification and Prevention revised on [DATE] read, in part, .[Facility Name] requires any employee who becomes aware of any such incident, or suspects any such incident to report the matter immediately to the Nursing Home Administrator (NHA) .Reporting: All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately but no later than 2 hours after the allegation is made. If the events do not involve abuse and do not result in serious bodily injury, report is expected to be made immediately but no later than 24 hours.

Based on interview and record review, the facility failed to conduct thorough investigations for allegations of verbal abuse for two Residents (R3, R14) of three residents reviewed for abuse. This deficient practice resulted in the potential for additional unidentified abuse. Findings include: Review of the facility's Investigation Summary/[Facility Name] dated [DATE] read, in part, .[DATE]th, 2024 interview with CNA L stated that CNA J works too many hours and is always tired .she's so worn out and treats others poorly .when asked for examples CNA L gave in room with (R3) with cares CNA J stated 'Come on, (R3), roll your fat over.' And with (R14) crying all the time, CNA J stated Stop your God D*** crying! (R14) also grips hands of employees tightly and CNA J will yank her hand away and say, 'Don't F******* dig into me with your nails.' Review of CNA K and CNA L written statements confirmed the facility's Investigation Summary. R3 was noted to have expired prior to the survey start date of [DATE]. Review of R14's Minimum Data Set (MDS) assessment dated [DATE] revealed she scored a 99 on the BIMS score and was unable to be interviewed. An interview was conducted with CNA J on [DATE] at 12:37 p.m. When asked if she ever becomes frustrated with caring for residents, including those with cognitive impairments CNA J stated, I got frustrated with one resident who constantly rings her call light, or cries. When asked if CNA J has experienced burnout, she replied, I have worked 103 hours every two weeks, I'm always picking up and working shifts because I'm American. When asked if she has ever sworn in front of resident's CNA J stated, It may slip here and there. An interview was conducted with the Nursing Home Administrator (NHA) on [DATE] at approximately 1:00 p.m. The NHA confirmed that CNA J was terminated from employment due to the nature of the statements given to her from staff. The NHA confirmed the allegations were substantiated by the facility and she did not report these incidents to the State Agency as they did not come to her knowledge right away. When asked why staff did not report these incidents sooner, the NHA stated she did not know. The NHA acknowledged investigations had just started and were not yet complete. Review of the facility's Resident Abuse Identification and Prevention revised on [DATE] read, in part, .Reporting: All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately but no later than 2 hours after the allegation is made. If the events do not involve abuse and do not result in serious bodily injury, report is expected to be made immediately but no later than 24 hours .Upon notification of an alleged incident, the NHA or designee will take the following steps: Immediate preventative measures to ensure any further violation is prevented during the investigation .The NHA or appropriate designee will be responsible for reporting all alleged abuse/mistreatment/neglect to the appropriate State agency immediately but not more than 24 hours of the incident .Investigations will include but are not limited to confidential interview with staff, family members, residents as appropriate to their cognitive abilities, or anyone who may have been involved or witness to the incident. NHA or designee will notify resident's family or responsible person of alleged incident and investigation .Any substantiated abuse or mistreatment will be reported to the nurse licensing board or CENA (CNA) registry .

Based on observation, interview, and record review, the facility failed to provide a homelike environment by serving residents their meals on institutional trays in the resident dining rooms. This deficient practice resulted in residents being positioned farther back from the dining tables, further from tablemates, and the potential for decreased socialization. Findings include: On 5/09/23 at approximately 11:59 AM, lunch was observed being served to residents in the main dining areas. Individual meals were placed on round tables on serving trays in front of each resident. Residents were seated four per table and the trays did not fit on the table. The trays hung off the edge of the table, thus causing each resident to be farther back from their meal at the table and took up more space in the dining room. Resident conversation was noted to be minimal. The adjacent room also had Residents eating their meal served on a tray on bedside tables. On 5/10/23 at 11:40 AM, the lunch meal again was observed placed before the residents on an institutional tray. The Director of Nursing (DON) was alerted, and she replied, I have told them before, we want it to be homelike. On 5/10/23 at 11:46 AM, Certified Nurse Aide (CNA) D was removing the trays from the resident tables. CNA D stated, We used to remove the trays before covid, that was our thing. During an interview on 5/10/23 at 1:10 PM, the Nursing Home Administrator (NHA) stated the facility had a policy on the dining process which was currently under revision. The facility current policy titled: Dining Program/Snacks was presented by the NHA and read in part: Purpose: It is the policy of (name of facility) to meet the nutritional needs of its residents by enhancing the dining/eating experience . D. Dishes and items will be removed from the tray and set on the table and cloth napkins will be provided. Other practices may be utilized to provide a more homelike environment such as music, place mats, table clothes (sic), centerpieces, etc.

Based on observation, interview, and record review, the facility failed to maintain safe hot water temperatures, resulting in the potential for scalding accidents, affecting all 28 residents in the facility. Finding include: On 5/9/23 at 12:08 PM, the hand sinks' hot water temperatures in the bathroom and living area of room [ROOM NUMBER] were observed to be 123 degrees Fahrenheit, by using a digital probe thermometer. On 5/9/23 at 12:10 PM, the hand sink, located in the bathroom of room [ROOM NUMBER], was observed to be measuring 124 degrees Fahrenheit. On 5/9/23 at 12:11 PM, the hand sink, located in the bathroom of room [ROOM NUMBER], was observed to be measuring 124 degrees Fahrenheit. During an interview on 5/9/23 at 12:19 PM, Plant Operations Lead (POL) P was queried on what the water temperature should be and stated 120 degrees. POL P continued to say that [NAME] Hall is provided hot water by one boiler system on a recirculating loop. At this time, the gauge for the mixing valve that tempers the hot water was reading 120 degrees. POL P stated that the gauge might not be accurate. During an interview on 5/9/23 at 1:31 PM, Maintenance Lead Q was queried if the hot water fixtures are monitored on [NAME] Hall and stated that it is not monitored routinely, but he believes it is monitored once a year. Maintenance Lead Q continue to say that the hot water mixing valve was adjusted and the hot water temperatures at the fixtures are measuring 118 degrees Fahrenheit. According to the facility's policy, Legionella, and other Waterborne Pathogens, FAC.1.03, Revised 6/1/2015, it noted under heading GENERAL INFORMATION, . Domestic Hot water systems are maintained, monitored, and recorded at a delivered temperature not to exceed 120 (degrees) Fahrenheit in accordance with applicable regulatory standards. According to the facility's Resident Census and Conditions of Residents, dated 5/9/23, it noted that 16 residents were identified to have Dementia or Alzheimer's Disease.

Based on observation, interview and record review, the facility failed to ensure the delivery of oxygen services in a safe and sanitary manner for three Residents (#1, #3, & #14) of three residents reviewed for oxygen services. This deficient practice resulted in the potential for respiratory complications, including shortness of breath, infections, and rehospitalization . Findings include: Resident #1 On 5/9/23 at 10:59 a.m., the room of Resident #1 was observed with an oxygen concentrator located next to her bed. Resident #1 was not located in her room. There was a nasal cannula (oxygen delivery device that enters the nostrils) attached. The cannula was not contained in any type of sanitary bag, and the prongs of the nasal cannula were draped over the back of the machine in contact with the surface of the intake vent and filter area. On 5/10/23 at 4:33 p.m., Resident #1 was not observed in her room. The nasal cannula for Resident #1 was observed not contained in a sanitary bag and the prongs of the cannula were draped over the back in contact with the air intake vent and filter area. On 5/10/23 at 6:30 p.m. Registered Nurse (RN) A was asked to look into the details of oxygen usage for Resident #1 to find out when and how often she used the oxygen concentrator. RN A stated she was unaware there was even an oxygen concentrator in use for Resident #1. During a follow-up interview on 5/11/23 at 11:07 a.m., RN A stated Resident #1 last used the oxygen on the night of 4/25/23, because she was experiencing chest pain. The oxygen tubing was not dated. A review of the Progress Notes section of the Electronic Medical Record (EMR) revealed the following: 4/25/2023 (7:03 a.m.) Clinical Assessment . Resident (#1) reporting pressure in her chest. She states It doesn't hurt, but there is just pressure BP (blood pressure) 182/81, Pulse 68 Oxygen at 96% RA (room air). Resident (#1) seems calm. Call to hospice. Oxygen applied for comfort. They report they will send nurse and will be here at 7:30. Will continue to monitor. (Author RN B) Resident #3 On 5/9/23 at 11:14 a.m., Resident #3 was observed sitting in the common area in a chair between the nurses station and the dining room. Resident #3 was observed receiving oxygen from a nasal cannula attached to an E-tank (Tank Size) portable oxygen cylinder. An observation of the tank gauge read 0, indicating the tank was empty. This was verified by photograph and zoom enhancement of the image. A review of the EMR for Resident #3 revealed diagnoses including, congestive heart failure, chronic obstructive pulmonary disease, and oxygen dependence. On 5/9/23 at 11:33 a.m., when asked how much oxygen Resident #3 was supposed to be receiving RN C stated he was on 4 liters. RN C was asked to obtained an oxygen saturation for Resident #3, and obtained a reading of 88% (Normal Range 92-100%). An unidentified Certified Nurse Aide (CNA) was observed changing out the oxygen tank after the oxygen saturation reading. On 5/9/23 at 11:37 a.m., RN C rechecked the oxygen saturation of Resident #3. RN C obtained a reading of 90% with Resident #3 on oxygen at 4 liters by nasal cannula. On 5/10/23 at 11:30 a.m., Resident #3 was observed entering the dining room for the lunch meal. The oxygen tank was observed in the red area and the tubing was observed with an approximate 25 degree bend near where the tubing attached to the tank. CNA D observed this surveyor looking at the oxygen gauge and asked CNA E to check and change the oxygen tank if it was needed. CNA E was assisting Resident #3 with propelling his wheelchair into the dininig room at that point. When asked if the tubing should be kinked off as observed, CNA E stated the tubing should not be like it was. Once CNA E changed the oxygen tank, air flow could be heard audibly at the nasal cannula prong area entering the nose of Resident #3. On 5/10/23 at 5:06 p.m., Resident #3 was observed in the hallway. Air movement could not be detected audibly coming from the nasal cannula. The oxygen tank gauge was then observed, and visually verified in the red zone (1/8th full, suggestive of low or empty and tank change needed). On 5/10/23 at 5:35 p.m., the gauge attached to the tank delivering oxygen to Resident #3 was again observed and read at or close to 0 and verified by photograph enhancement. Staff were beginning to pass meal trays at that time. On 5/10/23 at 5:42 p.m., the oxygen tank gauge for Resident #3 read at 0 and verified via photograph enhancement. Resident #3's hands and lips were observed markedly cyanotic (blue/lack of oxygen) compared to prior observations. On 5/10/23 at 5:59 p.m., the oxygen tank gauge for Resident #3 was observed and remained at 0. and verified via photograph enhancement. Resident #3 continued to appear cyanotic. On 5/10/23 at 6:05 p.m., RN F was asked to take a pulse oximetry (oxygen percentage level and pulse rate) reading on Resident #3. RN F asked this Surveyor if this request was due to the appearance of his hands being blue. This Surveyor confirmed this was the reason for asking RN F to obtain a pulse oximetry. Resident #3 was saturating at 80-81 %. RN F then looked at the tank and realized the tank was empty. RN F replaced the oxygen tank at 6:06 p.m. Resident #3's pulse value was also observed at a highly variable range of 49 to 84 (Normal 60-90). At 6:13 p.m., RN F changed Resident #3 over to a non-rebreather (high flow oxygen delivery) mask and kept it at 4 liters. At 6:18 p.m. the oxygen reading was ranging between 81-86% and the pulse was observed at 30-91. RN F then stated she was turning the tank liter flow up to 6 liters. The oxygen saturation was taken via an ear probe at 88%. RN F stated they were going to lay Resident #3 down and see if the oxygen saturation improved. RN F stated another staff member had called Resident #3's representative who declined to send him to the emergency room . At 6:20 p.m., RN A came into the dining and told RN F the hospital respiratory therapist stated to turn up the liter flow all the way (10-15 liters max depending on the regulator). During a follow-up interview on 5/11/23 at 7:30 a.m., RN A stated Resident #3's oxygen level did return to 95% once they got him laid down the night prior. On 5/11/23 at 9:13 a.m., the oxygen concentrator Resident #3 uses at night was observed in the room. The non-rebreather mask used the night prior was observed laying on top of the oxygen concentrator with portion that comes in contact with the face of Resident #3 facing up and the end which attached to the oxygen source was laying on the floor. A nasal cannula was also sitting on top of the oxygen concentrator with the prongs draped down the front of the machine. Neither of these oxygen delivery devices were contained in a sanitary bag. On 5/11/23 at approximately 9:15 a.m., RN A was shown the sanitary storage concerns of the oxygen delivery devices for Resident #3. RN A acknowledged the concern and addressed it. RN A confirmed the staff used to keep delivery devices house in a plastic bag to keep them sanitary. On 5/11/23 at 9:28 a.m., a review of the care plan for Resident #3 reflected an intervention which stated he was receiving oxygen at 2 liters per minute. RN A confirmed he has been on 4 liters per minute for a long time. During an interview on 5/11/23 at 4:10 p.m., the Director of Nursing (DON) stated staff do not put oxygen orders in the EMR because staff have standing orders for all residents to give 2-4 liters per minute of oxygen to any resident in need of oxygen. The DON confirmed staff were correct in stating Resident #3 was on oxygen at 4 liters per minute continuously. This Surveyor informed the DON the liter flow Resident #3 was receiving conflicted with what was reflected in the care plan for Resident #3. The DON acknowledged the concern. Resident #14 On 5/11/23 at 9:29 a.m., the oxygen nasal cannula used by Resident #14 when in her wheelchair connected to a portable tank was observed. The nasal cannula prongs were observed laying on the surface of a wheelchair cushion. CNA G was asked how oxygen tubing should be stored when not in use. CNA G replied by stating the facility staff usually kept oxygen tubing and delivery devices in a plastic bag of some sort when not in use. CNA G was shown where the nasal cannula was and for Resident #14 and acknowledged where it was observed laying was not sanitary. A review of the website https://chinookrespiratorycare.com/oxygen-care/cylinder-duration-form/ revealed the following in part: Run times at 4 Liters for tanks at various content levels Full: 2.5 hours 3/4 Full: 1.75 hours 1/2 Full: 1 hour 1/4 Full: 0.5 hours

Based on observation, interview, and record review, the facility failed to secure an unattended medication cart for one of two medications cart reviewed for medication storage. This deficient practice has the potential for unauthorized persons or residents to gain access to medications and supplies in the cart and is a safety risk. Findings include: On 3/16/22 at approximately 10:57 AM, an observation was made of Registered Nurse (RN) B who was standing at her medication cart. The medication cart was open, and she removed a medication box. RN B then proceeded to the phone behind the nurses' station and left her medication cart unlocked and unattended. RN B made a phone call and then got up for her chair and went into the medication storage room behind the nurses' station. RN B exited the medication storage room without the medication box and proceeded to the first room down the south hallway on the right. RN B was in the room for approximately 3 minutes. RN B then exited the room and went to her medication cart and then locked it and walked away. On 3/16/22 at approximately 2:20 PM, an interview with RN B was asked about earlier in the day if she recalled talking in the phone about a medication and responded, Yes. RN B was asked if she locked her medication cart before she talked on the phone behind the nurses' station, enter the medication storage room and enter a resident room down the south hallway and responded, No, I did not and I should have never walked away with it unlocked. On 3/16/22 at approximately 2:30 PM, an interviewed with the Director of Nursing (DON) regarding medication carts. The DON was asked what her expectation was if the nurse was working at the medication cart unlocked and then had to leave the cart was and responded, To lock it before they leave or walk away. Review of facility policy titled Medication Administration date revised 11/2/20, read in part; Purpose to provide guidelines to ensure safe medication administration based on standards of nursing practice and in accordance with state and federal guidelines .L.) The medication cart will be locked when not in use or if it is unattended.

Based on observation, interview, and record review, the facility failed to ensure foot pedals were used to propel residents safely in the halls for four Residents (#2, #4, #120 and #172) of four residents reviewed for safety. This deficient practice has the potential to cause accidental foot injuries. Findings include: Resident #2 Review of Care Plan for Resident #2 date initiated 2/23/22, read in part; Focus: Has an activities of daily living self-care performance deficit related to history of [CONDITION(S)] ([CONDITION(S)]) (stroke). Goal: Will maintain current level of function through the next review date. Intervention: Is able to propel himself in the wheelchair independently. Encourage to wear gloves while propelling wheelchair. On 3/15/22 at approximately 12:30 PM, an observation was made of Certified Nurse Aide (CNA) H pushing Resident #2 in his wheelchair without foot pedals from the south hallway to the front of the shower door located in the west hallway. CNA I was observed pushing Resident #2 from the front of the west hallway shower entrance door into the shower room without foot pedals. Resident #2's feet were dangling near the floor while he was being pushed. Resident #4 Review of Care Plan for Resident #4 date initiated on 12/21/21, read in part; Focus: Is at risk for falls r/t Dementia, decreased safety awareness. Goal: Will have no preventable injuries related to falls through the review date. Intervention: Encourage resident to propel himself in w/c for independent movement until weight bearing status is increased by orthopedics. Ensure resident has appropriate footwear in place prior to transfers and ambulation. On 3/15/22 at approximately 11:25 AM, an observation was made of Resident #4 being transported in his wheelchair from his room down the west hallway without foot pedals to the front of the nurses' station by Registered Nurse (RN) J. Resident #4's feet were dangling near the floor surface as he was being pushed through the hallway. Resident #120 Review of Care Plan for Resident #120 date initiated on 3/4/22, read in part; Focus: Poor safety awareness with risk of falling as resident will get up unassisted. Goal: The resident will develop skills to cope with cognitive decline and maintain safety by the review date. Intervention: Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. On 3/15/22 at approximately 12:13 PM, an observation was made of Resident #120 being transported in his wheelchair without foot pedals near the activities room area to the front of the nurses' station by CNA D. Resident #120's feet were dangling near the floor as he was being pushed in his wheelchair. Resident # 172 Review of Care Plan for Resident #172 date initiated on 3/4/22, read in part; Focus: Has impaired cognitive function post [CONDITION(S)] . This has affected his safety awareness and puts him at a higher risk of falling. Goal: The resident will develop skills to cope with cognitive decline and maintain safety by the review date. Intervention: Cue, reorient and supervise as needed. On 3/15/22 at approximately 12:10 PM, an observation was made of Resident #172 being transported in his wheelchair by CNA E without foot pedals from the nurses' station area down the west hallway to his room. Resident #172's feet were dangling near the floor, and he was propelled for approximately 45 feet. On 3/16/22 at approximately 11:35 AM, an observation was made of Resident #172 being transported in his wheelchair by License Practical Nurse (LPN) C, from his room down the west hallway to the front of the nurses' station to eat his lunch. Resident #172 did not have foot pedals as he was transported for approximately 45 feet in his wheelchair and his feet were just above the floor surface. On 3/16/22 at approximately 9:40 AM, a request was made via email to the Nursing Home Administrator (NHA) for any facility policy regarding foot pedals. The NHA responded that she referred the email to the Director of Nursing (DON), who when asked about a foot pedal facility policy responded, We do not have a foot pedal policy, but I (DON) feel this is a concern and am in the process of developing a policy regarding foot pedals. On 3/16/22 at approximately 12:45 PM, the DON was interviewed. The DON was asked what her expectation was when residents have no foot pedals and need to be transported to a different area. The DON responded, For staff to get foot pedals or encourage the resident to self-propel on their own.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE PHYSICAL ASSISTANCE OF STAFF AND USE OF A GAIT BELT FOR ONE (RESIDENT #101) OF FOUR RESIDENTS REVIEWED FOR FALLS, OUT OF A TOTAL FACILITY POPULATION OF 28. THIS DEFICIENT PRACTICE RESULTED IN RESIDENT #101 FALLING AND SUSTAINING FOUR FRACTURES IN HER PELVIS, A DECLINE IN PHYSICAL FUNCTIONING, AND INCREASED LEVEL OF PAIN. FINDINGS INCLUDE: THE FACILITY'S 2/25/13 INVESTIGATION REPORT SHOWED ON 2/22/13 AT 6:30 A.M., CERTIFIED NURSE AIDE (CNA) "E" WAS ASSISTING RESIDENT #101 TO THE BATHROOM. THE REPORT DOCUMENTED RESIDENT #101'S OXYGEN TUBING BECAME TANGLED ON THE WAY TO THE BATHROOM. CNA "E" LEFT RESIDENT #101'S SIDE TO UNTANGLE IT. WHEN CNA "E" STEPPED AWAY FROM RESIDENT #101, RESIDENT LOST HER BALANCE AND fell . A HIP X-RAY DONE ON 2/22/13, WAS NEGATIVE FOR FRACTURE. RESIDENT #101 CONTINUED TO COMPLAIN OF PAIN. AN ADDITIONAL X-RAY ON 2/25/13, DEMONSTRATED PELVIC FRACTURE. A REVIEW OF RESIDENT #101'S MEDICAL RECORD FACE SHEET DATED 9/12/12, SHOWED RESIDENT #101 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE QUARTERLY MINIMUM DATA SET (MDS) assessment dated [DATE], SHOWED RESIDENT #101'S COGNITION AS 'INTACT'. HER TRANSFERS AND AMBULATION ABILITIES REQUIRED ONE PERSON PHYSICAL ASSIST. THE CARE PLAN DATED 9/10/12, DOCUMENTED RESIDENT #101 NEEDED ONE ASSIST WITH TRANSFERS AND AMBULATION WITH USE OF GAIT BELT AND WALKER. AN INTERVIEW WAS CONDUCTED WITH CNA "E" ON 3/11/13 AT 12:55 P.M. CNA "E" STATED: "RESIDENT (#101) STOOD UP FROM THE BED, SEEMED STEADY ON HER FEET... SHE (RESIDENT #101) HAS A LONG EXTENSION TUBING FOR HER OXYGEN... I THOUGHT WE HAD ENOUGH TO GO INTO THE BATHROOM. IT (TUBING) GOT CAUGHT AND I TOLD HER (RESIDENT #101) TO STAND STILL. I LET GO OF HER TO UNTANGLE IT AND SHE fell BACKWARDS." WHEN ASKED IF SHE WAS USING A GAIT BELT DURING THIS TRANSFER, CNA "E" REPLIED "NO." A REVIEW OF THE POLICY AND PROCEDURE TITLED "SAFE TRANSFERS AND AMBULATION" DATED 9/2012, READS IN PART: "POLICY: ...A GAIT BELT WILL BE UTILIZED WHEN TRANSFERRING OR AMBULATING ANY RESIDENT THAT DOES NOT HAVE ORDERS TO AMBULATE INDEPENDENTLY. PROCEDURE: ...2. LEVELS OF ASSIST INCLUDE THE FOLLOWING: ...C. ASSIST OF ONE: ONE INDIVIDUAL MUST ASSIST THE RESIDENT..." A REVIEW OF THE MDS ASSESSMENT FOR SIGNIFICANT CHANGE (DATED 3/5/13) SHOWED RESIDENT #101 WAS assessed with [REDACTED]. RANGE OF MOTION IMPAIRMENT OF BOTH SIDES. RESIDENT #101'S CARE PLAN WAS REVISED AFTER SHE fell on [DATE]. THE REVISED CARE PLAN DATED 2/25/13, SHOWED RESIDENT #101 WAS NWB (NON WEIGHT BEARING). THE CARE PLAN WAS UPDATED ON 3/05/13, TO TTWB (TOE TOUCH WEIGHT BEARING) LEFT LEG 2P (2 PERSON) PIVOT TRANSFERS. THE MEDICATION ADMINISTRATION RECORD (MAR) FOR JANUARY 2013, REVEALED RESIDENT #101 RECEIVED (1) VICODIN 10/325 MGS (MILLIGRAMS) FOUR TIMES A DAY SCHEDULED. AFTER THE FALL ON 2/22/13, RESIDENT #101 REQUESTED AN ADDITIONAL VICODIN 10/325 MG PILL FOR PAIN IN HER HIP/BUTTOCKS DAILY. A physician's orders [REDACTED]./325 MGS (1.5) TABLET SCHEDULED FOR 6 A.M., 12 NOON AND 6 P.M. POST FALL, RESIDENT #101 WENT FROM A TOTAL OF 4 MG VICODIN DAILY TO 4.5 MG VICODIN DAILY. AN OBSERVATION OCCURRED ON 3/12/13 AT 10:40 A.M. OF RESIDENT #101 IN HER WHEELCHAIR, AS SHE WAS WHEELED TO THE ACTIVITY ROOM BY HER DAUGHTER. RESIDENT #101 APPEARED ALERT AND STATED IT WAS A GOOD DAY TODAY. IN AN INTERVIEW ON 3/12/13 AT 11:30 A.M. WITH RESIDENT #101 AND HER DAUGHTERS, FAMILY MEMBERS (FM) #1 AND #2, RESIDENT #101 WAS ASKED HOW HER FALL ON 2/22/13 AFFECTED HER FUNCTIONING. SHE STATED: "... I USED TO ... LIFT MY LEG SO I COULD PUT IT DOWN (FROM BED TO THE FLOOR ) WITHOUT A PROBLEM... FOR 2 TO 4 DAYS AFTER THE FALL I COULD BARELY LIFT MY LEGS." RESIDENT #101 STATED SHE NEEDED A CATHETER AFTER THE FALL ON 2/22/13, SO SHE WOULDN'T HAVE TO GET UP TO GET TO THE BATHROOM. AN INTERVIEW WAS CONDUCTED WITH THE DIRECTOR OF NURSING (DON) ON 03/11/13 AT APPROXIMATELY 2:30 P.M. THE DON CONFIRMED, PER HER INTERVIEW WITH CNA "E", RESIDENT #101 WAS NOT TRANSFERRED IN A SAFE MANNER WHEN CNA "E" TOOK HER HANDS OFF RESIDENT #101 AND RESIDENT #101 fell . THE DON CONFIRMED RESIDENT #101 HAS HAD AN INCREASE IN HER PAIN LEVEL AND SHE HAS HAD A PHYSICAL DECLINE. ( )