Every finding on record at Nashua Post Acute Care

Based on observation and interview, it was determined that the facility failed to provide a safe and clean environment for 3 of 5 units observed and 1 of 5 kitchenettes observed.Findings include:Unit #6 Observation on 11/18/25 at approximately 9:11 a.m. in room [ROOM NUMBER] revealed there was black tape adhered to floor threshold over uneven surface where the floor was lifting. Observation on 11/18/25 at approximately 9:18 a.m. in room [ROOM NUMBER] revealed the oxygen concentrator had a layer of dust on the concentrator near the controls. Observation on 11/18/25 at approximately 9:23 a.m. in room [ROOM NUMBER] revealed the wall between the bathroom and the resident's bed had a two by four foot area with exposed drywall. Further observation revealed a brown substance on the bed rail. The side table surface top was peeling along 25 percent of the table. Observation on 11/18/25 at approximately 9:50 a.m. in room [ROOM NUMBER] revealed the privacy curtain had a brown substance in the midsection of the curtain facing away from the resident's bed. The wall between the bathroom and the resident's bed had multiple scraps, dings, and discoloration in an area approximately six by three feet wide. Observation on 11/18/25 at approximately 10:01 a.m. in room [ROOM NUMBER] revealed a long continuous crack that resembled stairs in an area on the wall approximately six by twelve inches. Observation on 11/18/25 at approximately 1:17 p.m. in room [ROOM NUMBER] revealed that the floor at the entrance was lifting. Observation on 11/18/25 at approximately 2:15 p.m. in room [ROOM NUMBER] revealed a brown substance on the outside mid-area of the privacy curtain. The bed rail had a brown substance smeared along the bed rail. The bedside table was visually soiled with crumbs, dried brown and reddish color substance on the top surface of the table. Interview on 11/18/25 at approximately 2:18 p.m. with Staff D (Unit Manager) confirmed all the findings from Unit #6. Unit #5 Observation on 11/18/2025 at approximately 1:21 p.m. in room [ROOM NUMBER] revealed that there was floor tile on the side of the bed where he/she exits that were curled on the edges and lifted. Observation on 11/19/2025 at approximately 8:38 a.m in room [ROOM NUMBER] revealed that the above floor tile was loose and could be moved completely out of place with light pressure. Interview on 11/19/2025 at approximately 8:44 a.m. with Staff Y(Licensed Practical Nurse) confirmed that the floor was damaged and that the tile moved. Observation on 11/18/2025 at approximately 12:57 p.m. in room [ROOM NUMBER] revealed that there were floor tiles on the side of the bed where the resident exits their bed that were loose and curled. There was also missing trim to his/her bedside table. Interview on 11/20/2025 at approximately 9:59 a.m. with Staff W (Unit Manager) confirmed the above findings of missing trim and loose/curled flooring. Unit 1# West Observation on 11/18/2025 at approximately 10:00 a.m. of Unit #1 [NAME] kitchenette revealed missing tiles resulting in uneven flooring. The edges of the tiles remaining where covered with black tape. Interview on 11/18/2025 at approximately 12:30 p.m. with Staff Q (Activities Aide) confirmed the missing tiles on the kitchenette floor. Observation on 11/18/2025 at approximately 12:30 p.m. revealed a resident walking over the uneven flooring to get to the kitchenette fridge.

Based on observation, interview, and policy review, it was determined that the facility failed to ensure that food was stored in accordance with professional standards for food service safety for main kitchen and 3 of 5 kitchenettes observed. Findings Include:Review of the facilities Food Receiving and Storage Policy , undated, on 11/18/25 revealed . Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date).7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.Foods and Snacks Kept on Nursing Units.2. All foods belonging to residents are labeled with the resident's name, the item and the use by date. 3. Refrigerators must have a working thermometers and are monitored for temperature according to specific guidelines.Main KitchenObservation on 11/18/25 at approximately 8:25 a.m. with Staff R (Food Services Director), of the Deli 2 refrigerator revealed the following items without and open or use by date: a pastry bag of whipped cream with decorative tip attached without coverage of the open tip and an opened container of Thicken Easy Nectar. Observation on 11/18/25 at approximately 8:38 a.m. with Staff R of the Deli 1 refrigerator revealed that following: a partial block of mozzarella cheese wrapped in [NAME] wrap with date of 10/9 with brown liquid on the edges. Further observation revealed 4 sandwiches sliced in half with a side of pasta salad wrapped in [NAME] wrap without a use by date.Observation on 11/18/25 at approximately 8:45 a.m. with Staff R of the Cooler 3 refrigerator revealed the following items without and open or use by date: a block of butter partially unwrapped.Observation on 11/18/25 at approximately 8:50 a.m. with Staff R of the walk- in refrigerator revealed the following items without open or use by dates:1 package of American cheese slices, shredded orange cheese in an unmarked bag, and shredded white cheese in an unmarked bag. Further observation revealed three 1-pound packages of fresh strawberries with visible fuzzy grey growth, 1-pint container of blueberries with visible fuzzy grey growth and 1- package of whole grain rolls with a torn bag.Observation on 11/18/25 at approximately 8:55 a.m. in the main kitchen revealed a covered bulk container of granulated sugar that contained black particles with a prep date of 9/1/25 and no use by date.KitchenettesObservation on 11/18/25 at approximately 9:10 a.m. of the 1 [NAME] kitchenette with Staff R (Food Services Director) revealed that 3 of 4 draws located to the right of the sink contained brownish-green fuzzy growth covering greater than one third of the inside of the draw base.Observation on 11/18/25 at approximately 9:10 a.m. of the 1 [NAME] kitchenette revealed that the external refrigerator thermometer was showing an error code and there was no thermometer inside the refrigerator to assess the temperature. Observation on 11/18/25 at approximately 9:15 a.m. with Staff R of the unit 3/4 kitchenette revealed three clothes resembling washable mop heads approximately 4 inches by 18 inches in the base of the cabinet under the work sink that had black fuzzy residue on them. Further observation revealed two plates covered in [NAME] wrap that contained a sandwich cut in half with a side of pasta closed into the top of the deli prep station. Interview on 11/18/25 at approximately 9:15 a.m. with Staff R confirmed the above findings for Unit 1 [NAME] and Unit 3/4. Observation on 11/18/25 at approximately 9:05 a.m. with Staff R of the Unit 5 kitchenette revealed that there was a paper towel with brown spots located in the unit microwave.

Based on observation, interview, and record review, it was determined that the facility failed to ensure proper processing of resident's clothing and failed to implement policies and procedures for Enhanced Barrier Precautions (EBP) for 1 of 3 residents reviewed for EBP.Findings include:Observation on 11/20/25 between at approximately 11:00 a.m. in the laundry room with Staff P (Infection Preventionist) and Staff O (Director of Housekeeping) revealed two residential washing machines were running on the normal mode and the warm water setting. Interview on 11/20/25 at approximately 11:00 a.m. with Staff O revealed the residential washing machines had been used for over a year for cleaning the resident's personal clothes. They use a household detergent on all personal clothes. Interview on 11/20/25 at approximately 2:30 pm with Staff V (laundry aide) revealed that the residential washers were used on the Normal Mode using the warm water setting and that the only detergent that was used was a household detergent. Staff V did not know the water temperature used when the warm water setting was selected. Review on 11/20/25 of the facility policy titled Departmental (Environmental Services)- Laundry and Linen, revision date January 2014, revealed . Washing Linen and other Soiled Items 1. Laundry may be processed in either low-temperature or high-temperature cycles. A. For High-temperature processing, wash linen in water that is at least 160 degrees Fahrenheit, for a minimum of twenty-five (25) minutes. B. For low-temperature processing, wash linen in water that is at least 71-77 degrees Fahrenheit and use a 125-parts-per-million (ppm) chlorine bleach rinse if the materials being washed can withstand bleach and remain intact. C. Ozone cleaning systems are also acceptable means of processing laundry. Review on 11/20/25 of the residential washing machine manufacturer's instructions revealed the following .Water temperature by cycle Sanitize: up to 150 degrees Fahrenheit, Extra Hot: Around 141 degrees Fahrenheit, Hot: 110 degrees Fahrenheit and above, Warm: Approximately 90 degrees Fahrenheit, Cold: Approximately 60 degrees Fahrenheit. Interview on 11/20/25 at approximately 1:40 p.m. with Staff S (Regional Plant Operations) did not know what water temperature the clothes in the residential machines were being washed at or temperature personal clothing needed to be washed at using the residential washing machine and the household detergent. Resident #183 Observation on 11/19/25 at approximately 11:00 a.m. outside of Resident #183's room revealed an EBP signage, indicating that Resident #183 was on EBP. Observation on 11/19/25 at approximately 11:00 a.m. in Resident #183's bedroom revealed Staff F (Hospice Licensed Nursing Assistant) was leaning over Resident #183's bed and shaving him/her with gloves on and no protective gown for Personal Protective Equipment (PPE). Interview on 11/19/25 at approximately 11:00 a.m. with Staff F revealed that he/she was providing hygiene to Resident #183 and confirmed that Staff F had gloves on and no protective gown for PPE. Review on 11/19/25 of Resident #183 physician's orders revealed an order for .Enhanced Barrier Precautions: R/T [related to] Wound: open wound every shift for Supportive Documentation, Start Date 10/9/24. Interview on 11/19/25 at approximately 11:05 a.m. with Staff D (Unit Manager) revealed that Resident #183 was on EBP for a Stage IV pressure ulcer. Review on 11/19/25 of the facility's policy titled, Enhanced Barrier Precautions, dated 2001 revealed: .Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDRO) during high contact resident care activities .Enhanced barrier precautions apply when .b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained .8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: .c. providing hygiene or grooming .

Based on interview and record review, it was determined that the facility failed to ensure residents who chose and were scheduled to have a weekly showers received showers for 3 of 8 residents reviewed for activities of daily living (ADL) in a final sample of 35 residents (Resident Identifiers are #36, #107 and #176).Findings include:Resident #176Interview on 11/18/25 at 11:55 a.m. with Resident #176 revealed that he/she gets a shower once a month and they would like one weekly. Review on 11/21/25 of Resident #176's Care Plan, dated 8/6/25, revealed that the he/she required one staff assistance with bathing. Review on 11/21/25 of the Unit 1 Licensed Nursing Assistants (LNA) Assignment Sheet revealed that Resident #176 was scheduled for showers weekly on the 3-11 p.m. shift every Thursday.Review on 11/21/25 of LNA Task Documentation for Resident #176's during the past 30 days revealed that under Shower Thursday 3-11 there was no documentation that a shower had been completed. Interview on 11/21/25 at 10:35 a.m. with Staff K (LNA) revealed that he/she had worked 11/20/25 (Thursday) on the 3-11 p.m. shift and Resident #176 had not received a shower. Interview on 11/21/2025 at 10:40 a.m. with Staff L (Unit Manager) confirmed that there was no documentation that Resident #176 had a shower in the past 30 days.Resident #36Interview on 11/18/25 at approximately 11:45 a.m. with Resident #36 revealed that he/she did not always get a weekly shower. Resident #36 stated that sometimes he/she will go 2-3 weeks without a shower. Review on 11/20/25 of Resident #36's LNA task documentation for 10/20/25 through 11/20/25 revealed that no showers were marked as completed.Review on 11/20/25 of the LNA Assignment sheet revealed that Resident #36 was scheduled for a weekly shower on Tuesday during the 3-11 p.m. shift.Review on 11/21/25 of Resident #36's Quarterly Minimum Data Set with an Assessment Reference Date of 9/9/25 revealed the resident needed substantial to maximum assistance with bathing. Interview on 11/20/25 at approximately 8:45 a.m. with Staff M (unit manager) confirmed that there was no documentation that a shower had been given or offered to Resident #36 for the above time frame.Resident #107Interview on 11/18/25 at approximately 9:30 a.m. with Resident #107 revealed that they had not received a shower in over two weeks. Resident #107 stated that it is usually 2-3 weeks between his/her showers.Review on 11/20/25 of Resident #107's LNA task documentation for 10/20/25 through 11/20/25 revealed that the only shower that was documented as completed was on 11/2/25.Review on 11/20/25 of the Building 2 LNA Assignment revealed that Resident #107 is scheduled for a weekly shower on Tuesday during the 3-11 p.m. shift.Review on 11/21/25 of Resident #107's Quarterly Minimum Data Set, Assessment Reference Date of 8/13/25, Section GG, revealed the resident needed substantial to maximum assistance with bathing. Interview on 11/20/25 at approximately 8:45 a.m. with Staff M confirmed that there was one shower documented for Resident #107 between 10/20/25 through 11/20/25.Review on 11/20/2025 of the facility policy titled Activities of Daily Living (ADL), Supporting, revision date April 2025, revealed .Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL).4. If a resident with cognitive impairment or dementia resists care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way, at a different time, or having another staff member speak with the resident may be appropriate. 5. Appropriate care and services are provided for residents who are unable to carry out ADL's independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care).

Based on observation, record review, and interview, it was determined that the facility failed to keep a resident free from involuntary seclusion for 1 of 1 resident reviewed for restraints in a final sample of 35 residents (Resident identifier is #131).Findings include:Observation on 11/18/25 at 8:30 a.m. through approximately 9:30 a.m., 12:00 p.m. through approximately 2:00 p.m. revealed Resident #131 sitting in his/her room at the bedside table coloring. Staff G (Activity Aide) was sitting in a chair with a bedside table outside of Resident #131's room blocking Resident #131's exit. Interview on 11/18/25 at approximately 9:00 a.m. with Staff G revealed that he/she was sitting outside of Resident #131's door for the day because Resident #131 required 1:1 (constant) supervision. Further interview revealed that Resident #131 Had been on 1:1's for about a week due to wandering. Interview on 11/18/25 at approximately 9:10 a.m. with Resident #131 revealed that he/she was unable to answer simple questions requiring a yes and no response. Observation on 11/19/25 at approximately 8:30 through approximately 9:30 a.m. revealed Resident #131 sitting at the bedside table, inside his/her room, staring at the wall. Staff J (Licensed Nursing Assistant) was sitting outside the door with a bedside table blocking the exit of Resident #131's doorway. Observation on 11/19/25 at approximately 12:45 p.m. through 1:00 p.m. revealed Staff J was sitting outside the door with a bedside table blocking the exit of Resident #131's. Observation on 11/20/25 at approximately 9:10 a.m. through 9:30 a.m. revealed Staff I (Licensed Nursing Aide) was sitting at a table inside of Resident #131's room in the hallway of the exit blocking the doorway. Resident #131 was coloring. Interview on 11/20/25 at approximately 9:50 a.m. with Staff A (Physician) confirmed that Resident #131 had been assigned a staff member for 1:1 supervision for about a week due to Resident #131's behaviors. Observation on 11/21/25 at approximately 8:00 a.m. through 8:30 a.m. of Resident #131's room revealed a staff member blocking the doorway into Resident #131's room. Review on 11/21/25 of Resident #131's nursing notes revealed the following:11/16/25 7:43 a.m., Resident was kept on 1:1 supervision through the night, no issues noted. Got out of room once and escorted through the hallways and returned to bed until morning. 11/17/25 5:00 a.m., res [resident] continues on 1:1 supervision due to change in behaviors. 1:1 maintained, res stayed in [pronoun omitted] room most of the night, got out twice trying to open the clean laundry closet for [pronoun omitted] shoes. Redirected with ease, and stayed in [pronoun omitted] room. Able to hold simple conversations with assigned staff, no aggression noted or reported. Interview on 11/20/25 at approximately 12:25 p.m. with Staff H (Administrator) revealed that Resident #131 had been on 1:1 with staff since approximately 11/14/25 . Review on 11/20/25 of the facility policy titled, Identifying Involuntary Seclusion and Unauthorized Restraint, dated 2011, revealed: .1. Involuntary Seclusion is defined as a separation of a resident from other residents or from his or her room or confinement to his or her room . 2. Examples of involuntary seclusion include: a. any attempt to keep a resident confined to a certain area by blocking the exit with furniture or a closed door; .d. confining a resident to his or her room as a form of punishment or for staff convenience .

Based on interview and record review, it was determined that the facility failed to ensure residents receive care in accordance with plan of care for 1 of 8 residents reviewed for choices in a final sample of 35 residents. (Resident identifier is #185.)Findings include:Interview on 11/18/25 at approximately 9:30 a.m. with Resident #185 revealed that he/she has been waiting to go to a follow up visit with the ENT (Ear, Nose, and Throat Specialist) for months. Further interview revealed that Resident #185 had been having an ongoing sore throat since September and had been asking nursing to make an appointment.Review on 11/21/25 of Resident #185's ENT office visit note, dated 7/1/25 revealed: . the following physician's order: nystatin (Mycostatin) 100,000 unit/ml suspension, Swish and swallow 5 ml (500,000 Units) four times daily for 10 days, Start Date 7/1/25, End Date 7/11/25, Indications: Chronic sore throat. Further review of the office visit note revealed, Follow up in about 8 weeks (around approximately 8/26/25).Review on 11/19/25 of Resident #185's medical record revealed that the following progress notes:On 9/24/25, a Health Status Note read: Resident complained sore throat, coughing covid test performed result negative.On 10/29/25, a Nurse Practitioner Note read: . who continues to complain of a sore throat. Saw ENT and was given nystatin. Was suppose to follow up in Sept. [September] but not done. Assessment/Plan . 15. Sore throat- completed nystatin treatment. Needs follow up with ENT.On 11/2/25, a Health Status Note read: Resident complained sore throat during this shift, Robitussin syrup 15 ml [milliliters] prn [as needed] po [by mouth] Adm. [administered] Review on 11/21/25 of Resident #185's physician's orders revealed the following order dated 11/3/25: Please send patient back to ENT for a 2 month follow up which should of been done in Sept. [September].Interview on 11/20/25 at approximately 2:45 p.m. with Staff D (Unit Manager) revealed that Resident #185 went to an ENT appointment in July 2025 and did not currently have a follow up appointment scheduled.

Based on observation, interview and record review, it was determined that the facility failed to label medications with open expiration dates, monitor proper temperature controls, and permit only authorized personnel to have access to the keys for 2 of 6 medication carts observed and 2 of 3 medication room refrigerators observed. Findings Include:Observation on 11/18/25 at approximately 10:45 a.m. on Unit #6 revealed Staff E (Regional Registered Nurse) going through medications inside medication cart #5302 with no other facility staff present. Staff E appeared to be removing medications. Interview on 11/18/25 at approximately 10:45 a.m. with Staff E revealed that he/she was not assigned to the cart. Further interview revealed that Staff E works at another facility and was in the facility assisting during the survey. Interview on 11/18/25 at approximately 11:40 a.m. with Staff H (Administrator) confirmed that Staff E was not an employee of the facility. Staff E was employed by the corporation. Review on 11/18/25 of the facility policy titled, Medication Labeling and Storage, Dated 2001 revealed: . Only authorized personnel have access to keys. Resident #123 Observation on 11/19/25 at approximately 2:00 p.m. on Unit #6 medication cart #3501 revealed: Resident #123's one used Fluticasone 250 mg (milligrams)/ 50 mcg (micrograms) inhaler without a date of opening or open expiration date; and Resident #123's one used Incruse Ellipta 62.5 mcg inhaler without a date of opening or open expiration date. Review on 11/19/25 of Resident #123's November 2025's MAR (Medication Administration Record) revealed that Resident #123 received Fluticasone 250 mg / 50 mcg and the Incruse Ellipta 62.5 mcg inhaler on 11/19/25. Interview on 11/19/25 at approximately 2:00 p.m. with Staff X (Licensed Practical Nurse) confirmed the above findings. Further interview revealed that Resident #123 received both the inhalers listed above on 11/19/25. Review on 11/19/25 of the manufacturer's instructions for Incruse Ellipta, Revision Date December 2023, revealed: Safely throw away Incruse Ellipta in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label of the inhaler. Review on 11/19/25 of the manufacturer's instructions for Fluticasone Propionate and Salmeterol Diskus, Dated 2023, revealed: . Safely throw away Fluticasone Propionate/Salmeterol Diskus in the trash 1 month after you open the foil pouch or when the counter reads 0, whichever comes first. Review on 11/18/25 of the facility policy titled, Medication Labeling and Storage, Dated 2001 revealed: .Medication Labeling . 2. d. expiration date, when applicable; . Review on 11/19/25 of October 2025 medication refrigerator logs on Unit #5 revealed the following missing temperatures: 2-7, 9-16, 20-26 and 28, 29, and 31. Review on 11/19/25 of November 2025 medication refrigerator logs on Unit #5 revealed the following missing temperatures: 1-16. Review on 11/19/25 of facility policy titled MEDICATION STORAGE IN THE FACILITY dated November 2021 revealed .Procedures .L. All medications are maintained within the temperature ranges noted in the United States Pharmacopeia (USP) and by the Centers of Disease Control (CDC) .3) Refrigerated 36 [degrees] F [Fahrenheit] to 46 [degrees] F .Temperature .E. The Facility should maintain a temperature log in the storage area to record temperatures at least once a day . Interview on 11/19/25 at approximately 8:15 a.m. with Staff W (Unit Manager) confirmed the above findings. Review on 11/19/25 of October 2025 medication refrigerator logs on Unit #3 revealed the following missing temperatures: 5-8, 10-12, 18, 19, 23, 25-27, and 30 Review on 11/19/25 of November 2025 medication refrigerator logs on Unit #3 revealed the following missing temperatures: 1-7, 11, 12, 16, and 17. Interview on 11/19/25 at approximately 08:35 a.m. with Staff Z (Licensed Practical Nurse) confirmed the above findings.

Based on interview, and record review, it was determined that the facility failed to ensure that a nourishing snacks was provided to residents consistent with the resident's plan of care for 1 of 1 residents reviewed for food and 1 of 6 residents reviewed for nutrition in a final sample of 35 residents. (Resident identifiers are #53 and #181).Findings include:Resident #53Interview on 11/18/25 at 11:23 a.m. with Resident #53 revealed that he/she was not offered snacks and the only snacks available when Resident #53 requests snacks were crackers and cookies.Review on 11/20/25 of Resident #53's care plan revealed that Resident #53 had potential for nutritional problems due to diabetes. Further review revealed an intervention initiated on 7/1/25 to offer a nourishing HS (Hour of Sleep) snack daily. Resident #181Interview on 11/18/25 at 9:54 a.m. with Resident #181 revealed that snacks offered in the evening were saltines or graham crackers and juice. He/she stated that he/she was a diabetic and he/she was not offered a snack with protein. Interview further revealed that staff had told her/him that there was no snacks with protein available in the evenings, they did not have the ability to get anything down in the main kitchen, and there wasn't anything in the kitchenette.Review on 11/20/25 of Resident #181 physician's orders revealed the following: Offer HS snack with protein/carb at bedtime for diabetes, dated 11/6/24.Interview on 11/20/25 at 12:30 a.m. with Resident #181 revealed that Resident #181 was not offered a snack on the evening of 11/19/25. Resident #181 stated that he/she had asked for an evening snack and was given 4 saltine crackers and water.Interview on 11/20/25 at 10:00 a.m. with Staff U (Dietician) revealed that he/she would consider a nourishing snack for a diabetic to consist of a half sandwich with a protein salad (egg, chicken, or tuna) or peanut butter, cottage cheese, peanut butter, cheese with fruit or crackers, or yogurt. Interview further revealed that he/she was told by residents and staff that residents with or without diabetes were receiving graham crackers or saltines, or cookies as a snack.

Based on observation, interview, and review, it was determined that the facility failed to ensure that dietary staff used facial hair restraints when cooking and serving food from the steam table for 1 of 1 kitchens observed for meal service, and failed to label and store food in accordance with professional standards for food safety to prevent foodborne illness for 1 of 1 kitchens and 5 of 7 kitchenettes observed. Findings include: Review on 10/10/24 of the U.S. Food and Drug Administration Food Code, dated 2017, retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2017 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines .Chapter 2 Management and Personnel .2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens .Chapter 3 Food .3-305.11 Food Storage .Food shall be protected from contamination by storing the Food: .On-premises preparation .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical . (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded .; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods .Products which are damaged, spoiled, or otherwise unfit for sale or use in a food establishment may become mistaken for safe and wholesome products and/or cause contamination of other foods . (5) Certain foodborne pathogens that are anaerobes or facultative anaerobes are able to multiply under either aerobic or anaerobic conditions. Therefore special controls are necessary to control their growth. Refrigerated storage temperatures of 5 C (41 F) may be adequate to prevent growth and/or toxin production of some pathogenic microorganisms . Beard Restraints: Observation on 10/8/24 between 8:05 a.m. to 8:25 a.m. of Staff H (Cook) in the kitchen revealed that Staff H was preparing and cooking for lunch. Staff H had a beard that was over an inch long that was not covered with a beard restraint. Interview on 10/8/24 at 8:25 a.m. with Staff H revealed that he/she never wore a covering over his/her beard. Interview on 10/8/24 at 8:45 a.m. with Staff E (Director of Culinary) confirmed the above findings. Observation on 10/9/24 between 11:15 a.m. and 11:25 a.m. of Staff I (Dietary Aide) in the kitchen revealed that Staff I was preparing soup and salad for lunch to be served to the residents in the dining room. Staff I had a beard that was over an inch long that was not covered with a beard restraint. Observation on 10/9/24 at 11:27 a.m. of Staff H in the kitchen revealed that Staff H was cutting quiche that was to be served to the residents for lunch. Staff H had a beard that was over an inch long that was not covered with a beard restraint. Interview on 10/8/24 at 11:28 a.m. with Staff E confirmed the above findings that staff with beards who were cooking and serving in the kitchen should always be wearing beard restraints. Review on 10/10/24 of the facility's policy titled, Food Safety Requirements, last revised 2/2023, revealed: .1b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms .7d. Dietary staff must wear hair restraints (e.g. hairnet, and/or beard restraints) to prevent hair from contacting food . Main Kitchen: Observation on 10/8/24 at 8:20 a.m. of the dairy refrigerator revealed the following: 1 container of mayonnaise with a manufacturer's use by date of 7/22/24; 1 clear plastic container of pasta salad with no prepared date or use by date; 1 clear plastic container of sliced tomatoes with no prepared date or use by date; 1 open package of shredded cheddar cheese with no prepared date or use by date; 1 clear plastic container of cooked meat with a preparation date of 9/14/24. Observation on 10/8/24 at 8:25 a.m. of the dessert refrigerator revealed the following: 1 paper plate with 2 slices of pizza covered by saran wrap with no prepared or use by date; 1 metal container of salad exposed to the air with no prepared date or use by date; 1 open package of sliced cheese with no open or use by date; 15 slices of cheese, not wrapped, open to the air with dried edges sitting on the shelf of the refrigerator; 1 metal container of unknown liquid with a prepared date or use by date; 1 clear package of whipped cream topping with no manufacturer's, open, or use by date. Interview on 10/8/24 at 9:00 a.m. with Staff E confirmed the above findings. 48515 Unit 5 Kitchenette: Review on 10/8/2024 of September 2024 refrigerator temperature logs for Unit 5 Kitchenette revealed the following missing September temperatures: 9/18, 9/19, 9/21, 9/25, 9/26, 9/27, 9/28, 9/29. 45419 Unit 3 Kitchenette: Observation on 10/08/2024 of the Unit 3 Kitchenettete freezer revealed that there was a plate containing a sandwich, pasta salad, a leaf of lettuce and a slice of tomato. The plate was not dated or labeled with a resident's name. Interview on 10/08/24 at 8:15 a.m. with Staff V (Licensed Nursing Assistant) confirmed the above findings Review on 10/8/2024 of the September 2024 refrigerator temperature logs for Unit 3 Kitchenette revealed the following missing September temperatures: 9/18, 9/19, 9/21, 9/25, 9/26, 9/27, 9/28, 9/29. Interview on 10/08/24 at approximately 8:45 a.m. with Staff N (Unit Manager) confirmed the above findings. 50163 Unit 2 Kitchenette: Review on 10/8/24 at approximately 9:45 a.m. of the Unit 2 Kitchenette refrigerator and freezer temperature logs revealed the following missing September temperatures: 9/18, 9/19, 9/21, 9/25, 9/26, 9/27, 9/28, 9/29. 49819 Unit 1 Kitchenette: Review on 10/8/24 of Unit 1's [NAME] kitchenette refrigerator logs revealed the following missing September temperatures: 9/18, 9/19, 9/21, 9/25, 9/26, 9/27, 9/28, and 9/29. Review on 10/8/24 of Unit 1's East kitchenette refrigerator logs revealed the following missing September temperatures: 9/18, 9/19, 9/21, 9/25, 9/26, 9/27, 9/28, and 9/29. 43002 Observation on 10/9/24 at 8:11 a.m. of Unit 1 [NAME] side kitchenette revealed there was a half loaf of slightly hard bread that had a fresh by date of 9/21/24. Interview on 10/9/24 at 8:22 a.m. with Staff CC (Unit Manager) confirmed the above. Review on 10/10/24 of the facility's policy titled, Date Marking for Food Safety, dated 5/2022, revealed: .2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded .

Based on observation, record review, and interview, it was determined that the facility failed to follow established infection control guidelines for facility water management that had the potential to effect the facility census of 220 residents who resided at the facility. Findings include: Observation on 10/8/24 at approximately 8:30 a.m. of Unit 4 revealed the unit was not in use. Review on 10/9/24 of the facility's Legionella Surveillance with a revised date of 6/2023, revealed .5. Primary prevention strategies: .d. Temperature controls: . ii. Hot water shall be stored above 140 degrees Fahrenheit . Review on 10/9/24 of the facility's undated Water Management Plan Overview for: Premier Rehab and Healthcare revealed on page 12 .Control Measures: Hot Water Systems .Water Heater Control Measure: Check flow and return temperatures at hot water heater .Frequency: Monthly .Monitoring: Supply Temperature should be checked at the outlet of the Hot Water Heater and should not be lower than 140 degrees [Fahrenheit] . Further review revealed on page 21 .Risk factors: Little used Outlets Control Measures: .flush program .frequency: Twice weekly where users are at high risk . Interview on 10/10/24 at approximately 10:00 a.m. with Staff J (Maintenance and Environmental Services Director) confirmed that Unit 4 had been closed a long time. Interview further revealed that he/she had been performing random flushes of Unit 4 and had no documentation of flushes or monitoring of temperature for the water heater. 51109

Based on observation, interview and record review, it was determined that the facility failed to ensure a resident who was unable to carry out activities of daily living (ADL) received services to maintain good personal hygiene for 1 of 3 residents reviewed for ADL in a final sample of 37 residents (Resident Identifier #62). Findings include: Observation on 10/8/24 at 9:39 a.m. of Resident #62 revealed he/she was in their room dressed and sitting in a chair. Resident #62 had disheveled hair and long dark stubble on their face and chin. During an interview on 10/8/24 at 9:39 a.m. with Resident #62, the resident asked Can you help me shave and shower? Observation on 10/9/24 at 11:00 a.m. of Resident #62 revealed there was long, dark stubble on their face and chin. This was again observed on 10/10/24 at 9:25 a.m. Review on 10/10/24 of Resident #62's Quarterly Minimum Data Set revealed under Section GG - Functional Abilities and Goals, the resident had been coded as Dependent for showers/bathing and for personal hygiene (which included shaving). Review on 10/10/24 of Resident #62's care plan, initiated on 7/30/21 with a target date of 10/9/24, revealed that the resident had an activities of daily living self care deficit related to dementia. Further review revealed under Interventions that the resident needed 1 staff to assist for bathing and personal hygiene tasks. Review on 10/10/24 of Resident #62's weekly bath in the electronic record, which was where the nurses's aides document care that was received, revealed that Resident #62 was scheduled for a weekly bath on Fridays on the 7-3 shift. Further review for the months of September 2024 revealed on 9/6/24, 9/20/24 and 9/27/24, not applicable was coded and on 9/13/24 there was no entry that a shower had been given. Interview on 10/10/24 at 10:56 a.m. with Staff L (Licensed Practical Nurse), who was Resident #62's nurse, revealed that they were not sure when Resident #62 had last had a shower or shaved. Interview on 10/10/24 at approximately 11:30 a.m. with Staff R (Licensed Nursing Assistant (LNA)) and Staff S (LNA), who routinely work with Resident #62, revealed that neither had provided a shower or a shave to Resident #62 in the past 7 days. Interview on 10/10/24 at 11:23 a.m. with Staff AA (Assistant Director of Nursing) confirmed that showers for Resident #62 had not been documented in September 2024. Staff AA revealed that shaving should be done per resident preferences and with routine daily care. Review on 10/10/24 of the facility's policy Activities of Daily Living, revised 2/2023, revealed: . Care and services will be provided for the following activities of daily living; 1. Bathing . grooming . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good . grooming, and personal . hygiene .

Based on observation, interview, and record review, it was determined that the facility failed to label and date opened multi-dose medications on 1 of 6 medications carts observed and 1 of 5 medication rooms observed. Findings include: 45419 48515 5 East Medication Cart Observation on [DATE] at approximately 8:14 a.m. of the 5 East Medication Cart with Staff F (Licensed Practical Nurse) revealed one opened Lispro Insulin Quik Pen with no name, open date or expiration date. Interview on [DATE] at approximately 8:14 a.m. with Staff F confirmed the above findings. Review on [DATE] of policy titled, Insulin Pen, date reviewed ,d+[DATE], revealed: .2. Insulin pens must be clearly labeled with the resident name, type of insulin, amount to be given, frequency, and expiration date. 3. If the label is missing, the pen will not be used . 49819 100's Medication Room Observation on [DATE] at approximately 8:30 a.m. of the medication refrigerator revealed influenza vaccine (1 box of prefilled syringes) and of Tuberculin Protein Derivitative (1 vial). Further observation revealed open/in use Tuberculin Purified Protein Derivative with two hand written dates [DATE] and [DATE]. Interview on [DATE] at approximately 8:30 a.m. Staff A (Licensed Practical Nurse) confirmed the above findings and he/she was not sure when the vaccine had been opened or when it expired. Review on [DATE] of manufacturer instructions for 'Aplisol' Tuberculin Purified Protein Derivative revealed: .Storage .Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.

Based on observation, interview and record review, it was determined that the facility failed to provide dental services and assist the resident with making dental appointments when referred to an oral surgeon for 1 of 1 residents reviewed for dental services in a final sample of 37 residents (Resident Identifier #88). Findings include: Interview on 10/8/24 at 1:19 p.m. with Resident #88 revealed that their teeth were all broken. Resident #88 stated that they had been asking to see a dentist, but was told by the facility that they can't get him/her in to see a dentist. Observation on 10/8/24 at 1:19 p.m. of Resident #88's teeth revealed nearly all were broken and black. Review on 10/10/24 of Resident #88's care plan, initiated on 5/26/23 with a target date of 11/17/24, revealed that the resident had dental health problems with multiple decaying teeth and roots. Interventions included to coordinate arrangements for dental care and transportation as needed. Review on 10/10/24 of Resident #88's Dental Visit notes revealed the following; On 4/26/21, patient states all teeth are broken and wants all to be pulled and dentures made. Will be referred to oral surgeon for evaluation for extractions; On 10/5/21, patient report tooth #9 and #11 painful. Referred to outside oral surgeon; On 9/2/22, patient report tooth #12 and #26 bother when eating. Referred to oral surgeon; On 10/4/22, Staff X (Unit Manager) was informed that patient need extraction of tooth #12 and #26 and referred to oral surgeon. and On 5/8/23, patient with generalized breakdown of teeth, multiple decay, multiple roots. recommend dental treatment every 6 months. There were no additional dental visits noted for Resident #88. Review on 10/10/24 of Resident #88's outside provider dental visit revealed a treatment plan was made on 11/5/21 for removal of teeth and upper/lower dentures fabrication. There was no follow-up to this visit noted in the medical record. Interview on 10/10/24 at 10:13 a.m. with Staff X confirmed the above findings. Interview on 10/10/24 at 10:44 a.m. with Staff K (Medical Records) confirmed that there were no additional dental visits for Resident #88. Review on 10/10/24 of the facility's policy titled Dental Services revised 2/2023, revealed: .It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care . 1. The dental needs of each resident are identified through the physical assessment and MDS [Minimum Data Set] assessment process, and are addressed in each resident's plan of care. a. Oral/dental status shall be documented according to assessment findings. b. Oral care . shall be provided with identified needs and as specified in the plan of care . c. Referral to . dental providers shall be made as appropriate . 4. The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location . 8. For residents or resident representative who do not which to be referred for dental services: a. The physician shall be notified . c. The resident's plan of care will be revised to reflect preferences. 9. All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record.

Based on observation, interview, and record review, it was determined that the facility failed to follow menu preferences, allergies, and intolerances for 2 of 8 residents reviewed for meal/food concerns in a final sample of 37 residents (Resident Identifiers are #4 and #49). Findings include: Resident #4 Interview on 10/8/24 at approximately 8:15 a.m. with Resident #4 revealed they frequently received meal trays with items they have allergies to, such as chocolate and tomatoes. Resident #4 stated that they get sick to their stomach if they eat chocolate or tomatoes. Observation on 10/10/24 at approximately 11:45 a.m. of Resident #4's lunch tray revealed vanilla cake with chocolate frosting. Review of their meal ticket revealed an allergy to chocolate and tomatoes. Review on 10/10/24 of Resident #4's record revealed an allergy to chocolate and tomatoes. Interview on 10/10/24 at approximately 11:55 a.m. with Staff X (Unit Manager) stated Resident #4 had an allergy to chocolate and tomatoes and confirmed Resident #4 had received vanilla cake with chocolate frosting for lunch. 50163 51109 Resident #49 Interview on 10/9/24 at 8:11 a.m. with Resident #49 revealed Resident #49 had been served beef every time it was on the menu, but he/she had an allergy to beef listed on their meal ticket. Review on 10/9/24 of Resident #49's meal ticket confirmed beef was listed as an allergy. Review of the facility policy revised 9/2024 and titled, Food Preparation Guideline, revealed, .Resident preferences and allergies shall be obtained during the resident assessment process and added to the resident's dietary tray card. Staff shall accommodate resident allergies, intolerances, and preferences, providing appropriate alternatives when needed .

Based on record review and interview, it was determined that the facility failed to provide pneumococcal immunization for 1 of 5 residents reviewed for pneumoccocal vaccination in a final sample of 37 residents (Resident Identifier #73). Findings include: Review on 10/9/24 of Resident #73 immunizations revealed: Pneumococcal - historical type unknown: Pneumoccocal given 3/1/2017. Review on 10/9/24 of Resident #73 medical record revealed a consent for pneumococcal vaccine signed by the resident on 4/5/23. Further review revealed the pneumoccocal vaccine was not given to Resident #73. Interview on 10/10/24 at approximately 11:45 p.m. with Staff M (Infection Preventionist) confirmed Resident #73 had not received the consented second pneumoccocal vaccine. Review on 10/10/24 of the facility policy titled Pneumococcal Vaccine (Series), revised 5/2023, revealed: .Policy Explanation and Compliance Guidelines: .6. The type of pneumococcal vaccine (PCV15, PCV20, or PPSV23) offered .in accordance with current CDC (Center for Disease Control and Prevention) guidelines and recommendations .TABLE 1. Pneumococcal vaccine schedules for adults [AGE] years or older .Vaccine received previously at any age .PCV13 only .Schedule option A .Administer a single dose of PCV20 after a year or more interval since the last PCV13 .No specified immunocompromising condition .Schedule option B .Administer a single dose of PPSV23 after a year or more interval since the last PCV13 .Specified immunocompromising condition .Schedule option B .Administer a single dose of PPSV23 after 8 weeks or more interval since the last PCV13 .

Based on record review and interview, it was determined that the facility failed to notify the resident or resident representative of the bed hold policy before discharge to the hospital for 2 of 2 residents reviewed for hospitalization s in a final sample of 37 residents (Resident Identifiers are #75 and #97). Findings include: Resident #75 Review on 10/9/24 of Resident #75's nursing notes revealed a note dated 4/27/24 stating the resident was sent to hospital and admitted . Interview on 10/10/24 at approximately 11:15 a.m. with Staff T (Social Services Office Coordinator) confirmed Resident #75 was hospitalized on [DATE]. Staff T revealed that the facility provides residents their bed hold policy on admission but not upon transfer. Staff T stated the facility will readmit all residents after hospitalization . Resident #97 Review on 10/10/24 of Resident #97's progress notes revealed that the resident was sent to the hospital on 8/11/24 and on 9/9/24. Review on 10/10/24 of Resident #97's medical record revealed that there was no documentation that the facility's bed hold policy had been given to Resident #97 or Resident #97's representative for either hospitalization . Interview on 10/10/24 at approximately 12:00 p.m. with Staff B (Administrator) confirmed the above findings. 49819 Review on 10/10/24 of facility policy titled, Bed Hold Notice Upon Transfer, dated 5/2022, revealed: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold-policy and addresses information explaining the return of the resident to the next available bed. Review on 10/10/24 of facility policy titled Transfer and Discharge (including AMA), revised 5/2023, revealed: .Policy Explanation and Compliance Guidelines: .12. Emergency Transfers/Discharges .g. Provide .the facility's bed hold policy to the resident and representative as indicated .

Based on record review and interview, it was determined that the facility failed to conduct a comprehensive Minimum Data Set (MDS) assessment within 14 days after a significant change was determined for 2 of 4 residents reviewed for hospice in a final sample of 37 residents (Resident identifiers are #165 and #11). Findings include: Resident #165 Review on 10/8/24 of Resident #165's medical record revealed he/she was admitted to Hospice on 7/5/24. Further review revealed the Significant Change MDS was completed on 8/2/24, 28 days after the determination of the significant change. Resident #11 Review on 10/9/24 of Resident #11's medical record revealed he/she was admitted to hospice on 9/13/24. Further review revealed the Significant Change MDS was completed on 10/4/24, 21 days after the determination of the significant change. Interview on 10/10/24 at approximately 12:00 p.m. with Staff Z (MDS Coordinator) confirmed the above findings.

Based on observation, interview, and record review, it was determined that the facility failed to provide services or assist a resident in making appointments to maintain good foot health for 1 of 3 residents reviewed for foot care (Resident Identifier #5). Findings include: Interview on 7/26/24 at approximately 12:30 p.m. with Resident #5 revealed they had been requesting to see a podiatrist for overgrown toenails. Review on 7/26/24 of Resident #5's medical record revealed a podiatry visit note dated 9/14/23 that stated .Routine podiatry care is medically necessary due to patient's atherosclerosis of the extremities and DM II [Diabetes Mellitus Type 2] due to the associated increased risk of bone infection, and digital or limb loss . Further review of Resident #5's medical record revealed no other podiatry visit notes. Review on 7/26/24 of Resident #5's Dialysis Communication Book revealed an entry dated 7/3/24 from the Dialysis Center to the Facility that stated .Please make sure [name omitted] has [pronoun omitted] toenails trimmed ASAP [as soon as possible], they are too long and could cut [pronoun omitted] toes . Observation on 7/26/24 at approximately 1:55 p.m. of Resident #5's toes on the left foot with Staff A (Unit Manager) revealed all 5 toenails to be grown out past the end of the toes and the 4th toe nail was noted to be curled under the toe. (Right foot not observed) Interview on 7/26/24 at approximately 2:00 p.m. with Staff B (Director of Nursing) confirmed the above findings. Staff B stated that Resident #5 had been seen by the podiatrist but was at Dialysis when the podiatrist was at the facility. Review on 7/26/24 of the facility policy titled, Podiatry Services revised on 2/2023, revealed: .To ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health .Residents requiring foot care who have complicating disease process will be referred to qualified professionals such as a Podiatrist, Doctor of Medicine, and/or Doctor of Osteopathy .The social worker or designee will assist residents in making appointments to obtain needed services .

Based on interview, observation, and record review, it was determined that the facility failed to ensure that physician's orders were followed for 4 residents in a final sample size of 41 residents and 1 out of 28 medication administrations observed. (Resident Identifiers are #3, #64, #83, #158, and #163) Findings include: Standards: [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #163 Review on 10/3/23 of Resident #163's September 2023 and October 2023 Medication Administration Records (MAR) revealed the following physician's order: Hydralazine HCL [Hydrochloric Acid] Tablet 25 mg [milligrams] Give 1 tablet by mouth four times a day for Hypertension, call MD [physician] with SBP [Systolic Blood Pressure] greater than 150, start date 9/22/23. Further review of the MAR revealed that Hydralazine HCL was administered when Resident #163's SBP was greater than 150 on the following dates and times: September 2023 8:00 a.m.: 9/23 SBP 172, 9/24 SBP 170, 9/26 SBP 158, 9/27 SBP 180, 9/28 SBP 176, 9/29 SBP 172 4:00 p.m.: 9/25 SBP 151, 9/27 SBP 158, 9/30 SBP 173 October 2023 8:00 a.m.: 10/1 SBP 155, 10/3 SBP 177 4:00 p.m.: 10/1 SBP 176, 10/3 SBP 152 Review on 10/3/23 of Resident #163's medical record revealed no evidence that the physician was notified of the above SBP's above 150. Interview on 10/5/23 at approximately 8:30 a.m. with Staff I (Unit Manager) confirmed the above findings. Staff I stated that the physician should have been notified on the above mentioned dates of when Resident #163's SBP was greater than 150. Resident #64 Review on 10/5/23 of Resident #64's current physician's orders revealed an order for 1800 ml [milliliter] Fluid Restriction every shift: 7-3 [7:00 a.m. to 3:00 p.m. shift] mls: 480 mls (Breakfast tray 240 mls, Lunch tray 240 mls), 3-11 [3:00 p.m. to 11:00 p.m. shift] mls: 480 mls (Dinner tray 240 mls), and 11-7 [11:00 p.m. to 7:00 a.m. shift] mls: 120 mls. All shifts enter cc's (cubic centimeters) consumed and 11-7 calculates the total, Start Date 5/22/23. Further record review revealed no documentation of Resident #64's fluid intake. Interview on 10/5/23 with Staff J (Director of Nursing) confirmed the above findings for Resident #64. Resident #3 Review on 10/4/23 of Resident #3's September and October 2023 MARs revealed the following physician's order: Metoprolol Succinate ER [Extended Release] Tablet 24 hour 100 mg [milligrams], Give 1 tablet by mouth one time a day for HTN [hypertension] hold for SBP less than 100, HR [heart rate] less than 50, Start Date 5/4/23. Further review of Resident #3's medical record revealed that there were no documented SBPs or HRs prior to administering the medication. Interview on 10/5/23 at approximately 8:30 a.m. with Staff J confirmed the above findings for Resident #3 Resident #83 Review on 10/4/23 of Resident #83's September and October 2023 MARs revealed the following physician's order: BP [Blood Pressure] daily in the AM [morning] one time a day for low BP monitor, Start Date 1/24/23. Further review of Resident #83's medical record revealed that there were no documented BPs in the morning as ordered by the physician. Interview on 10/5/23 at approximately 8:30 a.m. with Staff J confirmed the above findings for Resident #83. Resident #158 Observation on 10/4/23 at approximately 7:35 a.m. of medication administration with Staff H (Licensed Practical Nurse) revealed that Staff H was going to administer a Calcium 600 mg Vitamin D 400 Units tablet to Resident #158. Review on 10/4/23 at approximately 7:35 a.m. of Resident #158's October 2023 MAR revealed a physician's order to administer Calcium Vitamin D Tablet 600-200 mg/unit 1 tablet by mouth two times a day for bone health with a start date of 12/21/22. Interview on 10/4/23 at approximately 7:35 a.m. with Staff H confirmed the above findings for Resident #158.

Based on interview and record review, it was determined that the facility failed to provide sufficient staff to meet the residents' needs for a census of 238 residents (Resident Identifiers are # 115, #128, #186, and #187). Findings include: Review on 10/6/23 of the facility assessment reviewed by the Quality Assessment and Assurance (QAA) Committee on 7/20/23 and 8/17/23 revealed the following staffing levels for direct care staff: 7 a.m. -3 p.m. shift (Day Shift) Units 1, 2, 5, and 6 - 2 Nurse (Registered Nurse (RN) or Licensed Practical Nurse (LPN)) and 5 Licenced Nursing Assistants (LNAs). Unit 3 - 3 Nurse and 5 LNAs. 3 p.m. -11 p.m. shift (Evening Shift) - Units 1, 2, 5, and 6 - 2 Nurse and 4 LNAs. Unit 3 - 3 Nurse and 4 LNAs. 11 p.m. -7 a.m. shift (Night Shift)- Units 1, 2, 5, and 6, 2 Nurse and 2 LNAs. Unit 3 - 3 Nurse and 3 LNAs. Interview with Staff F (Administrator) confirmed the above staffing levels. Review of Daily Staffing Sheets for the month of September 2023 revealed the following: September 4, 2023 Unit 6 - Day Shift - 3.0 LNAs and 1.0 Nurse - Census 46 Unit 2 - Night Shift - 1.0 LNAs - Census 47 September 5, 2023 Unit 1 - Day Shift - 3.0 LNAs - Census of 48 Unit 6 - Day Shift - 3.0 LNAs - Census of 48 September 7, 2023 Unit 2 - Evening Shift - 3.0 LNAs - Census 48 Unit 6 - Evening Shift - 3.0 LNAs - Census 47 September 9, 2023 Unit 2 - Day Shift - 3.0 LNAs - Census 48 Unit 3 - Day Shift - 3.0 LNAs - Census 46 Unit 5 - Day Shift - 3.0 LNAs - Census 48 Unit 5 - Evening Shift - 3.0 LNAs. Unit 6 - Day Shift - 3.0 LNAs and 1.0 Nurse - Census 46 Unit 6 - Evening Shift - 3.0 LNAs September 10, 2023 Unit 1 - Day Shift - 3.0 LNAs - Census 48 Unit 2 - Day Shift - 3.0 LNAs - Census 46 Unit 3 - Day Shift - 3.0 LNAs - Census 45 Unit 5 - Day Shift - 3.0 LNAs - Census 48 Unit 6 - Day Shift - 3.0 LNAs and 1.0 Nurse - Census 46 September 11, 2023 Unit 2 - Day Shift - 3.0 LNAs - Census 46 Unit 5 - Day Shift - 3.0 LNAs - Census 48 Unit 6 - Evening Shift - 2.5 LNAs - Census 46 September 12, 2023 Unit 2 - Day Shift - 3.0 LNAs - Census 46 Unit 5 - Day Shift - 3.0 LNAs - Census 46 Unit 6 - Day Shift - 1.0 Nurse - Census 48 September 13, 2023 Unit 5 - Day Shift - 3.0 LNAs - Census 49 Unit 6 - Day Shift - 1.0 Nurse - Census 48 September 14, 2023 Unit 3 - Day Shift - 2.9 LNAs - Census 45 Unit 5 - Day Shift - 3.0 LNAs - Census 49 Unit 6 - Day Shift - 1.0 Nurse - Census 48 September 16, 2023 Unit 2 - Day Shift - 3.0 LNAs - Census 47 Unit 5 - Day Shift - 3.0 LNAs - Census 49 Unit 6 - Day Shift - 1.0 Nurse - Census 47 September 17, 2023 Unit 1 - Day Shift - 3.0 LNAs - Census 48 Unit 2 - Day Shift - 3.0 LNAs - Census 47 Unit 5 - Day Shift - 3.0 LNAs - Census 49 Unit 6 - Day Shift - 3.0 LNAs - Census 47 September 18 2023 Unit 2 - Day Shift - 3.0 LNAs - Census 46 Unit 5 - Day Shift - 3.0 LNAs - Census 50 Unit 6 - Day Shift - 3.0 LNAs - Census 46 September 20, 2023 Unit 6 - Evening Shift - 3.0 LNAs - Census 48 September 23, 2023 Unit 3 - Day Shift - 2.9 LNAs - Census 41 September 24, 2023 Unit 3 - Day Shift - 3.0 LNAs - Census 42 Unit 6 - Day Shift - 3.0 LNAs - Census 49 September 30, 2023 Unit 3 - Day Shift - 3.0 LNAs - Census 45 Unit 5 - Day Shift - 2.9 LNAs - Census 47 Unit 6 - Day Shift - 3.0 LNAs - Census 49 October 1, 2023 Unit 2 - Day Shift -3.0 LNAs - Census 45 Unit 5 - Day Shift - 2.9 LNAs - Census 48 Interview with Staff P (Unit Manager) on 10/06/23 at 8:51 a.m. revealed that the unit has had two callouts today. He/She had to work as a medication nurse for the first part of the shift and there are only 3 LNAs working the 7 a.m. - 3 p.m. shift today. The current census is 48 on the unit. Interview with Staff F on 10/6/23 at 10:09 a.m. confirmed that the Daily Staffing Sheets were correct and included all staff call-outs. 38218 Observation on 10/2/23 at approximately 6:00 p.m. revealed a strong odor of urine on the nursing units. Interview on 10/3/23 at approximately 8:45 a.m. with Resident #115 revealed that he/she had concerns with staffing at the facility. Sometimes I have to wait for a half hour for my call light to be answered and then another hour or so for them to find someone help me. Interview on 10/3/23 at approximately 9:00 a.m. with Resident #187 revealed that receiving help from staff can be anywhere from 30 minutes to 2 hours. It is horrible, I wet myself sometimes and will be in pain for that long because there is no one to answer my call bell. Interview on 10/3/23 at approximately 10:00 a.m. with Resident #186 revealed, Over this past weekend there were a bunch of no shows which meant we waited for anything we needed. All of these people (staff members) are not on the floor helping out, this is only because you are here. Interview on 10/6/23 at approximately 9:15 a.m. with Staff L (Anonymous) and Staff M (Anonymous) revealed, Staffing is horrible and the residents suffer from it. At times we have worked with only 2 LNAs on the floor for like 50 people. Weekends are horrible too, we have to do bare minimum care to just get to everyone, the residents are not receiving the care they need. 47129 Resident #128 Interview on 10/4/23 at 3:00 p.m. with Resident #128's family member revealed that their main concern was staff shortage. Family member stated that last month Resident #128 called [pronoun omitted] to come to the facility. When [pronoun omitted] arrived, Resident #128 was in a soiled brief. Resident #128 told the family member that he/she was waiting all morning to be changed. Resident #128's family member went to find help. Resident #128's family member was told there was only 1 aid on shift. Resident #128's family member had to change Resident #128's soiled brief.

Based on record review and interviews, it was determined that the facility failed to obtain diagnostic services in a timely manner to meet the needs for diagnosis, treatment, and prevention for 1 resident in a standard survey sample of 30 residents. This resulted in an Immediate Jeopardy as the facility failed to communicate with the physician when implementation of a physician order [REDACTED].#16.) Findings include: Clinical Guideline Review: [DIAGNOSES REDACTED].D., on September 1, 2013, relates in part . the consequences of missing the [DIAGNOSES REDACTED]. Per http://www.acepnow.com/article/clinical-guideline-review-diagnosis-[MEDICAL CONDITION]/ - accessed 5/17/17. Review on 4/21/17 of Resident #16's Physician order [REDACTED]. This was ordered by Staff A (Physician Assistant). Review on 4/21/17 of Resident #16's progress notes from 3/31/17 revealed MD/PA wrote an order for [REDACTED]. Shift Nurse Called (names of laboratory/portable X-ray supplier omitted) and requested a STAT Ultrasound at 14:00, but was told at 19:00 that the Lab is not coming tonight or weekend. Interview on 4/21/17 at approximately 3:00 p.m. with Staff B (Registered Nurse, Unit Manager) revealed that it was actually the contracted portable x-ray supplier, not the lab, that did not come that night and over the weekend. Staff B also revealed that neither Staff A (ordering Physician Assistant) nor the on-call physician were notified that the ultrasound would not be done until Monday. Staff B also revealed that radiology studies ordered in the afternoon would often be performed the next day depending on the portable x-ray supplier's schedule. Review on 4/21/17 of Resident #16's Radiology reports revealed that Resident #16 had a Venous Doppler ultrasound for right leg pain on 4/3/17 at 6:30 p.m. performed by a portable X-ray supplier at the facility, more than 72 hours after it was ordered. Results from this study were Positive [MEDICAL CONDITION] in the right lower extremity. Interview on 4/21/17 at approximately 4:45 p.m. with Staff C (Chief Clinical Officer) revealed that it was Staff C's belief that staff and providers knew that radiology studies ordered in the afternoon might not be done that day or over the weekend. Interview on 4/21/17 at approximately 5:00 p.m. with Staff A (Physician Assistant), confirmed that Staff A ordered an ultrasound of the right leg early Friday (3/31/17) afternoon to rule out [MEDICAL CONDITION]. Staff A stated they were not aware that ultrasounds were not performed on the weekends at the facility. Staff A revealed they had not been notified that the ultrasound would not be performed until Monday evening (4/3/17). Staff A stated that if they had been notified of the delay in the ultrasound until Monday, Staff A would have sent Resident #16 out to the hospital for an ultrasound or started the resident on medications for treating [MEDICAL CONDITION] instead of waiting until Monday. Interview on 4/21/17 at approximately 5:10 p.m. with Staff A, Staff A stated that Resident #16 had presented with a red, swollen, warm to touch right leg and Resident #16 had complained of pain so at that time Staff A ordered an ultrasound of the right leg early Friday (3/31/17) afternoon to rule out [MEDICAL CONDITION]. Review on 4/21/17 on Resident #16's Medication Administration Record [REDACTED] From the review of this incident, thru interview and record review it was revealed that there was no documented evidence that once the facility became aware of Resident #16's [MEDICAL CONDITION] that the staff and providers were educated or re-educated after this event that studies ordered from this company had the potential to be delayed due to operating only during contractual hours.