Every finding on record at Nocona Rehabilitation and Care Center

Based on interview and record review, the facility failed to electronically submit to Center for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 1 of 4 Fiscal Year (FY) quarters reviewed. FY Quarter 4 2025 (July 1 - September 30) reviewed for administration. The facility failed to submit data to CMS for FY Quarter 4 2025 (July 1 - September 30). This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.Findings included: Review of the facility's Employee List dated 2/10/2026 indicated the following:1 Administrator 5 RNs (including Director of Nursing and MDS Coordinator)7 LVNs 16 CNAs (including 1 MA and Activity Director)1 Maintenance Personnel3 Housekeeping Personnel1 BOM (Business Office Manager)2 Laundry Personnel5 Dietary Personnel (Included Dietary Supervisor)7 Therapist (Included Director of Rehabilitation, Physical/Occupational and Speech Therapists)1 Social Worker Record review of the facility CMS form 802 Matrix (Resident Census and Conditions of Residents) dated 2/10/2026 provided by the MDS Coordinator indicated a total of 32 residents in the facility. Record Review of the CMS Payroll Based Journal report for CMS for FY Quarter 4 2025 (July 1 - September 30) indicated the facility had failed to submit data for the quarter triggered. On 2/12/2026 at 9:20am a policy was requested from the Regional Nurse Consultant for maintaining resident and facility records. In an interview on 02/12/2026 at 11:15am with the Director of Information Services (DIS) stated the new management group partners with a third party company who will submit their payroll reports to CMS on their behalf starting that week. She stated in attempts to retrieve information from the previous management company, their [NAME] President of Human Resources was very difficult to contact, and she had been awaiting a response from her as to why their company did not submit their payroll information for quarter 4 of 2025 to CMS. She stated when the previous management team left, their administrator took all documentation out of the facility leaving them with nothing regarding staffing, training, and other information. During this interview it was revealed she could not find a policy regarding maintaining records. In an interview on 02/12/2026 at 11:45am with the [NAME] President of Clinical Services (VPCS), she stated her expectation was for the CMS PBJ reports to be submitted on time and accurate. Stated a negative outcome could have a negative impact on resident care. In a follow up email received on 02/13/2026 at 11:17am the DIS stated she had not received any follow up information from the previous management group after submitting two emails highlighting the urgency to receive an update. In an interview on 02/13/2026 at 11:30am with the Regional Nurse Consultant, she stated she did not have an individual policy for PBJ Reporting. She stated they followed the CMS Electronic Staffing Data Submission Payroll-Base Journal Long-Term Care Facility Policy Manual as their policy for PBJ Reporting.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in one of one kitchen, in that: The facility failed to store nonperishable dry foods in the kitchen that were sealed and/or labeled with open date.The facility failed to store foods in the refrigerator that were labeled with an identifier and/or open date.The facility failed to discard expired or spoiled foods. These failures could place residents at risk for decline in nutritional health status and foodborne illness. The findings included: During observations and interviews on 2/10/2026 beginning at 8:55am, during the initial tour of the kitchen, the following was observed on the shelf above the food preparation area;1 quart size zip lock bag labeled Bacon Bits 1/4 full dated 1/04 opened/not sealed1 5lb bag of Blueberry Muffin Mix 1/4 full in original bag dated 12/27 not sealed/closed or in resealable bag.1 5lb bag [NAME] Gravy Mix in original bag dated 12/19/2025 opened/not sealed or in sealable bag.1 1lb 12oz bag Creamy Wheat in original bag with seal dated 1/3 opened/not sealed.On the bread shelves, a 6-rack rolling storage cart, revealed:1 of 4 packages of Hamburger Buns not dated, in original packaging containing 8 buns with blue green mold affecting all buns.1 package of 1 hamburger buns dated 2/1/26 with expiration date of 2/6/2026 remained on shelving.In #1 of 3 refrigerators inspected revealed:1 sandwich size zip lock bag of yellow firm substance unsealed/opened dated 2/10 with no label. [NAME] A stated it was leftover scrambled eggs from breakfast and she forgot to label it.1 gallon size reusable container labeled Oranges with expiration date of 1/25/20261 sandwich size zip lock bag with no date or label: [NAME] A stated they appeared to be cooked Pork chops, (6 count), left over but did not know when they were prepared.1 gallon size reusable container 1/4 full labeled [NAME] Gravy dated 2/1/2026 and use by dated 2/5/20261 gallon zip lock bag 1/4 full labeled Pork dated 2/4/2026 and use by 2/7/2026. [NAME] A stated it was chopped cooked pork that should have been discarded.1 reusable bowl 1/2 full labeled B. Pudding dated 2/01 and use by dated 2/04In an observation of a sign in sheet taped to the outside door of refrigerator #1 for Freezer and Refrigerator Temperature checks revealed spots for morning and evening shifts to initial areas for 3 refrigerators and 2 freezer temps to be checked and confirmed. Dates of 2/1-2/4 had been initialed, dates 2/5-2/10 were not completed. [NAME] A stated it is the cooks' job to check temperatures in all refrigerators and freezers and she had been checking them but had forgotten to log it. In an interview on 2/13/2026 at 1:32 pm with RNC, she stated her expectations for storage of foods was that they are stored properly, labeled and dated when opened, thrown away before expiration date and possible adverse effects could be GI upset and possible diarrhea/vomiting. Stated her expectations for refrigerator and freezer temps was that they would be checked according to policy by the cooks and dietary aide on AM and PM shift and documented on sign off sheets. Stated possible adverse effects could be spoiled food in the refrigerators and gastrointestinal upset. Stated [NAME] A and dietary manager were responsible for checking storage and dates on food items. Kitchen manager and dietician were not in facility to interview during survey. In an interview on 2/13/2026 at 1:40pm with RDO, she stated her expectations for storage of foods was that they are stored properly, labeled and dated when arrived and opened, thrown away before expiration date and possible adverse effects could be gastrointestinal upset and possible diarrhea/vomiting. She stated her expectations for refrigerator and freezer temps was that they will be checked according to policy by the cooks and dietary aide on AM and PM shift and documented on sign off sheets. She stated possible adverse effects could be spoiled food in the refrigerators and gastrointestinal upset. In an interview with [NAME] A on 2/13/2026 at 2:11pm she stated her expectations was for all foods to be stored and labeled appropriately and for outdated items to be thrown away according to policy. She stated possible negative effects for residents could be they become sick with vomiting or diarrhea. [NAME] A stated the dietary manager and herself were responsible for these duties. Record review of policy Titled Food Storage dated 10/18/2018 and revised on 6/1/2019 stated [in part]:Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all foods will be stored according to the state, federal and US Food Codes and HACCP guidelines.1. Dry Storage rooms- d. All containers must be labeled and dated2. Refrigerators- d. date label and tightly seal all refrigerated foodse. use all leftovers within 72 hours. Discard items that are over 72 hours old.h. check the temperatures of all refrigerators using the internal thermometer to make sure the temperature stays at 41 degrees F or below. Temperatures should be checked each morning and again on the PM shift.3. Freezers-h. Place a thermometer inside freezers near the door where the temperature is warmest. Check the temperature of all freezers using the internal thermometer to make sure the temperature stays at 0 degrees F or below. Temperatures should be checked each morning and again on the PM shift. Record the temperatures on a log that is kept near the freezer. Record review of facility policy titled Food Storage in the Pantry (Shelf Stable- Foods) dated 2013 by Academy Of Nutrition and Dietitians revealed in partKeeping Food Safe:Throw away moldy bread. Record review of a policy on the #1 refrigerator door titled Sunday Food Safety Checklist for Dietary Departments stated [in part]:All food in dry storage and on kitchen shelves are covered, labeled, and dated.All food in reach-in and walk in coolers are properly covered/sealed, labeled, and dated INCLUDING use by dates on opened items.No expired food in coolers/freezersAll logs are up to date: Coolers, Freezers

Based on interview and record reviews the facility failed to maintain documentation and demonstrate evidence of training requirements for 7 of 16 (DON, RN C, RN D, LVN E, CNA F, Laundry G, and Housekeeping H) employees reviewed for training.The facility failed to maintain evidence that the DON, RN C, RN D, LVN E, CNA F, Laundry G, and Housekeeping H were trained for infection control.The facility failed to maintain evidence that RN C, RN D, LVN E, CNA F, Laundry G, and Housekeeping H were trained for compliance and ethics.The facility failed to maintain evidence that RN C, RN D, CNA F, and Laundry G were trained for Resident Rights.The facility failed to maintain evidence that RN C, LVN E, CNA F, Laundry G, and Housekeeping H were trained for QAPI.The facility failed to maintain evidence that RN C, CNA F, and Laundry G were trained for abuse and neglect.The facility failed to maintain evidence that RN C, CNA F, Laundry G, and Housekeeping H were trained for communication.The facility failed to maintain evidence that RN C, CNA F, Laundry G, and Housekeeping H were trained for Behavioral Health.The facility failed to maintain evidence that the DON, RN C, RN D, LVN E, CNA F, Laundry G, and Housekeeping H were trained for Fall Prevention.The facility failed to maintain evidence that the DON, RN C, RN D, LVN E, CNA F, Laundry G and Housekeeping H were trained for Restraint Reduction.The facility failed to maintain evidence that RN C, Laundry G, and Housekeeping H were trained for HIV.The facility failed to maintain evidence that RN C, and LVN E were trained for Annual 1hr Dementia. These failures could place residents at risk of receiving care from incompetent/untrained staff.Findings included: Record review of personnel files revealed the following evidence of training documents could not be provided.DON hired 12/1/2025:Infection control RN C hired 06/01/2021:Resident rightsInfection controlCompliance and ethicsQAPIAbuse and NeglectCommunicationBehavioral HealthFall PreventionHIVRestraint ReductionAnnual 1hr Dementia RN D hired 02/01/2026Resident RightsInfection controlCompliance and ethicsFall PreventionRestraint reduction LVN E hired 11/03/2024Infection controlCompliance and ethicsQAPIFall preventionRestraint reductionAnnual 1hr Dementia CNA F hired 04/17/2025Resident rightsInfection controlCompliance and ethicsQAPIAbuse and NeglectCommunicationBehavioral HealthFall PreventionRestraint ReductionAnnual 1hr Dementia Laundry G hired 07/03/2018Resident rightsInfection controlCompliance and ethicsQAPIAbuse and NeglectCommunicationBehavioral HealthFall PreventionHIVRestraint Reduction Housekeeping H hired 5/17/2024Infection controlCompliance and ethicsQAPICommunicationBehavioral HealthFall PreventionHIVRestraint ReductionAnnual 1hr Dementia In an interview on 02/10/2026 at 10:00am with CNA F, she stated she had worked there for about 8 months. Stated she works here PRN and full time at another facility. She stated she was hired by the previous management company and completed some training when she was hired and has been there for an in-service or two. She stated it was important to know about abuse and neglect and who to talk to if she were to witness any that she would go to the administrator. In an interview on 02/10/2026 at 11:40am, with Housekeeping H, stated she has worked here for a couple of years. She stated she hasn't done as much training with the current company but did a bunch with the company that was there before who hired her. She further stated it was important to be trained to know how to take care of the residents and if she witnessed or was informed of abuse or neglect she would speak with the administrator or DON. In an interview on 02/11/2026 at 3:15pm with the BOM, she stated the records she has delivered to the conference room are all of the personnel records and trainings she has available. She stated the previous management company took all records the last day they were there leaving them with nothing so they had to start all over with files unless an employee happened to keep a copy of records they had nothing to go by. In an interview on 02/12/2026 at 10:30am with the Regional Nurse Consultant (RNC), she stated she was unable to provide any documentation from dates prior to their takeover on 11/19/2025. She stated the previous management company took all records when they left. She stated she along with other employees have sent multiple emails to the prior company asking for them to return records and they have not received a response as of that day. She stated this act left them with no way to produce records the survey team had requested prior to that date. She said the expectation of the management company would be to maintain and provide all records requested to remain in compliance with federal and state laws. She stated a negative outcome could be a resident's not receiving proper care. In an interview on 02/12/2026 at 11:45 AM with the [NAME] President of Clinical Services, she stated with the personnel records they can only provide what they have which was what they had completed since the takeover. She stated they were doing the best they could with what they were left with and were expecting to receive citations for those missing records, but it was out of their control. Record review of facility provided policy titled Orientation Policy undated, revealed [in part]:11. All documentation to support completion of the orientation process shall be maintained in the staff member's personnel file. During an interview on 02/13/2026 at 3:45pm, the corporate administrative staff did not have facility policies and procedures for maintaining facility records.

Based on interview and record reviews the facility failed to maintain documentation and demonstrate evidence of its ongoing Antibiotic Stewardship program for 1 of 1 facility's reviewed for Antibiotic Stewardship. The facility failed to provide documentation of appropriate monitoring of antibiotic use for residents by not providing the track and trending log prior to November 2025. These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections.Findings included: Record review of antibiotics and infection tracking revealed: Facility had maintained tracking for November 2025, December 2025, and January 2026. No previous records were available for review. In an interview on 02/12/2026 at 10:30am with the Regional Nurse Consultant (RNC), she stated she was unable to provide any documentation from dates prior to their takeover on 11/19/2025. She stated the previous management company took all records when they left. She stated she along with other employees have sent multiple emails to the prior company asking for them to return records and they have not received a response as of that day. She stated this act left them with no way to produce records the survey team had requested prior to that date. She said the expectation of the management company would be to maintain and provide all records requested to remain in compliance with federal and state laws. She stated a negative outcome could be a resident's not receiving proper care. Review of facility provided policy titled Antibiotic Stewardship Program undated, revealed [in part]:4. The program includes antibiotic use protocols and a system to monitor antibiotic use.b. Monitoring antibiotic use:vi. Antibiotic use shall be measured by (monthly prevalence, antibiotic starts, and/or antibiotic days of therapy).vii. At least one outcome measure associated with antibiotic use will be tracked monthly, as prioritized from the facilities infection control risk assessment and other infection surveillance data. During an interview on 02/13/2026 at 3:45pm, the corporate administrative staff did not have facility policies and procedures for maintaining facility records.

Based on interview and record reviews the facility failed to maintain documentation and demonstrate evidence of its ongoing QAPI program for 1 of 1 facility's reviewed for QAPI. The facility failed to maintain documentation of QAPI meetings prior to November of 2025. This failure placed residents at risk of maintaining and improving safety and quality of life.Findings included: Record review of QAPI meetings revealed: Facility had maintained QAPI meeting minutes from 11/20/2025. No previous meeting documentation was available.In an interview on 02/12/2026 at 10:30am with the Regional Nurse Consultant (RNC), she stated she was unable to provide any documentation from dates prior to their takeover on 11/19/2025. She stated the previous management company took all records when they left. She stated she along with other employees have sent multiple emails to the prior company asking for them to return records and they have not received a response as of that day. She stated this act left them with no way to produce records the survey team had requested prior to that date. She said the expectation of the management company would be to maintain and provide all records requested to remain in compliance with federal and state laws. She stated a negative outcome could be a resident's not receiving proper care. Record review of the QAPI Plan revised 11/19/2025 revealed on page 3 [in part]:Meeting frequency: Monthly QAPI Meeting and Ad-Hoc QAPI meeting as the need arises. During an interview on 02/13/2026 at 3:45pm, the corporate administrative staff did not have facility policies and procedures for maintaining facility records.

Based on observation, interview, and record review, the facility failed to act upon the consultant pharmacist's medication regimen review report to the attending physician for 1 of 5 residents (Resident #7) reviewed for unnecessary medications. Resident #7's attending physician wrote an order dated 1/11/2026 for a dose reduction in the antipsychotic medication Seroquel 50 mg at HS to Seroquel 25 mg at HS per the Consultant Pharmacist's recommendation dated 11/23/2025. The order was not noted by the facility's licensed nursing staff and the order was not changed. This failure placed the resident at risk for adverse effects from continued medication administration at a dose that was not reduced as ordered by the physician.The findings included: Record review of Resident #7's admission Record, dated 2/13/2026, indicated a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included non-Hodgkin lymphoma (cancer cells in the lymph nodes), type 2 diabetes mellitus (development of high blood sugar level over the course of time), dementia (mental decline that affects memory, thinking, and behavior), hypertension (high blood pressure), atrial fibrillation (rapid and irregular heartbeat), hyperlipidemia (high cholesterol), Parkinsonism (physical movement impaired by rigidity, tremor, or slowness of motion), left femur fracture (hip fracture), hallucinations (false perceptions of sensory experiences), and insomnia (sleep disorder). Record review of Resident #7's Order Summary Report, dated 2/13/2026, indicated an order dated 8/22/2025 for the antipsychotic medication of Seroquel 50 mg by mouth at bedtime for hallucinations. Record review of the Pharmaceutical Consultant Report - Psychotropic Gradual Dose Reduction, dated 11/23/2025, indicated the Consultant Pharmacist documented a letter to Resident #7's attending physician. The Consultant Pharmacist documented the recommendation for evaluation of Seroquel 50 mg at HS, consideration of a dose reduction, and a rationale for continued use. The form was signed by the facility's DON. The Physician Response to Review section was signed and dated by Resident #7's attending physician on 1/11/2026. The physician selected A dose reduction is appropriate and he wrote a new order for Seroquel 25 mg at HS. The physician selected the options for other causes for symptoms have been ruled out, symptoms are persistent enough to warrant continuation, non-pharmacological interventions were considered, medication clinically indicated to manage the symptom, and actual benefit sufficient to justify the potential risk(s) or adverse consequences associated with the selected medication dose and duration. There was no documented evidence the order had been noted by the facility's DON or other licensed nursing staff.[The order for the dose reduction in Seroquel 50 mg at HS to Seroquel 25 mg at HS was not changed on Resident #7's order summary.] In a telephone interview on 02/12/2026 at 11:07 AM, the contracted Consultant Pharmacist stated he began working with the facility in February 2025. He stated after he completed the GDR/MRR reviews, he emailed the reports and recommendations in a PDF format to the designated staff member, usually the DON. He stated that staff member was responsible for getting the reports to the ordering physician to review to make his or her recommendations or changes and sign the report. He stated once the reports were signed the facility staff were responsible for entering the changed or new orders if needed into the residents' electronic health records. In a telephone interview on 02/12/2026 at 2:23 PM, the facility's Medical Director stated he was unaware that the facility was missing so many records. He Sstated he could remember signing some GDR/MRR reviews recently but he was not sure if the facility picked them up or what happened to them. He sStated his expectation would be for the facility to keep records according to federal and state law, and once the facility received the GDR/MRR reports, the facility staff were to print and bring them to his office for his review and signature. The Medical Director stated a negative outcome could be a missed medication change or unnecessary administration of medications. During an observation and interview on 2/13/2026 at 9:20 AM, LVN B unlocked the medication cart and pulled out the medication card with Seroquel for Resident #7. Resident #7's medication card was labeled as Seroquel 50 mg at HS. LVN B stated the resident had been on the medication for a long time. LVN B stated she did not know the physician wrote an order to decrease the Seroquel dose to 25 mg at HS. She stated the resident's family member may not have agreed to a dose reduction. LVN B stated she would research it. In an interview on 2/13/2026 at 9:52 AM, the RN Regional Clinical Support Nurse Consultant stated there was not a specific facility policy for follow-up to Pharmacy Consultant recommendations. She stated the facility had policies for medication orders and GDRs. The RN Regional Clinical Support Nurse Consultant stated the expectation was that the Consultant Pharmacist would send a recommendation letter for the physician to the facility, the DON would review and sign the recommendation letter and send the letter to the physician, and the physician would document a response of the letter and return it to the facility. She stated the DON would note and date the physician's response and make the order change or give a copy of the order to the charge nurse to make the change. The RN Regional Clinical Support Nurse Consultant stated she had already spoken with LVN B regarding Resident #7's Seroquel dose not being changed as ordered. She stated LVN B had called the physician's office and was waiting for a return call. The RN Regional Clinical Support Nurse Consultant stated she had instructed LVN B to notify the physician that the dose reduction and order change for Seroquel was not done and verify that he still wanted to reduce the medication. Review of the facility policy for Medication Orders, dated 2025, indicated [in part]: Policy:This facility shall use uniform guidelines for the ordering of medications.Policy Explanation and Compliance Guidelines:1. Medications should be administered only upon the signed order of a person lawfully authorized to prescribe.4. Documentation of Medication Orders:a. Each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR).b. Clarify the order.d. If using electronic medication records, input the medication order according to the electronic health record (E.H.R.) instructions and facility policy.e. Call or fax the medication order to the provider pharmacy.f. Transcribe newly prescribed medications on the MAR or treatment record or ensure the order is in the electronic MAR.g. When a new order changes the dosage of a previously prescribed medication, discontinue previous entry by writing DC'd [discontinued] and the date, or discontinue the order as per the electronic software instructions and retype the new order. h. Enter the new order on the MAR or ensure the new order is in the electronic MAR.i. Notify resident's sponsor/family of new medication order.5. Specific Procedures for Medication Orders:a. Handwritten Order Signed by the Physician - The charge nurse on duty at the time the order is received should note the order and enter it on the physician order sheet or electronic order format, if not written by the physician. If necessary, the order should be clarified before the physician leaves the nursing station, whenever possible. Review of the facility policy for Gradual Dose Reduction of Psychotropic Drugs, dated 2025, indicated [in part]: Policy:Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to be managed at a lower dose or to discontinue these drugs.Compliance Guidelines:3. The timeframes and duration of attempts to taper any medication shall depend on factors including the coexisting medication regimen, the underlying causes of symptoms, individual risk factors, and pharmacological characteristics of the medications.c. Opportunities during the care process to consider whether the medications should be continued, reduced, discontinued, or otherwise modified include:i. During the monthly medication regimen review by the pharmacist.ii. When the physician or prescribing practitioner evaluates the resident's progress.iii. During the quarterly MDS review by the interdisciplinary team.

Based on interview and record review the facility failed to implement a grievance policy that included the maintenance of documentation of all grievances for no less than 3 years from the issuance of the grievance decision.The facility failed to have documentation and evidence of grievances filed for the previous 3 years.This failure could place the residents at risk for a decreased quality of life and care within their living environment, and/or not having their needs met.The findings included: Record review of grievance files provided by AD revealed no grievance log tracking or copies of filed grievances prior to 11/19/2025. In a group interview on 02/11/2026 at 2:30pm with the Resident Council, stated since the new management company has taken over things seem to be getting better, especially the answering of call lights and that was a big issue before. In an interview on 02/12/2026 at 10:30am with the Regional Nurse Consultant (RNC), she stated she was unable to provide any documentation from dates prior to their takeover on 11/19/2025. She stated the previous management company took all records when they left. She stated she along with other employees have sent multiple emails to the prior company asking for them to return records and they have not received a response as of that day. She stated this act left them with no way to produce records the survey team had requested prior to that date. She said the expectation of the management company would be to maintain and provide all records requested to remain in compliance with federal and state laws. She stated a negative outcome could be a residents' feelings not heard or corrections made to things they would like done. During an interview on 02/13/2026 at 3:45pm, the corporate administrative staff did not have facility policies and procedures for maintaining facility records.

Based on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 13 of 104 days for months (July 2025, August 2025, September 2025 and partial October 2025) reviewed for RN coverage. The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 13 of 104 days in July, August, September and partial October 2025. This failure could place the residents at risk of not making decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff.Findings included: Record review on 10/14/25 at 1:30pm of timesheets for RN hours on weekends revealed the facility failed to provide 8 hours of RN coverage on weekends on:7/20/25, 7/26/25, 8/10/25, 8/16/25, 8/24/25, 9/6/25, 9/7/25, 9/20/25, 9/21/25, 9/28/25, 10/5/25, 10/11/25, and 10/12/25. In an interview on 10/15/25 at 12:00pm, the Administrator verbally confirmed the facility did not have 8 hours of RN coverage on these weekend days: 7/20/25, 7/26/25, 8/10/25, 8/16/25, 8/24/25, 9/6/25, 9/7/25, 9/20/25, 9/21/25, 9/28/25, 10/5/25, 10/11/25, and 10/12/25. In an interview on 10/14/2025 at 12:54 PM, the DON said her understanding of the facility policy was an RN was to be on staff 8 hours a day. She stated they tried their best to schedule RNs for the weekend, and they were not always successful. The DON continued to say it is always better to have them. DON stated that the possible negative outcomes for not having a RN on duty would be if a resident needed an assessment that only an RN could do. Record review of facility policy titled Staffing no date:1. A registered nurse (RN) must be onsite 8 consecutive hours a day, 7 days a week.

Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests in one of one kitchen observed for evidence of pests. The facility failed to ensure an effective pest control program was implemented to prevent the presence of a lizard in the kitchen. The facility's failure placed the residents at risk for foodborne illness and/or disease spread by pests.The findings included: During an observation on 10/10/25 at 3:45pm, a live lizard was observed running across a shelf above the dishwashing machine and 3 -compartment sink area. During an interview on 10/10/2025 at 3:48pm, the [NAME] stated she had seen lizards in the kitchen before. The [NAME] stated she had not seen any other pest like roaches or any other bug. During an interview on 10/10/2025 at 4:00pm, the Maintenance Director stated the facility did not have a pest control contract with pest control vendor. The Maintenance Director stated he had not seen any pest control company come to the facility in the four months he worked at facility. The Maintenance Director supplied a business card for a local pest control and stated he thought it was the pest control that facility used at one time. During an interview on 10/10/2025 at 4:40pm, the owner of the local pest control stated the last time they provided service was 02/02/2025. Services stopped due to failure to pay. Stated has no contact with facility. During an interview on 10/13/2025 at 9:07am, the DM stated she saw lizards in the kitchen but did not know where they come from. The DM stated she reported that pest was found in kitchen but could not recall who she reported to. During an interview on 10/15/25 at 12:10pm, the Administrator stated she knew the facility lost their pest control vendor due to failure to pay the bill. The Administrator stated she was not aware of any pest problems in dietary with lizards. Record review of the facility's policy, Insect and Rodent Control, dated 2012, reflected, The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department . 2. Facility will maintain appropriate screens, close fitting doors, proper sealed water/sewer pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents .

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 2 of 5 (Resident # 9 and Resident #5) reviewed for the physical environment. The facility failed to ensure Resident #9's window blind and chest of drawers were damaged and Resident #5's window blind was damaged. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment.Findings included: Observation on 10/13/2025 at 10:00am revealed Resident's room had broken window blind (blades that when shut omit light from entering the room). The bottom drawer of the chest of drawers was missing. During an interview on 10/10/2025 at 10:03am, Resident #9 stated the window blinds were damaged when she moved into the room, and it was annoying when the sun shines in the morning. Resident #9 said the chest of drawers was missing a drawer. Resident #9 stated that it made the room appear junky and unkept. Resident #9 stated that she had not complained about the broken window blind and chest of drawers. During an interview on 10/10/2025 at 10:07am, the RP for Resident #9 was visiting and stated the broken window blind and missing drawer for the chest of drawers were damaged and missing when Resident #9 was admitted . The RP stated she mentioned to staff about repairing the items but could not remember who or when but stated it has been a while. The RP stated she believed that as much money it would cost to stay at the facility the place would be more concerned about making the resident's home more presentable. Observation on 10/10/2025 at 3:15pm revealed Resident's s window blind had missing and broken blades. During an interview on 10/10/25 at 3:16pm, Resident #5 stated the room looked cheap and sunlight came in all the time. Resident #5 stated the window blind had been broken for a long time and did not recall telling facility staff about it. Resident #5 stated if they wanted the residents' rooms to look nice, they would have fixed the window blind, but they do not care. Resident #5 stated the broken window blind made him feel like he was living in a cheap motel, not home-like. At an interview on 10/15/25 at 12:07pm, the Administrator stated she did not know about the damaged blinds in Resident #5's and Resident #9's room. The administrator stated she would order replacement blinds today (10/15/25). The Administrator stated the Maintenance man would repair the chest of drawers for Resident #9. The Administrator stated her expectation was that the equipment and furnishing in resident's room be in good repair and failing to do so could diminish quality of life and well-being of residents. Record review of facility policy titled, Maintenance Service, no date:1. The Maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 (hot water heater for the laundry) of 1 reviewed for essential equipment. The facility failed to repair or replace the water heater that supplied hot water for laundry for 2 months. This failure could place residents at risk of diminishing quality of life and declining health.Findings included: Observation on 10/13/2025 at 9:00am revealed that the hot water heater in the laundry was not working. No hot water was running in washing machine, handwash sink and the hot water heater was cold to the touch. During an interview on 10/13/2025 at 9:05am, Laundry Staff stated the hot water was out for several months. Laundry stated that Maintenance man and Administrator knew and tried to repair but it did not work. Laundry using bleach for sanitizing while hot water was out. During an interview on 10/13/2025 at 9:55am, the Maintenance Director stated he had worked at the facility for four months. The Maintenance Director stated the hot water heater for laundry had been out as long as he worked at the facility. The Maintenance Director stated the ordered parts was the wrong part, and he was waiting for the right part to come in to repair the water heater.During an interview on 10/15/2025 at 12:10pm, the Administrator stated the hot water heater in laundry was out for a while but, could not recall how long. The Administrator made several attempts to repair it. The Maintenance Director ordered the right part, and the water heater should be repaired today (10/15/25).Record review of facility policy titled, Maintenance Service, no date:1. The Maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times.2. D). Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order.

Based on interview and record review, The facility must employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services, taking into consideration resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required at S483.70(e), in that: The facility failed to designate a qualified person to serve as the director of food service when there is no full-time dietitian. This failure could place residents at risk of not having their nutritional needs met and place them at risk for food born illnesses.Findings included: Record review undated of the DM's employee file revealed there was no documented evidence of a Dietary Manager Certificate found in the file. In an interview on 10/13/2025 at 9:00am, the DM stated she did not have her dietary manager certification. The DM stated she worked for the facility in dietary for 3 years and was named Dietary Manager in January 2025. The DM stated she is not certified and had not registered for any classes, stating she has no financial funds for school. In an interview on 10/14/2025 at 12:30pm, the facility's Dietitian stated she was contracted by the facility to visit quarterly, the last time at the facility was September. The Dietitian said the facility had stable residents and that it was not necessary to visit once per month. The Dietitian stated she was aware the facility did not have a certified DM and nine months ago gave the Administrator and DM the information to start on-line courses to obtain D certification. The dietitian did not know why the classes were not starting. In an interview on 10/15/2025 at 12:00 PM, the administrator stated she was aware the DM was not certified and had not applied for certification. She stated the failure could result in the residents not having their nutritional needs met and place them at risk for foodborne illness. Review of the Job description of the Dietary Manager, dated effective 11/2022, revealed in part: Job summary - Manage the operations of the dietary department to include staffing, food ordering and preparation, food delivery and cleaning, in accordance with facility policies, physician orders, care plans, and appropriate regulations.

Based on observation, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 (Resident #6) of 6 residents reviewed for resident call system, in that: The facility failed to provide a working communication system on 10/10/25 that was easily accessible and that would allow Resident #6 the ability to safely call staff for assistance.This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they need support for daily living.The findings included: Record review of Resident #6's face sheet, dated 10/13/25, revealed a [AGE] year-old-female admitted on [DATE], with the following diagnoses dementia (mental impairment), repeated falls, glaucoma right and left eyes (loss of vision due to optic damage), chronic obstruction pulmonary disease (lung damage limiting airflow). Record review of Resident #6's Quarterly MDS, dated [DATE], revealed the following:*Section C- Cognitive Patterns revealed Resident #6's BIMS score of 3 indicated severe cognitive impairment.*Section GG- Functional Abilities and Goals revealed Resident #6 was dependent on staff for all ADLs.*Section J Health Conditions revealed Resident #6 had a history of falls. Record review of Resident #6's Care Plan, dated 08/7/2025, revealed Resident #6 had a history of falls-8/12/24, 4/12/25, and an intervention was for the call light to be in reach. During an observation on 10/13/25 at 9:30 AM, Resident #6 was lying in her bed in her room, no call light access in room, call light on wall did not have any means to activate call system. During an interview on 10/13/25 at 9:31 am Resident #6 stated she did not have any way to use the call light if she needed help. Resident #6 stated if she needed help, she would have to yell for help. During an interview on 10/13/25 at 9:40 am, the Administrator did not know why Resident #6's room did not have a way to activate the call light but would be fixed immediately. The Administrator stated her expectation was that call lights should have been placed within reach of residents and in working order. The Administrator stated the effect on residents could have prevented them calling for assistance. The Administrator stated that everyone that worked in the room was responsible for ensuring the call light was in reach of residents and operational. The Administrator could not provide a reason for what led to the failure of the call light not being operational. Record review of facility policy titled, Call Lights: Accessibility and Timely Response, dated 01/01/2024, revealed, Staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed .Providing access to assistive devices . Installing longer cords or providing remote controlled overhead or task lighting so that they are easily accessible.

Based on observation, interview, and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 1 facility reviewed for administration. The facility failed to have sufficient resources to satisfy (pay) debts timely and when they were due. The facility had a past due balance of four months with the water vendor with a disconnection notice given with a date that had already passed (10/25/25); a past due balance with the electricity vendor for services provided; and a past due balance of two months with the gas vendor with a disconnection notice given with a date that had already passed (11/6/25). This failure could place residents at risk of not receiving essential care and services. Findings included: Record review of invoices provided by the Administrator on 11/09/25 indicated unpaid balances for the following:1. [Gas Vendor] - Invoice dated 10/27/25. Past due balance of $351.92 with total account balance due of $747.44 with a due date of 11/6/25 or services could be disconnected if not paid in full.2. [Water Vendor] - Invoice dated 10/27/25. Past due balance of $4,171.53. A total balance of $5,562.04 with a due date of 11/15/25.3. [Water Vendor] - Disconnect Notice for Non-Payment or Delinquent Accounts with an amount due of $4,171.53. Service will be disconnected if the past due amount is not paid before closing time on October 25, 2025.4. [Electricity Vendor] - Invoice dated 10/16/25. Past due balance of $21,036.65 with total balance due of $25,124.73 with a due date of 10/31/25. In an interview on 11/09/25 at 4:55 p.m., the ADM said that when the facility received a bill, it was forwarded to Accounts Payable and the CEO for payment in an email. She said she did not make payments for the facility and only passed the bills on when they come in. The ADM stated the CEO and Accounts payable met every Monday to decide which bills to pay but she did not attend or know the outcome. She said she was aware of a past due balance for the [Water Vendor], and a termination notice was sent to the facility for disconnection. She said she emailed the CEO and Accounts Payable when the vendor called again requesting payment on 10/22/25. The ADM stated she was aware of a past due balance for the [Gas Vendor] and the disconnect notice. She said she was aware of a past due balance for the [Electricity Vendor] but no disconnect notice yet. She said she last sent the water bill, gas bill, and the disconnection notices to Accounts Payable and CEO on 11/3/25. In an interview on 11/7/25 at 3:29 p.m., the employee for the [Water Vendor] stated the facility owed four months past due to a total of $5,562.04 from services provided due since August 2025. The employee stated the [Water Vendor] sent disconnect notices before this last 4-month timeframe and reported to the state previously to get paid. The last payment received was for July 2025. The employee stated the [Water Vendor]'s policy was to disconnect services within 30 days of non-payment but the only reason they did not was because they know it is not the residents of the facility's fault. The employee stated the [Water Vendor] might consider disconnecting service if this continued in the future. The employee stated the [Water Vendor] emailed and called and left multiple messages to the CEO and he never called back or paid. In an interview on 11/09/25 at 6:29 p.m., the CEO said he believed the bills were paid on November 3rd, 2025. He said bills were sent to a company that managed the accounts and sent out payment, but they needed to be instructed to send payment by him. The CEO stated the ADM told the CEO and Accounts Payable the bills needed to be paid and by when and he instructed them to pay. The CEO said he was unable to provide any receipts at this time due to accounts payable being closed. The CEO did not comment on how non-payment could affect the residents. In an interview on 11/10/25 at 10:26 a.m., the automated system of the [Gas Vendor] revealed payment for $747.44 was received on Tuesday November 4th, 2025. The current total due was $0. The next meter read date was Tuesday November 11th, 2025. No other information would be provided because this writer was not a named person on the account. In an interview on 11/10/25 at 10:31a.m., the automated system of the [Electric vendor] revealed they received payment of $21,036.65 on 11/10/25. No further information would be provided because this writer was not a named person on the account. In observations of the facility on 11/09/25 and 11/10/25 revealed the facility had water, electricity, and gas services. Record review of Administrative Management (Governing Board), undated, revealed, The governing board shall be responsible for the management and operation of the facility. 1. The facility's governing board is the supreme authority and has full legal authority and responsibility for the management and operation of our facility.3. The governing board is responsible for, but not limited to: a. Oversight of facility care and services in accordance with professional standards of practice and principles.g. Provision of a safe physical environment equipped and staffed to maintain the facility and services.

Based on record review, observation and interview, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 1 facility reviewed for Administration. The facility failed to have sufficient resources to satisfy (pay) debts timely and when they come due. The facility had a past due balance of 4 months with the water vendor with a disconnection notice given with a date that had already passed; and a past due balance of 3 months with the fire vendor for services provided in September 2024 and January 2024. The failure to have sufficient financial resources to pay debts timely had the potential to adversely affect the delivery of essential care and services. This failure could affect the 31 residents who utilized services provided and paid for by the facility. Findings included: Record review of invoices provided by the Administrator on 6/3/25 indicated unpaid balances for the following: 1. [Fire Vendor] - Invoice dated 1/31/25. Past due balance of $1000 was a due date of 2/28/25. 2. [Water Vendor] - Invoice dated 5/22/25. Past due balance of $6907.95. A total balance of $8298.46 with a due date of 6/15/23. 3. [Water Vendor] - Disconnect Notice for Non-Payment or Delinquent Accounts with an amount due of $6907.95. Service will be disconnected if the past due amount is not paid before closing time on May 25, 2025. In an interview on 6/3/25 at 11:46 am, the Administrator said when the facility receives a bill, it is forward to Accounts Payable for payment. She said she does not make payments for the facility and only passes the bills on when they come in. She said she was aware of a past due balance for the [Water Vendor] and a termination notice had been sent for disconnection. She was aware of 2 pervious charges by the [Fire Vendor] for a total of $1000. She said she last sent the water bill and the disconnection notice to Accounts Payable on 5/29/25. In an interview on 6/3/25 at 12:32 pm, the [NAME] Administrator for the [Fire and Water Vendor] stated the facility owes 2 past due fines for a total of $1000 from services provided on 9/17/24 and 1/6/25 when the fire department responded to false fire alarms. The [Fire Vendor] reviewed the facility's account yesterday and was considering having the facility's fire alarm disconnected and putting them on a fire watch for a past due balance. The [NAME] Administrator said the facility had a water bill that was 4 months past due for $6907.95. The [Water Vendor] issued a disconnect notice for 6/15/25 if the past due balance was not paid. The facility did not pay; however, water services will not be disconnected due to it being a nursing home. The [NAME] Administrator has emailed, sent certified letters, and talked to the CEO on the phone but it has done no good. In an interview on 6/3/25 at 2:22 pm, the COO stated the CEO was not available for interview. She said the process for bill payment was when the facility receives a bill, it is passed on to Accounts Payable which was an independent company. Every Monday, Accounts Payable and the CEO have a meeting and a decision was made on which bills to pay. She said she only has the ability to pay bills on an emergency basis. She said she just paid the 2 outstanding bills, today, for the [Fire Vendor] for $1000 and the past due balance for the [Water Vendor] for $6907.95. In an interview on 6/4/25 at 12:35 pm, the CEO said the 2 bills were paid and caught up yesterday, 6/3/25. He said bills are sent to an independent company for review and payment. The CEO said he did not remember there being past due balances for the [Water Vendor or Fire Vendor] or talking to anyone about them; he said the [Water Vendor] bill should not have gotten that far behind. He said he was going to find out where the breakdown occurred. In observations of the facility on 6/3/25 and 6/4/25 revealed the facility had water services. A facility policy was requested regarding vendor payment but not provided prior to exit on 06/04/2025.

Based on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for nursing services. The facility did not have RN coverage for 17 days on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. This failure could place the residents at risk of not receiving needed care and services. The findings were: Review of the facility RN timesheets revealed there were no RN hours for Saturdays on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the facility RN timesheets revealed there were no RN hours for Sundays on [DATE], [DATE], ,d+[DATE]/.24, [DATE], [DATE], [DATE], [DATE], and [DATE]. During interview with the DON on [DATE] at 2:26p.m, she said she had been employed in the facility since [DATE]. She stated to the best of her knowledge the facility doesn't have RN coverage especially on weekends. The DON explained the facility used to have a RN that came on weekend but not anymore. She stated she understood RN coverage as a person with broad responsibility that provides specialized nursing care that LVN cannot or not required or qualified to do. She came an example with a peripherally inserted central catheter (PICC line) which LVN are not qualified to do. The DON stated she was not aware of the specific days not covered in the facility. She explained the management was aware of the lack of RN coverage in the facility. This was because on one occasion, he asked if not having an RN coverage will affect her license as a RN/DON. She was assured by the management that her license will not be affected. The DON stated she is aware the facility does not have RN coverage in the required days including weekends. She indicated the facility has approved and placed an advertisement looking for weekend RN coverage and she will be interviewing candidates soon. In an interview with ADM on [DATE] at 2:49p.m, she is the Administrator and started working for the facility since [DATE]. The ADM explained the policy of the facility is to have RN coverage 8 hours a day, seven days a week. She knows there was some days the facility did not meet this requirement. She stated the purpose of RN coverage was to cover for any incident which the LVN cannot handle or not trained to provide service. The ADM noted the DON has covered some weekends. She said there was no negative effect because the facility has telehealth and can contact them if RN was needed. She stated the facility has not had incident requiring a RN on weekend recently. She monitors the RN coverage on her calendar in her office wall with names on who was covering on different days. She said she cannot force people to come in to work. The ADM explained the management has approved hire for a permanent RN coverage for the weekend. She noted the facility has placed recent advertising for RN coverage. Her expectation was to have RN coverage in the facility moving forward. During interview with MD D, on [DATE] at 11: 17a.m, he stated he was the medical director for the facility. He explained he was aware that the facility did not have RN coverage in some days especially on weekends. He stated the management was aware of the lack of RN coverage but decided to not have the coverage and bear the consequences. MD D stated he was not aware any significant incident where an RN coverage was needed. However, he was informed by his brother, a doctor with the facility that he came to pronounce a death on one of the weekends because RN was not available. Record review of the facility policy on staffing undated reflected the following: Policy Statement: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. oAt a minimum, the facility must maintain a ratio (for every 24-hour period) of one licensed nursing staff person for each 20 residents or a minimum of 4 licensed-care hours per resident day. A registered nurse (RN) must be onsite 8 consecutive hours a day, 7 days a week .

Based on observation, interview, and record review the facility failed to provide or obtain radiology and other diagnostic services to meet the needs of its residents for 1 of 7 residents (Resident #1) reviewed for resident care, in that: The facility failed to ensure Resident #1 was provided an x-ray as ordered by the physician. This failure could place residents at risk for a decline in health status. Findings included: Record review of Resident #1's Admission Record, dated 01/15/2025 revealed an [AGE] year-old male, with an admitted [DATE] with a principal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (gradual buildup of plaque in the walls of your arteries, limiting or blocking the flow of blood), dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and osteoarthritis (a condition that causes the breakdown of cartilage in the joints, leading to pain and stiffness). The resident was discharged from the facility on 12/24/2024. Record review of Resident's #1 nursing progress note, dated 12/12/2025 at 10:30 am, revealed the resident had a fall, complained of right shoulder and collarbone pain. The facility contacted the Physician, and he ordered an x-ray. The progress note stated, attempted several times to contact facility mobile x-ray company, unable to schedule at this time. There was no further documentation in the progress notes regarding acquiring an x-ray for the resident. Record review of Resident #1's Physician's Orders, dated 01/15/2025, revealed there was no order for an x-ray on 12/12/2024. In an interview on 1/15/2025 at 2:48 pm, the Physician said the facility notified him on 12/12/2024 that Resident #1 had fallen and he ordered an x-ray. The physician said he did not remember the facility calling him back and informing him that they were unable to reach the mobile x-ray. The physician said it was his expectation for the facility to contact him if they were not able to get an x-ray. In an interview on 1/15/2025 at 3:00 pm, the DON said she was aware the physician had ordered an x-ray and was not aware Resident #1 did not get an x-ray until the next morning. She said the nurse texted the Physician that she could not reach the mobile x-ray company, but never heard back from him. She said it was her expectation for the nurse to follow up with the physician and notify the DON when she did not hear back from him. The DON said the x-ray was never done and got missed. She said the nurse never passed it on in shift change or in morning report. Resident #1 did not receive an x-ray as ordered. She said Resident #1 was placed on neuro-checks at the time of the fall, he complained of right shoulder pain that night, but the next morning, he denied pain and was assessed with full range of motion. The DON said this failure had the potential of the resident not receiving appropriate care. In an interview on 1/25/2025 at 12:44 pm, Nurse A said the Resident #1 had a fall on 12/12/2024, she contacted the Physician, and he ordered a mobile x-ray. She attempted to call the mobile x-ray 6 times, but could never get through. She said she texted the doctor around 2:00 pm, but never heard back from him. She said she did not attempt to follow up with the doctor when he did not respond to her texts before she left her shift. She said she did not notify the DON or pass it on to the next shift she was not able to contact the mobile x-ray company. A facility policy was requested, but the provided undated policy titled Resident Rights, failed to address the incident.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, for 38 of 40 residents as evidence by : The facility failed to ensure: A. The low temperature dishwashing machine did not have a chemical sanitizer and the dietary staff failed to check the chlorine sanitizer content to ensure the dish washing machine was operating correctly to clean and sanitize the dishes consistently each meal; B. The 2 food carts were soiled with dust and food crumbs; C. Open food items were not placed in sealed containers and dated; D. The ice machine had mold at the top of the ice tray; E. The window seal including the window unit air conditioner was soiled with dust and food crumbs; F. The stove and oven were soiled with food and grease; G. The freezer in the storage room with soiled with dust and food crumbs; H. The floors in the storage room were soiled with dust, dirt, and food crumbs. The facility's failure could place residents receiving oral nutritional intake at risk for foodborne illness and a decline in health status. The findings included: On 11/19/24 at 8:45 AM, during the initial tour of kitchen, the container of chlorine chemical sanitizer to the low temperature dishwashing machine was empty, 2 food carts were soiled with dust and food crumbs, the ice machine had mold at the top of the ice storage area, in the freezer there was a box of biscuits opened to the air and was not sealed or dated, in the refrigerator there was a bag of shredded cheddar cheese open to the air and not sealed or dated, the window seal and the window air conditioner was covered with dust and food crumbs, the stove and oven were soiled with dried food and grease, the freezer in the dry foods storage room was soiled with dirt and food crumbs, and the floor in the dry foods storage room was soiled with dirt and food crumbs. In interviews on 11/19/24 at 8:50 am, Dietary [NAME] A said she did not know how to test the dish washing machine and did notn't know it was out of chemical sanitizer and had never been trained. Dietary [NAME] B said she didn't know how to test the dishwashing machine and didn't know it had been out of chemical sanitizer and had never been trained. Dietary [NAME] C said the chemical sanitizer had been out less than a week and said he reported it to the Maintenance Director. Dietary [NAME] C said he does not test the dish washing machine between meals but knew how to test it. Upon request, Dietary [NAME] C tested the machine and the chlorine registered at 0 ppm, In an interview on 11/19/24 at 9:30 am, the Administrator said the facility has not had a dietary manager since 10/01/24. She was not aware the chemical sanitizer was out. She said the company had not paid the vendor yet and was unable to order anymore chemicals until it was paid but had been paid today. She said the Maintenance Director had gone to a sister facility to pick up some chemical sanitizer. In an interview on 11/19/24 at 10:00 am, the Maintenance Director was in the kitchen working on attaching the chemical sanitizer to the dishwashing machine, he said that he notified corporate on 10/14/24 the facility was getting low on the chemical sanitizer. He said he was not for sure had long it was out, but it was not very long. In an observation and interview on 11/20/24 at 9:50 am, Dietary [NAME] C was asked to check the dish washing machine. It tested at 10 ppm (minimum was 50 ppm). The chemical sanitizer was attached to the dish washing machine. He said that it tested at 50 ppm yesterday when the Maintenance Director tested it after attaching the new chemical sanitizer. In an observation and interview on 11/20/24 at 11:59 am, the Maintenance Director tested the dish washing machine and it tested at 0 ppm, he said that it tested at 50 ppm yesterday after he attached the chemical sanitizer he got yesterday. He said the facility would switch to paper products until it was fixed and have the vendor come and service the machine. In an observation and interview on 11/21/24 at 2:41 pm, the vendor was in the facility working on the dish machine, they said that a squeeze tube had failed and was replaced. They said the dish machine was working correctly. In an interview on 11/21/24 at 2:55 pm, the Administrator said the facility was getting some new chemical sanitizer and would continue to use paper products until it comes in. She said there have been no reports of residents having symptoms of food born illnesses. She said there hads not been a Dietary Manager at the facility, officially since 10/01/24 as she had been out on FMLA prior to that date. She said Dietary [NAME] A is currently working on obtaining her certification to be a Dietary Manager. She said it was her expectation for the dish washing machine to be tested at every meal to ensure it was properly sanitizing the dishes. She said it was her expectation for the kitchen to be cleaned and all appliances clean and in good working order. She said theses failures had the potential for food born illnesses, poor food quality and unsanitary conditions. Record review of the facility policy Dishwashing Machine Use, not dated, revealed the following [in part]: Policy Statement: Food service staff required to operate the dishwashing machine will be trained on all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. Policy Interpretation and Implementation: 4. Dishwashing machine chemical sanitizer concentrations and contact times will be as follows: Chlorine, 50-100 ppm. 6. Corrective action will be taken immediately if sanitizer concentrations are too low. Record review of the facility policy Sanitization, not dated, revealed the following [in part]: Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation: 1. All kitchen, kitchen areas and dining areas shall be kept clean, free of litter and rubbish and protected from rodents, roaches, flies and other insects. 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use of proper cleaning. 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. 8. Dishwashing machines must be operated using the following specifications: Low-Temperature Dishwasher (Chemical Sanitization) b. Final rinse with 50 parts per million (ppm) hypochlorite (chlorine) for at least 10 seconds. 12. Ice machines and ice storage containers with be drained, cleaned and sanitized per manufacturer's instructions and facility policy. 17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Record review of the Food and Drug Administration Food Code, dated 2017, specified [in part]: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on interviews and record reviews, the facility failed to provide the services of an RN for 8 consecutive hours 7 days a week for 22 days out of 79 days and employ a full time DON for 19 of 79 days reviewed for RN coverage from September 2024 to November 2024. The facility failed: - to have an RN for 8 consecutive hours 7 days a week for 22 days from September 1, 2024, through November 18, 2024. - to employ a full time DON for 19 of 79 days from September 1, 2024, through November 18, 2024. This failure placed the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. Findings included: Review of daily staffing data revealed the facility did not provide the services of an RN on the following dates: September 1, 2024, September 2, 2024, September 3, 2024, September 4, 2024, September 5, 2024, September 14, 2024, October 6, 2024, October 27, 2024, November 1, 2024, November 4, 2024, November 5, 2024, November 6, 2024, November 7, 2024, November 8, 2024, November 11, 2024, November 12, 2024, November 13, 2024, November 14, 2024, November 15, 2024, November 16, 2024, November 17, 2024, November 18, 2024. Review of daily staffing data revealed the facility did not employ a full time DON on the following dates: September 1, 2024, September 2, 2024, September 3, 2024, September 4, 2024, September 5, 2024, November 1, 2024, November 4, 2024, November 5, 2024, November 6, 2024, November 7, 2024, November 8, 2024, November 11, 2024, November 12, 2024, November 13, 2024, November 14, 2024, November 15, 2024, November 16, 2024, November 17, 2024, November 18, 2024. During an interview on 11/19/24 at 8:35 AM, the CNO stated the facility currently did not have a DON. She stated a DON had been hired, the facility was waiting for her to work out her notice at her former job. The CNO stated the facility currently did not have consistent weekend RN coverage. During an interview on 11/21/24 at 8:31 AM, the Administrator stated staff was notified when an RN will not be in building via group text. The Administrator denied experiencing an issue of a resident needing the services of an RN and not receiving those services. She explained the facility subscribed to a telehealth service and had 24-hour access to a corporate RN. The Administrator stated in an emergency, residents were transferred to the hospital or the physicians, who live close by, had no problem coming to the facility when needed. The Administrator stated she did not feel no RN in the building had a negative effect on residents due to access to the corporate RN and other resources available. She stated her expectations were for the new DON to start next week as scheduled. The Administrator stated she had plans to be more diligent on getting weekend RN coverage and increase the PRN RN pool. She explained the facility recruits via online advertising and word of mouth. During a group interview on 11/21/24 at 10:17 AM, LVN D and MA E stated they felt the residents were not affected if an RN was not in the building. LVN A stated when a resident needs service only an RN can perform, one of the weekend RNs would come in or the resident would be transferred to the hospital. LVN D stated staff was not notified when an RN would not be in the building but had got used to it. During an interview on 11/21/24 at 12:38 PM, the CNO stated the issue with RN coverage was on Monday thru Friday the facility did not have a full time DON. The facility was in the process of transitioning from one DON to another. She stated it was difficult to find staff in a rural area. The CNO stated a DON had been hired and was scheduled to start working the following Monday, but the weekends seemed to be an issue. She stated she had reached out to some of the PRN RN's and begged them to accept the DON position, but they had other jobs and did not want to commit to full time employment with the facility. The CNO explained the nursing staff were aware when an RN would not be in the building because the schedule would indicate when an RN was not available to be in the building. The CNO stated If a resident required the skill level of an RN and one was not in the building, the resident would be transferred to the local emergency department. The CNO stated the facility received assistance in recruiting staff from the bank that owns the building. She explained the bank paid for advertising on a major online recruitment site. Review of the facility policy, titled Staffing, undated, revealed Policy Interpretation and Implementation 1. Licensed nurses and certified nurse assistants are available 24 hours a day to provide direct resident care services. At a minimum, the facility must maintain a ratio (for every 24-hour period) of one licensed nursing staff person for each 20 residents or a minimum of .4 licensed-care hours per resident day. A registered nurse (RN) must be onsite 8 consecutive hours a day, 7 days a week.

Based on interview and record review the facility failed to refer 1 of 3 residents (Resident #13), for PASRR screening and evaluation, with a newly evident mental disorder or a related condition for a level II PASRR review, in that: Resident #13 was not referred to the state-designated authority for a PASRR re-evaluation upon evidence of new diagnoses of major depressive disorder, dated 09/01/2023 and evidence of potential indicator of psychosis on MDS significant change dated 05/01/2024. This failure placed residents at risk of not receiving adequate services or care related to mental illnesses. Findings included: Record review of Resident #13's face sheet, dated 05/23/2023, revealed a [AGE] year-old female, who was admitted into the facility on [DATE] with a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (confusion without behaviors), repeated falls, muscle weakness, unsteadiness on feet and lack of coordination. Record review of Resident #13's diagnosis report revealed she was diagnosed with major depressive disorder on 09/01/2023 and anxiety disorder effective 11/21/2024. Record review of Resident #13's PASRR level 1 screening, dated 05/23/2023, revealed the resident was coded for not having a diagnosis of mental illness. Record review of Resident #13''s MDS, dated [DATE] revealed the residents Brief Interview for Mental Status (BIMS) was coded as a 0, resident is rarely/never understood; Behaviors - Potential indicators of psychosis including hallucinations and delusions worsening since last MDS assessment. Record review of Resident #13's physician's orders, dated 11/21/2024, revealed the following: 1. Referral to senior psych care psychiatry to evaluate and treat starting 09/01/2023. 2. Monitor for signs of depression, suicidal ideation and insomnia. 09/01/2023 3. Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every morning and at bedtime for Agitation/Aggression, order date 09/18/2024 4. Depakote Oral Tablet Delayed Release 500 MG (Divalproex Sodium) Give 1 tablet by mouth three times a day related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY (F03.90), order date 10/16/2024 5. trazodone HCl Oral Tablet 50 MG (Trazodone HCl) Give 25 mg by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE (F33.1) give 1/2 a 50mg tab to = 25mg. GDR attempt order date 12/17/2023 Review of Resident #13's Care Plan revised on 11/11/2024 reflected the following: Focus: Resident is on an antidepressant medication r/t Depression and insomnia. Date Initiated: 09/01/2023. Goal: Resident #13 will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Date Initiated: 09/01/2023. In an interview on 11/21/2024 on 11:51 a.m., MDS coordinator stated, The resident has a diagnosis of major depressive disorder. I will review the chart for a 1012 form (form used to determine whether the individual has a primary dementia diagnosis or if the individual has a mental illness diagnosis) and get back with you. In an interview on 11/21/2024 on 12:26 p.m., MDS coordinator stated she was responsible for PASRR's, I looked in Resident #13's chart and could not find a 1012 form. There are some diagnoses in the chart that would warrant a 1012 form. She also stated A negative result in not having a current 1012 form is that the resident has not received PASRR services and may not be receiving psych services if needed . Review of the facilities policy and procedures titled PASRR Clinical Policy, not dated, reflected the following [in part]: Purpose: The PASRR level 1 (PL1) Screening Form is designed to identify persons who are suspected of having Mental Illness (MI), Intellectual Disability (ID) of a Developmental Disability (DD) also referred to as Related Conditions. The PASRR Evaluation (PE) is designed to confirm the suspicion of MI, ID or DD/RC and ensure the individual is placed in the most integrated residential setting receiving the specialized services needed to improve and maintain the individual's level of functioning. Section C; PASRR Screen (Screener) INTENT: This section to be completed for resident's suspected of having Mental Illness. Identify diagnoses: Review the medical record, if available, for diagnoses. Medical record sources can include but are not limited to verbal interview with the resident, or LAR, observation, progress notes, Annual Physical Exam, the most recent History and Physical, hospital discharge summaries or diagnosis list.

Based on observations, interviews, and record reviews the facility failed to assess the resident for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation or physician's orders for 1 (Resident #1) of 12 residents reviewed for bed rails in that: The facility failed to assess Resident #1 for entrapment from bed rails or contact Resident #1's representative to obtain informed consent, assess risk for entrapment or physician's orders. Resident #1 lodged (entrapped) his left arm on 12/28/22 into the 1/2 sized bed rail, causing him to sustain bruising to his chest, and psychosocial harm. An IJ (Immediate Jeopardy) was identified on (05/19/2023). The IJ template was provided to the facility on [DATE] at 5:10 PM. While the IJ was lowered on 05/20/2023 at 6:30 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy because the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could affect residents by putting them at an increased and unnecessary risk of harm, entrapment, and/or fatal injury. Findings included: Record review of Resident #1's undated Face Sheet on 05/18/2023 revealed he was a [AGE] year-old-male admitted to the facility on [DATE] and had the following diagnoses: difficulty walking, acute kidney disease failure, chronic obstructive pulmonary disease, and malignant neoplasm (malignant tumor, of the large intestine, which may affect the colon or rectum. The colon (also called the large intestine) is broken up into a few different anatomic segments and attached to your small intestine) of the colon. Review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1's BIMS (brief interview for mental status) was blank and unrated. It also indicated Resident #1 required extensive assistance with most ADLs and total assistance with transfers. Resident #1 required extensive assistance with 2 or more people for bed mobility and transfers. The MDS section that addressed the use of bed rails (Section P) was left blank and indicated the bed rails were not in use. Review of Resident #1's Care Plan revealed the following: Focus: Resident #1's initial care plan dated 09/23/2022 revealed Resident #1 was at risk for falls related to weakness and debility. Goal: Restraints used to prevent falls will be minimized/eliminated by target date 9/21/2022 Interventions: Anticipate and meet the resident's needs Be sure resident's call light is in reach. The resident requires prompt response to all requests. Focus: The resident uses side rails for repositioning Goal: The resident will remain free of complications related to side rails. Intervention: Discuss with the residents/family the risk and benefits when using side rails should be applied. Record review of Resident #1's initial assessment dated [DATE] or any other assessment until 05/18/2023 revealed there were no consents, no risk assessment or physician's orders for bed side rails. Record review of facility provided list revealed 12 residents who had bed rails none included consents, risk assessment or physician orders. Observation on 05/18/23 at 11:30 a.m. of each resident's bed revealed bed side rails were in place attached to the beds. Interview with the DON on 5/19/23 at 11:10 AM revealed if the facility had the physician's orders, consent, and risk assessments, they would be in the clinical record. She specified this was the responsibility of the DON Record review of the facility's self-report investigation dated 05/18/23 revealed the following: Resident #1 was noted to be against the left side rail with his lower body off the bed on 12/28/2022. No injury was noted. A small indention on his chest was indicated. No adverse reaction was noted. Actions and notifications reflected the resident was assessed for injury. The physician and family were notified. The family was educated prior to incident and post incident of side rail safety. Review of a 43 minute and 41-second-long video dated 12/28/22 beginning at time stamp 5:36 revealed: The door to Resident #1's room could not be view if his door was open or closed. -1-3 minutes - Resident #1 was lying on his back in bed, with half side rails up on each side of the bed. Resident #1 was holding the left side rail with his left hand. There was a trapeze bar hooked up to the bar above the bed, out of reach. Resident #1 was appeared restless and was fidgeting and adjusting the covers. He turned himself from his back to his left side, called out for help, then rolled back to his back - 4:00 - Video Timeline beginning: Resident #1 was rattling/shaking the side rail while yelling help - 4:47- Resident #1 turned onto his left side, moved his right leg across his body and off the bed. Resident #1's lower right side of his body rolled toward the left side off the bed onto knees. His upper left side of his body from the waist up remained between the side rail and mattress, with his right arm holding the top of the side rail. - 5:01- Resident #1 raised his head and looked around. His left arm was between the side rail and mattress. He attempted to push himself up with his leg and right arm. - 5:30 - 7:00- Resident #1 yelled, Help six times and rested his head on the mattress. His left arm remained between the mattress and the side rail. Resident #1 yelled, I can't., Help. an additional four times. Resident #1 yelled, Help; laying on the floor. twice. - 7:40- Resident #1 was getting lower in the side rail and his [NAME] was below the top of the side rail. Resident #1 used his right arm to try to raise himself up; his left arm remained between the side rail and mattress. - 7:53- Resident #1 yelled, Come help please, please come help. four times. - 9:00- Resident #1 pulled his pillow from the head of his bed and rested his head on it, yelling, Help - 12:41- Resident 31 yelled, Help, I'm in distress, and was making grunting noises, and said, Please come see. - 13:09 - Resident #1 said, I'm hurtin' bad; was grunting, and said, Please come see .my back's killing me .I can't move .Ohhh .Come on. - 14:01-15:30- Resident #1 continued to yell Help, and mad grunting noises. - 16:00-19:00- Resident #1 yelled, Ya gotta come .help .oh the pain .help me Resident #1 was lower to the ground, with the side rail pressing against his chest, his left arm remained between the side rail and mattress, and the top of the side rail was up to his [NAME]. - 20:54- Resident #1 yelled repeatedly, Help me I'm gonna die here. - 21:28-The top of the rail was at Resident #1's ear level. Resident #1 yelled, Help me I'm gonna die., while using his right hand to pull the side rail away from his neck. - 28:00- Resident #1 yelled, Ah, ah .ah repeatedly and pulling the side rail away from his neck while grunting and groaning. - 34:30- Resident #1 said, Help I'm gonna die here, please help. - 38:41- Staff could be heard saying, We are right here .oh god go get the nurse Record review of the incident report revealed LVN A documented on 12/28/2022 the following: Skilled Nurse was called to Resident #1 room and noted both legs out of the bed and on the floor mat. Upper body in bed with right side of chest pressed against the bed rail (left side of bed), resident states I rolled out of bed. Immediate Action Taken: Assessment done range of motion performed resident helped off of the floor PCP, Administrator, DON, Hospice Nurse, and POA notified. Type of Injury: Location-chest (no measurements of wound/bruise) Predisposed situation factor: Bedside rail up. During an interview on 05/18/2023 at 12:30 PM LVN A said she was there (started dayshift on 12/28/22) when Resident #1 was found caught between the bed rail and the mattress. LVN A said Resident #1 was trapped, and she heard him crying out for help. She said he had a large (unmeasured an opinion of the size) indention in his chest and he was complaining of pain. In regard to the incident report LVN A said initially there was not a bruise but an intention to his chest a little later. LVN A said she lifted his arm out from between the mattress and the railing and Resident #1 said it was painful. LVN A said the railings were up on both sides of the bed. LVN A said she went out into the hall and got CNA B to help, and they both lifted him up onto the bed. LVN A said the incident was communicated to the DON and she was told to call the physician after her assessment. LVN A said that all the beds in the facility have always had bed rails, all different types and sizes, but she said Resident #1 always went around the rails and scooted himself off the bed onto the floor mat, and that she never saw him grab on to the bed rails for assistance, she said she never mentioned this event (scooting himself off the bed) to anyone. LVN A said that she understood there was a probability for entrapment and injury with the use of any size bed rail, and there was the need for a consent due to the risks, and that an order had to be given by a doctor before the bedrails were applied to any resident's bed. Attempts to interview the PCP on 05/18/2023 at 1:00 PM and 05/19/2023 at 8:30 AM were unsuccessful due to no one answering the telephone and not returning calls after leaving a message. During an Interview with CNA B on 05/18/2023 at 3:15 PM revealed she did not remember the incident it was long time (December 2022) and does not remember what happened. She said she was at the facility when the incident happened but does not remember what happened. CNA B was asked what she would do if a resident was trapped in a bed rail and she said she would call out for help from her partner and never leave the room and get the nurse or someone. During a subsequent interview with CNA B on 05/18/2023 at 4:30 PM revealed on 12/28/22 she heard Resident #1 was yelling out and went to Resident #1's room and found him on the floor and holding the bed rail. She said she stayed with him and yelled for LVN A to help her get Resident #1 off the floor. LVN A arrived and helped CNA B get Resident #1 off the bed rail. She said he was holding the bed rail. During an interview with LVN C on 05/18/2023 at 4:45 PM revealed she was working on 12/28/2023 and unable to recall the incident. She said she was working that shift, but LVN A started the shift and was notified that Resident #1 was on the floor. She said she just heard that Resident #1 was caught in the bed rail. She said she did not know if Resident #1 had a physician's orders or if he had a bed rail assessment. During an observation on 05/18/2023 at 11:45 AM revealed a bed rail similar to Resident #1's bed had large bolts holding the rails in place, this potentially could have been pressing against Resident #1's chest. During an interview on 05/19/2023 at 10:45 AM with the DON and Administrator revealed the video shown of Resident #1 being caught in the bed rail, the DON said it should not have taken staff 45 (actually 31 minutes per video) to assist the resident who (DON and Administer said it looked like he was holding the rail and not caught in the bed rail just holding it). The Administrator said he was holding the rail and did not think it needed to be reported to the state. On 05/19/2023 at 5:10 PM an Immediate Jeopardy was identified, and the Administrator was informed. The IJ Template was provided at this time. During an interview with DON on 05/20/2023 at 11:00 AM the DON said she was unable to locate documentation for physician's orders, a bed rail assessment, consent to use the bed rails, or alternatives to use of the bed rails. Physician orders, bed rail assessment, consents and alternatives for bed rails was created and signed by the family and representatives as part of the Plan of Removal was provided at this time. (05/20/2023 at 11:00 AM) During an interview and observation on 05/20/23 from 4:00 PM until 5:00 PM) revealed the Certified Occupation Therapist assessed 12 residents on 05/20/2023 beginning at 4:00 PM using bed rails and assessed each resident for bed rail use. One resident's bed rail was discontinued and recommendation for overhead bed trapeze be included. During an interview on 05/20/23 at 11:00 AM the Maintenance Director said Resident #1's bed was supplied by the hospice service and his bed rails were already placed on the bed. He said he was unaware of any alerts or recalls by the manufacturer regarding bed rails. Review of the website: https://www.fda.gov/media/88765/download on 05/24/2023 at 4:00 PM revealed the recommendations for bed rail assessment. Resident Assessment After a facility has attempted alternatives to bed rails and determined that these alternatives do not meet the resident's needs, the facility must assess the resident for the risks of entrapment and possible benefits of bed rails. In determining whether to use bed rails to meet the needs of a resident, the following components of the resident assessment should be considered including, but not limited to: o medical diagnosis, conditions, symptoms, and/or behavioral symptoms. o Size and weight o Sleep habits o Medication(s) o Acute medical or surgical interventions o Underlying medical conditions o Existence of delirium o Ability to toilet self safely o Cognition o Communication o Mobility (in and out of bed) o Risk of falling. The following Plan of Removal was accepted on 5/20/23 at 11:45 AM. The Plan or Removal reflected the following: 1. Resident #1 was assisted by staff back to bed on 12/28/2022.Resident #1 was assessed by the licensed nurse on 12/28/22with a small red indention noted to his upper middle chest, no other [NAME] or injuries noted. Resident #1 was discharged from the facility on 2/26/23. 2. Residents have been reassessed/re-evaluated for use of bed rails to meet resident needs by the DON and designee on 5/19/2023. Those residents that require bed rails as an enabler have received verbal orders from the Medical Director on 5/19/2023. Residents/Responsible Party have been notified of the use of bed rails as an enabler for consent by the DON or designee on 5/19/2023. The DON or designee will review care plans for residents with side rails on or before 5/20/2023 to ensure care plans reflect current interventions and needs related to side rail use. The Maintenance or designee removed bed rails on 05/20/2023 from residents' beds that do not require bed rails as an enabler device and verified by surveyor. Therapy will screen residents for bed rail use on or before 5/20/2023 on the recommendation of the Certified Occupation Therapy Assistant on 05/20/23 on 4:30 PM two bed rails were removed and/or modified and verified by surveyor. 3. Education provided to licensed staff by the Administrator and designee on 5/18/2023 - 5/19/2023 regarding the requirement of providing alternatives to bed rails, and assessments for risk of entrapment. Education provided to staff by the Administrator and designee on 5/19/2023 regarding observations of residents' safety and timely assistance of residents, including resident calling out for assistance. Beginning on 5/20/2023 staff will be educated prior to the beginning of their next shift by the Administrator, DON, or designee regarding the 7 zones of bed entrapment, residents' physical conditions that increase risk of entrapment and the requirement of obtaining consents prior to implementing side rails. Staff will complete a posttest to confirm staffs understanding of education provided and verified by the surveyor. 4. The Director of Nursing or designee (DON was not available for interview but the Administrator) said audits will be will complete audits weekly for 4 weeks, then monthly for 2 months to ensure residents continue to be assessed for entrapment risk, alternatives continue to be provided for enable devices and consents continue to be obtained prior to implementing side rails. The Administrator or designee will complete audits weekly for 4 weeks and monthly for 2 months to ensure staff continue to be educated regarding bed entrapment and factors that increase risk for entrapment prior to providing resident care Findings of these audits will be presented at QAPI Committee meeting monthly for 3 months for review and recommendations as needed. The Director of Nursing is responsible for monitoring and follow-up as needed. The Assistant Director of Nursing and MDS nurse will be responsible for monitoring in the absence of the Director of Nursing. Date of compliance: 05/20//2023 The surveyor verified the implementation of the Plan of Removal as follows. During interviews with 14 (5 LVNs, 6 CNA, 2 maintenance personnel and 1 housekeeper) staff members revealed they were in-serviced on 05/20/23 from 12:00 PM until 4:30 PM and revealed the following: received a pre and posttest on the use of bed rails; they explained the test had questions on the size and type of bedrails, the need for a physician's order, and that a resident had to be assessed for the use of bedrails before the rails could be adjusted to the bed. The staff said there were serious risks for the resident when their bed had side rails and gave examples of choking hazard, and their limbs getting caught up in the rails and causing injuries. Observations on 5/20/23 from 4:00 PM until 5:00 PM revealed 12 resident beds with side rails were assessed by the Certified Occupation Therapy Assistant, 2 were removed. Reviews of the remaining residents with bed rails revealed they had physician's orders, care plans, assessments, and consents for the side rails. Review of the facility's policy titled, Clinical Program Manual Side Rails dated 04/2013, revealed the following: The use of side rails by a patient resident may be a restraint and ordinary depending on functional status and whether or not the side rails restricts freedom of movement. Prior to implementation side rails utilizes is evaluated by the interdisciplinary team to determine the reason for side rails and any alternative device that may be used to achieve the same goal Procedure: .2. Complete the side rail screen 3. Review the information with the interdisciplinary team, include not limited to reason for side rail consideration, ability to move self in bed with a or without a device, ability to transfer or without a device, ability to constantly request for assistance preventing falls and/or entrapment. Review alternatives to side rails but that will meet the identified needs alternatives may include but are not limited to trapeze concave mattress grab bars placing the bed lower to the floor and surrounding the bed with a soft mat bed alarms restorative nursing care to enhance ability to safely safety stand walk or improve bed mobility physical therapy occupational therapy to increase strength and mobility schedule toileting programs increasing visual and our verbal reminders to use call lights for a resident patient able to comprehend the information overview obtain A physician order to for side rails use if identified as a restraint order to include but not limited to reason for use type length of time to be used planned for side rails reduction and or elimination review the risk and benefits of side rails use with the resident patient or family legal representatives complete and provide a copy of the restraint information and consent review the risk and benefits of side rail use with the resident patient and or family legal representative document the plan for site rail reduction on the care plan or if side rails is determined to be a restraint communicate to staff that plan for side rails use and reduction educate staff on side rail use and reduction strategies as needed observe residents patients for the following risk factors of side rails use risk factor may include but not limited to protecting skin over areas of pressure decrease nutrition hydration intake increase difficulty behaviors increase withdrawal symptoms of depression incontinence increase fall risk document ongoing observation and the progress notes documentation to include but not limited to type of side rails length of time used frequency side rails are down resident patient participation and activities and interaction with others residents. On 5/20/23 at 6:30 pm the IJ was lowered The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure the acquiring and administering of all drugs and biologicals to meet the needs of 1 of 6 residents (Resident #9) whose records were reviewed for medication orders. The facility failed to ensure Resident #9 [MEDICATION(S)] ointment 0.3% ([MEDICATION(S)]) for [CONDITION(S)] was available for administration as ordered by the physician. This failure placed the resident at risk for eye discomfort and delayed healing and resolution of an eye infection. The findings include: Review of Resident #9's Admission Record/Face Sheet, printed 8/24/22, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a primary diagnosis of heart failure. Additional diagnoses included: [CONDITION(S)] infarction; pneumonia; major depressive disorder, recurrent, severe with psychotic symptoms; chronic pain syndrome; chronic obstructive pulmonary disease; hypertensive heart disease with heart failure; other idiopathic scoliosis, thoracolumbar region; unspecified dementia with behavioral disturbance; nicotine dependence; essential (primary) hypertension; and unspecified convulsions. Review of the Physician Visit Communication Record and Progress Note, dated 8/16/22, revealed documentation the facility notified Resident #9's physician's office regarding redness and [CONDITION(S)] of the left eye. The provider's response from the nurse practitioner documented a diagnosis of [CONDITION(S)] and an order for [MEDICATION(S)] every 12 hours for 7 days, with a strip applied to the lower lid. Review of Resident #9's current Physician Orders revealed an order for [MEDICATION(S)] 0.3% ([MEDICATION(S)]), instill 1 strip in left eye two times a day for [CONDITION(S)] for 7 days, dated 8/16/2022. Review of Resident #9's electronic medication administration records, dated 8/01/22-8/31/22, revealed the following: - [MEDICATION(S)] HCL Solution 0.5%, instill 2 drops in left eye three times a day for eye infection until 08/15/22; order date 8/08/2022. The nurses documented the eye drops were instilled three times daily at 8 AM, 12 PM, and 8 PM 8/09/22-8/15/22. There was no documented evidence on the medication administration record that the [MEDICATION(S)] eye drops were instilled after 8/15/22. - [MEDICATION(S)] 0.3% ([MEDICATION(S)]), instill 1 strip in left eye two times a day for [CONDITION(S)] for 7 days; order dated 8/16/2022. The nurses documented the eye ointment initial dose at 8 PM on 8/16/22, instillation two times daily at 8 AM and 8 PM on 8/17/22 - 8/22/22, and the final dose instillation dose at 8 AM on 8/23/22. During an observation and interview on 8/22/22 at 12:36 PM, Resident #9 was sitting on the side of her bed; the room light was off. The resident's left eye was red, including the upper and lower lids. Resident #9 stated she had an infection in her eye, and she went to the doctor. She stated the nurse put eye drops in her eye. She stated her left eye hurt and light hurt her eye, so she kept the overbed light off. In an interview on 8/22/22 at 12:38 PM, LPN G charge nurse stated Resident #9 did not receive eye ointment; she received eye drops. The LPN stated the eye ointment was not available and was not applied to the resident's left eye. In an interview on 8/23/22 at 10:24 AM, Resident #9 stated she had received eye drops in her left eye She stated the eye ointment was not available and she had not received it. She stated the doctor was supposed to come today. During an interview and record review on 8/24/22 at 2:22 PM, the ADON stated the charge nurses entered physician orders into the residents' electronic medication administration records. Review of Resident #9's medication orders with the ADON revealed the order for [MEDICATION(S)] eye ointment was no longer on the resident's current orders. The ADON stated it was probably discontinued yesterday. She stated the resident received the [MEDICATION(S)] eye drops. The ADON stated she would look for a policy and procedure for physician's orders. Review of the facility's policy and procedure for Ordering and Receiving Non-controlled Medications, dated as revised August 2020, revealed the following [in part]: Policy Medications and related products are received from the pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. Procedures Ordering Medications from the Pharmacy 1. Medications orders are written on a physician order form, telephone order sheet, or reorder form provided by the pharmacy, written in the chart by the physician, or entered into the facility's EHR system and transmitted to the pharmacy

Based on observation, interview, and record review, the facility failed to ensure freedom from a significant medication error for 1 of 6 residents (Resident #9) whose records were reviewed for medication orders. The facility failed to ensure Resident #9's [MEDICATION(S)] ointment 0.3% ([MEDICATION(S)]) for [CONDITION(S)] was administered as ordered by the physician. This failure placed the resident at risk for eye discomfort and delayed healing and resolution of an eye infection. The findings include: Review of Resident #9's Admission Record/Face Sheet, printed 8/24/22, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician Visit Communication Record and Progress Note, dated 8/16/22, revealed documentation the facility notified Resident #9's physician's office regarding redness and [CONDITION(S)] of the left eye. The provider's response from the nurse practitioner documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's electronic medication administration records, dated 8/01/22-8/31/22, revealed the following: - [MEDICATION(S)] HCL Solution 0.5%, instill 2 drops in left eye three times a day for eye infection until 08/15/22; order date 8/08/2022. The nurses documented the eye drops were instilled three times daily at 8 AM, 12 PM, and 8 PM 8/09/22-8/15/22. There was no documented evidence on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . - [MEDICATION(S)] 0.3% ([MEDICATION(S)]), instill 1 strip in left eye two times a day for [CONDITION(S)] for 7 days; order dated 8/16/2022. The nurses documented the eye ointment initial dose at 8 PM on 8/16/22, instillation two times daily at 8 AM and 8 PM on 8/17/22 - 8/22/22, and the final dose instillation dose at 8 AM on 8/23/22. During an observation and interview on 8/22/22 at 12:36 PM, Resident #9 was sitting on the side of her bed; the room light was off. The resident's left eye was red, including the upper and lower lids. Resident #9 stated she had an infection in her eye, and she went to the doctor. She stated the nurse put eye drops in her eye. She stated her left eye hurt and light hurt her eye, so she kept the overbed light off. In an interview on 8/22/22 at 12:38 PM, LPN G charge nurse stated Resident #9 did not receive eye ointment; she received eye drops. The LPN stated the eye ointment was not available and was not applied to the resident's left eye. In an interview on 8/23/22 at 10:24 AM, Resident #9 stated she had received eye drops in her left eye She stated the eye ointment was not available and she had not received it. She stated the doctor was supposed to come today. During an interview and record review on 8/24/22 at 2:22 PM, the ADON stated the charge nurses entered physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's medication orders with the ADON revealed the order for [MEDICATION(S)] eye ointment was no longer on the resident's current orders. The ADON stated it was probably discontinued yesterday. She stated the resident received the [MEDICATION(S)] eye drops. The ADON stated she would look for a policy and procedure for physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility's policy and procedure for Ordering and Receiving Non-controlled Medications, dated as revised August 2020, revealed the following [in part]: Policy Medications and related products are received from the pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. Procedures Ordering Medications from the Pharmacy 1. Medications orders are written on a physician order [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review, the facility failed to ensure 1 of 5 residents (residents # 1) reviewed for accidents received adequate supervision and assistance devices to prevent accidents. The facility did not provide the hoyer lift to transfer Resident # 1 in accordance with the plan of care. Resident #1 was transferred by 2 CNA's without the Hoyer lift, and had to be assisted to the floor when resident # 1's legs buckled underneath her; resulting in a fracture to the lower femur. This failure could place 5 residents who required the Hoyer lift for transfers at risk for injury. The findings included: Record review of the face sheet dated 10/20/17 documented resident # 1 was a [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the care plan dated 9/11/17 documented resident # 1 was to use the Hoyer lift for transfers as needed. Record review of the quarterly MDS dated [DATE] documented resident # 1 had a BIM's score of 13 (interviewable) and required extensive assistance of 2 or more persons for transfers. The MDS documented resident # 1 had not walked. Record review of the facility investigation dated 10/16/2017 documented a statement provided by RN B who wrote at around 9:15 PM staff took resident #1 to the room to put resident in bed. The staff could not get the lift arms down far enough to hook into the lift pad as it had slipped up resident #1's back. Resident # 1 told them she could stand and pivot with help. The gait belt would not fit around resident #1, when resident #1 stood her knees buckled and resident #1 went to the floor, the staff had a hold of the resident at the time. RN B wrote resident #1 was lying in the floor, crying out saying 'my knee'. RN B wrote she assessed resident #1, then they got the lift slaying under her and lifted resident #1 to the bed. The EMS system was then called, also resident # 1's daughter and she was sent to the hospital. Continued review of the investigation documented a statement from CNA C documenting she and CNA D went to put resident #12 bed the lift pad was not under resident #1 enough to lift her so they tried to use the gait belt but that did not work so they got the resident under her arms to stand her. Resident #1 said she could pivot herself but her legs buckled under her. A statement dated 10/17/17 and provided by CNA D documented she was putting resident #12 bed with CNA C, the Hoyer lift seat had moved upward on resident #1's back and they were unable to get it back in position. The statement read they then attempted to put the gate belt around resident #1 but it was too small and resident #1 told them she could stand and pivot; as resident #1 stood her legs buckled in and they eased resident #1 to the floor and called the charge nurse. The investgation documented CNA C and D were suspended and then retrained about safe transfers. The training was then provided to all staff. Interview on 10/31/17 at 11:40 AM LVN A said resident #1 could not be transferred with the Hoyer lift now because the fractured leg had to be supported at all times and resident #1 was on bed rest with the exception of doctor's visits at this time. Observation and interview on 10/31/2017 at 11:40 AM resident # 1 was transferred from the Geri chair to the bed with the use of 5 staff and a lift sheet, after returning from the orthopedic doctor's visit for a follow up on her fracture and the removal of the sutures from her leg. Resident # 1 said the facility staff always use the Hoyer lift to get her in and out of her bed and chair. Resident #1 said she had not walked in over 2 years and she did not understand why they had asked her to stand up. Resident # 1 said they came in that night, about 9:00 PM to put her to bed; they said the lift pad was too high and the 2 CNA's ask her to stand. Resident # 1 said she told them she could not walk. Resident # 1 said the staff attempted to use a gait belt but it was too small so they lifted her under her arms, her legs buckled and the staff assisted her to the floor. Resident #1 said she heard the leg pop, her legs were under her, the staff got the nurse right then, they got her into bed, with the lift and called the ambulance. Record review of the admission nurses notes dated 9/4/17 documented resident #1 arrived to the facility in a private vehicle. Resident # 1 was assisted from the car by 3 staff members and the grandson. Resident # 1 was unable to bear weight on bilateral lower extremities (both legs) and had pain in them. Record review of the nurses notes dated 10/16/2017 at 9:09 PM documented resident # 1 was being assisted to bed, the Hoyer lift pad was up too high, resident said she could stand and pivot, 2 staff assisted resident # 1,. her knees buckled and staff lowered resident # 1 tro the floor. EMS was called to transfer resident # 1 to the local emergency room and the daughter was notified. At 10:47 PM the notes documented the emergency room nurse called stating resident # 1 had a spiralfracture of the left Femur and was being admited until they decided what to do. In a telephone interview on 10/31/17 at 3:10 PM resident #1's daughter said resident #1 was recommended to have a knee replacement a year and a half ago, it was never done. Resident #1 had not walked in over a year and a half. Resident 1's daughter said resident #1 had attempted therapy in a previous facility, with use of a sling and walker but was unsuccessful. Resident # 1's daughter said she was not told about a problem with the lift pad at the time of the incident. Telephone messages were left for both CNA C and D,on 10/31/2017 at 1:20 PM, return calls were not received. The DON stated would try to contact them also. In an interview on 10/31/2017 at 3 PM CMA E said she had not seen resident #1 ever stand and pivot, resident #1 always used the lift. In an interview on 10/31/17 at 3:42 PM LVN F said resident #1 was not able to stand and always used the lift for transfers In an interview on 10/31/17 at 3:07 PM CNA G said resident #1 was non-weight bearing from the time of admission and resident #1 said she was non-weight bearing when asked about it, and the left was to be used for transferring resident # 1. In an interview on 10/31/17 at 3:08 PM CNA H said resident #1 always said she could not feel her legs and used the Hoyer lift. Record review of the facility policy for Safe Lifting and Movement of Residents, revised October 2009, documented resident would be assessed by the nursing staff in conjunction with the rehabilitation staff for their needs of transfer assistance, these needs would be documented in the care plan. The manual lifting of residents shall be eliminated when feasible. The policy documented mechanical lists shall be used for heavy lifting and moving of residents when necessary and enough slings (pads) and various sizes will be available at all times. The DON provided a list of residents who used the mechanical lift on 10/31/2017, the list identified 5 residents.