Every finding on record at Norridge Gardens

Based on observations, interviews, and record reviews, the facility failed to follow its Record of Food Temperature policy by serving hot foods at temperatures below the required minimum of 135 F. This applies to all 206 residents consuming food from the dietary services.The findings include:R1 is a [AGE] year-old female admitted on [DATE] with moderate impaired cognition as per the Minimum Data Set (MDS) dated [DATE].On 8/11/26 at 9:20 AM, R1 was observed on her bed and stated that food is cold, and every day it's the same thing.R3 is a [AGE] year-old male admitted on [DATE] with cognition intact as per the MDS dated [DATE].On 8/12/26 at 9:35 AM, R3 was observed on his bed with a clean gown, and R3 stated, I don't want to say anything about food. It could be better. They are serving cold food always.On 8/11/25 at 12:35 PM, as per the surveyor's request during kitchen tray line service, a test tray was loaded onto the tray cart bound for the last unit at the end of the Kitchen tray line service.On 8/11/26 at 12:50 PM, V4 (Dietary manager) checked the food temperature (temp) on the test tray: 132F with soft mechanical soft meat, 129F with mashed potatoes, 117F with regular meat, and 129F with potatoes.On 8/11/26 at 12:55 PM, V4 stated, The serving temp should be a minimum of 135F for hot foods. We had a good temp when we served from the kitchen. We should use an insulated cart to transport food from the kitchen to the various units to prevent temperature loss. The tray is sitting there in the units, waiting for staff to pass it out. If we could pass it without delay, that would also help us to serve food with a minimum serving temp of 135F.A review of the facility Record of Food Temperature policy dated 10/1/25 document:Hot foods will be held at 135 degrees Fahrenheit or greater.No food will be served that does not meet the food code standard temperature.On 8/12/26 at 10:40 AM, V2, Assistant Administrator stated that 206 residents are consuming food from the facility's dietary service.

Based on observation, interview, and record review, the facility failed to follow their Service Policy by failing to utilize a serving utensil for distributing food. The facility also failed to follow the Sanitizer Manufacturers instruction by failing to submerge items in sanitizing solution for one minute and failed to follow their Labeling and Dating Foods Policy by failing to label food items. These failures have the potential to affect all 201 residents with an oral diet residing in the facility.Findings include:On 1/27/26 at 8:04 AM, V11 (Dietary Aide) was working on the breakfast tray line in the kitchen. V11 was observed wearing gloves and handling multiple ladles, plates, warming covers, and touching multiple surfaces. V11 used her gloved hands to grab and plate toast on resident tray without using utensils. On 1/28/2026 at 8:30 AM V11 (Dietary Aide) said utensils are used to prevent cross contamination of food. V11 said labels are used to identify when food is no longer good to be used.On 01/28/2026 at 8:35 AM, V12 (Cook) said utensils are used to prevent cross contamination and prevent touching food when touching other surfaces. V12 said labels are used to determine how long food is good for and when to throw food out. V12 said the person who last used the food item is responsible for making sure the item is labeled correctly. On 01/28/2026 at 8:13 AM, V10 (Dietary Manager) said kitchen staff should be using utensils for grabbing food to minimize cross contamination.The facility's Service Policy dated 4/21 documents: Dishes and utensils are handled in a way which does not contaminate the surface the food it touches.On 1/28/26, during the preparation of the special diet lunch food, V13 (Assistant Cook) and V14 (Assistant Cook) used the 3-compartment sink to sanitize the blender, blender cover, and metal pans by dunking in the sanitizing compartment for 1 second and letting items air dry.On 01/29/2026 at 8:26 AM V13 (Assistant Cook) said items should be soaked in the sanitizer for 1 minute. V13 said soaking items in sanitizer for 1 minute to kill bacteria and disinfect. V13 said he is not aware of the sanitizing machine is not working because he uses the 3-compartment sink. On 01/29/2026 at 9:024 AM V14 (Assistant Cook) said items are to be submerged in the sanitizing compartment for 1 minute. V14 said submerging items for 1-minute kills all the bacteria. V14 said she received 3-compartment sink in-service yesterday by V10 (Dietary Manager).On 01/29/2026 at 9:08 AM V10 (Dietary Manager) said sanitizing items is intended to kill germs. V10 said items are submerged in sanitizer for no less than 1 minute according to the manufacturer's instructions.Manufacturer's Instructions documents: Directions for Use: To sanitize hard, non-porous food contact surfaces, pre-flush or pre-scrape gross food particles. Dilute this product at 0.75 to 2-ounces per 4 gallons of water. Apply as directed on product label. Surfaces must remain wet for at least 1 minute. Allow surfaces to drain or air-dry.On 1/27/26 at 9:05 AM, surveyor and V12 (Cook) reviewed the walk-in refrigerator and observed an undated pan of cucumbers and undated pan of sweet potatoes.On 1/27/26 at 9:06 AM V12 (Cook) said food should be labeled to let the staff know how long the food is good for and when it should be discarded. V12 said all staff are responsible for ensuring food items are labeled. On 01/28/2026 at 8:13 AM V10 (Dietary Manager) said all containers must be labeled with open date and used by date. The cooks and dietary aide (whoever is handling the food products) to ensure that the items are labeled. V10 said the label lets the person know if the food product is still good. Labeling and dating Foods Policy dated 2017 documents: Policy: To decrease the risk of food borne illness and to provide highest quality, foods is labeled with the date received, the date opened and the date by which the item should be discarded.

Based on observation, interview, and record review the facility failed to ensure the (high temperature) sanitizing machine was properly sanitizing kitchen items by failing to achieve desired washing (160 degrees) and rinsing temperatures (180 degrees.) This failure has the potential to affect all 201 residents with oral diets. Findings include:On 01/28/2026 at 9:17 AM, surveyor observed V15 (Dietary Aide) using the sanitizing machine. Dietary aide said the sanitizing machine should reach tempertaures of 160 degrees during the wash phase and 180 degrees during the rinse phase. V15 ran the machine for a total of 3 times, and the test strip did not register appropriate temperatures for proper sanitization. Surveyor observed the Wash and Rinse Temperature Gauges and the Wash Gauge did not achieve temperature of 160 degrees and the Rinse Gauge did not achieve 180 degrees. On 01/28/2026 at 9:20 AM, V10 (Dietary Manager) said he is aware of the sanitizing machine not reaching the desired temperatures. V10 said this has been ongoing for a week and a half to 2 weeks. V10 said the part has been ordered and the facility is using a chemical agent to aid in sanitizing in the sanitizing machine. V10 said he is unable to test the sanitizing agent with strips.01/29/2026 9:24 AM, V1 (Administrator) said he has been at facility for 2 weeks and returned from vacation today. V10 said since the facility is using chemical sanitizer, the facility should be testing the effectiveness of the chemical sanitizer. V1 said he will follow up with the ordered part and contact the 3rd party repair company.Surveyor requested to review order receipts for repair however, none were provided.

Based on interview, and record review, the facility failed to assess, develop and implement a care plan, and provide ongoing activity programs based on resident's assessment and preferences for four of four residents (R155, R187, R228, R229) reviewed for activities in a sample of 36.Findings include:During record review, no activity assessments or activity care plans noted on R155's, R187's, R228's and R229's electronic health records.On 1/28/2026 at 2:21 PM, V2 (Assistant Administrator) stated the last Activity Director that was recently hired the end of November 2025 resigned the first week of January 2026. V2 stated that the activities assessments and baseline care plan for activities department are completed by either her or the social services department since they do not have Activities Director currently. At 2:50PM, V2 stated that there are no activities assessments and care plan completed for R155, R187, R228 and R229.The Facilities Assessment Annual Update: August 2025 documents: The purpose of this assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations including nights weekends and emergencies. (Facility) has used this assessment to make decisions about direct care staff needs as well as their capabilities to provide services to the residents in the facility. This is a competency-based approach that focuses on ensuring that each resident is provided with care that allows the resident to maintain or attain their highest practical practicable physical mental and psychosocial well-being. The assessment compliance reads (the facility) will review and update this assessment whenever there is or the facility plans for any change that would require a substantial modification to any part of this assessment. The facility assessment states activities assesses each resident for likes and dislikes and includes this information in their plan of care period activities are focused on identifying individualized preferences and ensuring the resident has access and materials to pursue their passions.Reviewed the Activities Policy documents: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities-based on their assessments, care plan and preference. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities refer to any endeavor, other than routine activities of daily living (ADLs,) in which a resident participates that is intended to enhance her/his sense of well-being and to promote or enhance physical, cognitive, and emotional health. These include, but are not limited to, activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence.Activity Policy Procedure: #1. Residents' interest and needs will be assessed on a routine basis period the assessment shall include but is not limited to: A. RAI Process: MDS/CAA/Care Plan B. Activity assessment to include the resident's interest, preferences, and needed adaptations. C. Social History. D. Discharge Information when applicable. #6. Residents are encouraged, but not mandated, to participate in scheduled activities.

Based on observation, interview, and record review, the facility failed to implement low air loss mattresses appropriately by failing to set the low air loss mattresses according to the residents weights. The facility also failed to ensure no additional layers of incontinence supplies and/or linen were in between the resident and the low air loss mattress. These failures affects four of five residents (R1, R59, R165, R187) reviewed for pressure ulcers in a sample of 36. Findings include:1. R1's Order Summary Report dated 01/28/2026 indicated R1 was admitted on [DATE] with diagnoses including other cervical disc regeneration, subsequent encounter for displaced intertrochanteric fracture of left femur, generalized muscle weakness, abnormal posture and rhabdomyolysis. R1's weight documentation indicated R1's most recent weight is 115.9 lbs. R1's Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 11/21/2025 indicated R1 has a total score of 11 indicating R1 is high risk to develop pressure ulcer. R1's Wound Nurse Practitioner note dated 01/22/2026 indicates R1 has stage 4 pressure injury on sacrum, stage 4 pressure injury on right hip and unstageable pressure injury to right heel. On 01/27/2026 at 8:16AM during unit rounds, R1 was lying on low air loss mattress with the setting indicator light past 200 lbs (pounds) with flat sheet, disposable pad and disposable diaper in between the R1 and the low air loss mattress. On 01/27/2026 at 10:02AM during record review with V5 (Wound Care Nurse), V5 reviewed R1's weight in R1's electronic health record and was noted at 118.4 lbs. During unit rounds with V5, R1 was again lying on low air loss mattress with the setting indicator light past 200 lbs with flat sheet, disposable pad and disposable diaper in between the R1 and the low air loss mattress. On 01/27/2026 at 10:02AM during interview with V5, V5 stated that R1's low air loss mattress should be set according to R1's weight. On 01/28/2026 at 9:15AM during interview with V28 (Wound Care Nurse), V28 stated that there should only be one flat sheet and either a disposable pad or disposable brief in between the resident and the mattress. 2. Review of R59's Order Summary dated 01/28/2026 indicated R59 was admitted in the facility on 07/25/2025 with diagnoses of not limited to type 2 diabetes mellitus and severe protein-calorie malnutrition. R59's Skin Risk Scale for Predicting Pressure Ulcer Risk Evaluation dated 12/11/2025 indicated R59 has a total score of 14 indicating R1 is moderate risk to develop pressure ulcer. Review of R59's weight indicated R59's most recent weight is 112.2 lbs. On 01/27/2026 at 8:53AM R59 was lying on low air loss mattress with the setting at 240 lbs with flat sheet, disposable pad and disposable brief in between the R59 and the low air loss mattress. On 01/27/2026 at 10:05AM V5 (Wound Care Nurse), reviewed R59's weight in R59's electronic health record and was noted at 112.2 lbs. During unit rounds with V5, R59 was again lying on low air loss mattress with the setting at 240 lbs with flat sheet, disposable pad and disposable diaper in between the R59 and the low air loss mattress. On 01/27/2026 at 10:05AM, V5 stated that R59's low air loss mattress should be set according to R59's weight. On 01/28/2026 at 9:15AM V28 (Wound Care Nurse), stated there should only be one flat sheet and either a disposable pad or disposable brief in between the resident and the mattress. 3. R165's Order Summary dated 01/28/2026 indicated R165 was admitted in the facility on 12/15/2023 with diagnoses of not limited to functional quadriplegia, tracheostomy status, and type 2 diabetes mellitus. R165's weight indicated R165's most recent weight is 135 lbs. R165's Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 01/26/2026 indicated R165 has a total score of 11 indicating R165 is high risk to develop pressure ulcer. On 01/27/2026 at 9:26AM, R165 was lying on low air loss mattress with the setting at 330 lbs with flat sheet, disposable pad and disposable diaper in between the R165 and the low air loss mattress. On 01/27/2026 at 10:08AM during record review with V5 (Wound Care Nurse), V5 reviewed R165's weight in R165's electronic health record and was noted at 134.5 lbs. During unit rounds with V5, R165 was again lying on low air loss mattress with the setting at 330 lbs with flat sheet, disposable pad and disposable diaper in between the R165 and the low air loss mattress. On 01/27/2026 at 10:08AM during interview with V5, V5 stated that R165's low air loss mattress should be set according to R165's weight. On 01/28/2026 at 9:15AM during interview with V28 (Wound Care Nurse), V28 stated that there should only be one flat sheet and either a disposable pad or disposable brief in between the resident and the mattress. 4. R187's Order Summary dated 01/28/2026 indicated R187 was admitted in the facility on 01/07/2026 with diagnoses of not limited to cerebral infarction and chronic kidney disease. R187's Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 01/07/2026 indicated R187 has a total score of 11 indicating R187 is high risk to develop pressure ulcer. R187's weight indicated R187's most recent weight is 127 lbs. On 01/27/2026 at 8:05AM R187 was lying on low air loss mattress with the setting at 300 lbs with flat sheet, two disposable pad and disposable diaper in between the R187 and the low air loss mattress. On 01/27/2026 at 9:55AM during record review with V5 (Wound Care Nurse), V5 reviewed R187's weight in R187's electronic health record and was noted at 127 lbs. During unit rounds with V5, R187 was again lying on low air loss mattress with the setting at 300 lbs with flat sheet, two disposable pad and disposable diaper in between the R187 and the low air loss mattress. On 01/27/2026 at 9:55AM during interview with V5, V5 stated that R187's low air loss mattress should be set according to R187's weight. On 01/28/2026 at 9:15AM during interview with V28 (Wound Care Nurse), V28 stated that there should only be one flat sheet and either a disposable pad or disposable brief in between the resident and the mattress.

Based on observation, interview, and record review, the facility failed to follow its policies and procedures for handling controlled substances by failing to ensure the nurses completed a narcotic count to reconcile controlled substances at the end/change of each shift. This failure had the potential to affect 42 residents receiving controlled medications in 4 areas of the facility.On 1/27/2026 at 7:11 AM, on the 4th floor (4 West), the medication cart was inspected with night shift nurse V17 (Licensed Practical Nurse/LPN). During the inspection, it was observed that V17 had signed the Controlled Substances Check Form (dated 1/27/2026, 7-3 AM shift, outgoing OFF column) without conducting a narcotic count with the incoming morning shift nurse. The incoming morning shift nurse, V18 (LPN), stated that he had not yet reviewed the Controlled Substances Check Form nor completed a narcotic count with V17. V18 further stated, I am still doing my rounds and haven't checked the narcotics yet.On 1/27/2026 at 7:20 AM, on the 3rd floor (3 East), the Controlled Substances Check Form was reviewed with night shift nurse V19 (Registered Nurse/RN). Review of the Controlled Substances Check Form dated 01/26/2026 showed missing outgoing (OFF) and incoming (ON) shift signatures for the 7-3, 3-11, and 11-7 shifts. Nurse V19 reviewed the form and confirmed that all shifts on 1/26/2026 were missing the required nurses' signatures.On 1/27/2026 at 7:38 AM, on the 3rd floor (3 West), the medication cart was inspected with the incoming morning shift nurse, V20 (RN). Review of the Controlled Substances Check Form with V20 showed that the outgoing night shift nurse, V21 (LPN), had signed the 7-3 shift box dated 1/27/2026 without completing a narcotic count with V20. V21 stated, I should sign after I count with V20. V20 stated, We sign after we have counted and checked with the outgoing nurse. I am not sure why V21 signed it ahead; V21 should not have signed it yet.On 1/27/2026 at 8:18 AM on the 2nd floor (2 East), the morning shift nurse, V22 (RN) was observed passing morning medications. The Controlled Substances Check Form was inspected with V22. V22 stated that the night shift nurse, V23 (RN) left for the day. Upon inspecting the form, it showed that V22 did not sign the Controlled Substances Check Form for his shift which was 7-3. The form was only reflecting V23's signature. V22 acknowledged that he should sign the form after completing a narcotic count with the outgoing night shift nurse. On 1/29/2026 at 8:47 AM, V25 (Assistant Director of Nursing/ADON) was interviewed regarding the facility's process for handling and reconciling controlled substances. V25 stated that at the end of each shift, the outgoing nurse is required to conduct a narcotic count with the incoming nurse. V25 explained that the outgoing nurse reviews the controlled substance binder while the incoming nurse reviews the bingo cards to verify the quantity of controlled medications. The outgoing nurse states the pill count, and the incoming nurse verifies the count against the bingo card. If no discrepancies are identified, both nurses are required to sign the Controlled Substances Check Form at the same time. V25 stated, It must be done at the end of every shift during endorsement.When V25 was informed that there were nurses who signed the Controlled Substances Check Form without completing a narcotic count, V25 stated, They were not supposed to. Both nurses should sign at the same time after accounting for all controlled medications. Even in an emergency, it is required. It cannot be left blank or signed ahead. V25 further stated that controlled substances are narcotics and are very important medications, adding, Misuse might happen; they should be double locked, with proper accounting and receipt of the controlled drugs.On 01/29/2026 at 12:48 PM, V24 (RN) stated that she has worked at the facility for approximately 20 years. V24 stated that she conducted a narcotic count with the outgoing night shift nurse on the morning of 1/29/2026 between approximately 7:00 AM and 7:22 AM. V24 stated that she signed the Controlled Substances Check Form after completing the count with the night shift nurse. V24 stated, When I count, the outgoing nurse looks at the book and the incoming nurse checks the bingo cards. We do that to make sure the controlled medications are properly accounted for, with no missing medications, no excess, and no missing pills in the bingo cards. I never start my shift or receive endorsement without counting because they are controlled. If the medications are not accounted for, it should be reported to the supervisor and investigated. V24 further stated that this process is outlined in the facility's policies and procedures.The facilities Policy on Handling Controlled Substances (dated 10/1/2025) states: Controlled substances will be handled in a safe and controlled manner in accordance with the regulations. According to the facilities Procedure in Handling Controlled Substances:#12 : Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.

Based on observation, interview, and record review, the facility failed to ensure that urinary drainage bags are covered to maintain resident's dignity for one of three residents (R155) reviewed for dignity in a sample of 36. Findings include:On 01/27/2026 at 9:08AM R155 was lying on the bed. R155's urinary drainage bag was not covered and was visible from the hallway. On 01/27/2026 at 9:48AM during unit rounds with V4 (Infection Preventionist), R155's urinary drainage bag was again uncovered and visible from the hallway. On 01/27/2026 at 9:48AM V4 stated that R155's urinary drainage bags should be covered to maintain R155's dignity. Review of R155's Order Summary Report dated 01/30/2026 indicated R155 was admitted on [DATE] with diagnoses of neuromuscular dysfunction of bladder and multiple sclerosis. Review of facility's policy entitled Resident Rights, Privacy and Dignity dated 10/01/25 indicated the following:Policy Statement: Employees shall treat all residents with kindness, respect, and dignity, and uphold the residents' rights.Policy interpretation and Implementation:15 The facility should refrain from practices demeaning to residents, such as leaving urinary catheter bags uncovered, refusing to comply with a resident's request for bathroom assistance during mealtimes, and restricting residents from use of common areas open to the general public, such as lobbies and restrooms, unless they are on a transmission-based isolation precautions or restricted according to their care planned needs.

Based on observation, interview, and record review, the facility failed to ensure that physician orders are obtained prior to respiratory therapy administration. The facility also failed to ensure respiratory equipment is cleaned and maintained for two of two residents (R113, R229) reviewed for respiratory services in a sample of 36. Findings include:1. R113's Order Summary Report dated 01/28/2026 indicated R113 was admitted in the facility on 11/21/2025 with diagnoses of not limited to Obstructive Sleep Apnea and morbid obesity. R113's Provider Progress Notes dated 11/26/2025 indicated reason for visit was initial visit, Assessment/Plan includes Obstructive Sleep Apnea CPM (continue present management) with CPAP at night. On 01/27/2025 at 8:26AM R113's Continuous Positive Airway Pressure (CPAP) mask was hanging at R113's bedside armchair attached to the CPAP machine. R113's mask had marks of evaporated water, and a brown substance on the creases of the mask. R113 stated that R113 brought the CPAP machine from home, and R113 used to clean it at home every other day but since R113 does not have anything to clean it with, R113 was not able to. R113 stated that the last time R113 cleaned it was before R113 came to the facility in November. R113 stated that no one in the facility offered to clean the machine. R113 stated that R113 is the one putting the mask on herself, so R113 puts it on sporadically because when R113 gets to bed, R113 wanted to take a few minutes to rest and relax before putting on the mask, but R113 passes out during the process, so R113 won't be able to put it on until later in the night. On 01/27/2026 at 9:43AM during unit rounds with V4 (Infection Preventionist), R113's CPAP mask was still hanging at R113's bedside armchair attached to the CPAP machine. R113's mask had marks of evaporated water, and brown substances on the creases of the mask. On 01/27/2026 at 9:43AM V4 stated that the nurse who assists or monitors R113 should make sure to clean the CPAP mask after use and keep it in a secured bag. At 11:30AM, V4 stated that R113 had no physician order for CPAP use, so they had asked the physician to evaluate R113 for need for CPAP use. Review of facility's policy entitled Noninvasive Ventilation dated 10/01/2025 indicated the following: Policy: It is the policy of this facility to provide noninvasive ventilation as per the physician's orders and current standards of practice. Definitions: b. CPAP, Or continuous positive airway pressure, is a respiratory therapy intervention used to provide a patent airway during periods of sleep apnea. It uses air pressure generated by a machine, delivered through a tube into a mask that fits over the nose or mouth. Procedure: 2. The facility will obtain an order for the use of a CPAP, BiPAP, AVAPS, or Trilogy device and settings from the practitioner. 3. A personal CPAP/BiPAP/AVAPS/Trilogy device may/may not be brought into the facility for the resident's use. If brought in, the nurse/respiratory therapist will verify the settings on the machine prior to use. 2. R229 admitted to the facility on [DATE] with medical diagnoses including, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction, type 2 diabetes mellitus, unspecified dementia, myoclonus, acute on chronic diastolic congestive heart failure, unspecified asthma, unspecified atrial fibrillation. On 1/28/2026 at 11:51AM, R229 was lying in bed with the head of the bed elevating wearing a nasal oxygen tubing. V31 (R229s family member) sitting in the room next to R229s bed. V30 (Licensed Practical Nurse/LPN) confirmed R229 was receiving 2 Liters of oxygen via nasal cannula. R229's nasal canula tubing was not labeled with a date the tubing had been opened/began being used. V30 stated all oxygen tubing's should be labeled with a date. R229's medical health record does not have a physician's order for 2 Liters via nasal cannula. R229s Oxygen summary documents R229 has been receiving Oxygen via nasal cannula since the date of admission 1/21/2026 to 1/29/2026. R229 does not have a care plan for oxygen therapy. On 1/29/2026 at 12:23PM V3 (Director of Nursing/DON) stated it is expected for staff to label the oxygen tubing's and residents should have a physician's order to receive oxygen. The facility's Oxygen Administration Policy, provided by V3, documents: Oxygen is administered to residents who need it and as prescribed. #1 Oxygen is administered under orders of a physician except in the case of an emergency. In such a case, oxygen is administered, and orders for oxygen are obtained as soon as practical when that situation is under control. #4 The residents care plan shall identify the interventions for oxygen therapy, based upon the resident's assessments and orders, such as, but not limited to A. the type of oxygen delivery system, B. when to administer such as continuous or intermittent and or when to discontinue, E. monitoring for complications associated with the use of oxygen. #5E, if applicable change nebulizer tubing and delivery devices weekly and as needed if they become soiled or contaminated.

Based on interview and record review, the facility failed to provide an ongoing restorative nursing program per therapy recommendation to ensure current level of range of motion and joint mobility is maintained for one of three residents (R1) reviewed for range of motion in a sample of 36. Findings include:On 01/28/2026 during record review, R1's electronic health record did not indicate any restorative nursing program on point-of-care tasks and restorative nursing care plan. R1's electronic health record did not indicate any duration and frequency of any restorative nursing program. At 1:15PM, restorative nursing program recommendation from skilled therapy requested, and received 01/29/2026 at 10:10AM. On 01/29/2026 at 10:14AM during record review with V29 (Restorative Nurse), R1 was discharged from skilled therapy on 12/12/2025 with recommended restorative nursing programs including of AROM (active range of motion) of both upper and lower extremities on all available range or planes, gentle stretch to right knee towards extension, and bed mobility at total assist with goal for restorative nursing program to prevent further loss of ROM, skin integrity and joint mobility, which was signed by the physical therapist, occupational therapist and V29. During this review with V29, R1's point-of-care tasks included restorative for active/passive ROM and restorative bed mobility program with revision date of 01/28/2026, and with documented 15 minutes implementation of the programs within the past 14 days. During this review with V29, R1's restorative care plan for AROM/PROM and bed mobility were created on 01/28/2026. On 01/29/2026 at 10:14AM during interview with V29, V29 stated that when a resident gets discharged from skilled therapy, she assesses the resident to make sure that the recommendation of the therapists for restorative nursing program is still applicable to the resident. V29 stated that she assessed R1 when R1 got discharged from skilled therapy but was unable to provide documentation. V29 stated that the point-of-care tasks for restorative for active/passive ROM and restorative bed mobility program were put in R1's electronic health record on 01/28/2026 but was unable to explain how the 15 minutes implementation of the programs were documented. V29 stated that R1's restorative care plan for AROM/PROM and bed mobility were created on 01/28/2026. During review of R1's progress notes from 12/28/2025 to 01/29/2026 with V29, no restorative assessment or documentation of any restorative nursing program, duration and frequency were indicated. V29 also reviewed with surveyor R1's physician orders but no order for restorative nursing program was ordered. On 01/29/2026 at 10:50AM, V29 presented a restorative program note dated 01/29/2026 indicated In reality and actuality, (R1) has been in AROMs and bed mobility since 12/12/25. It has actually provided by the restorative team to the (R1) and It was more of a paper compliance update but otherwise it has been provided to the (R1). V29 unable to provide documentation of given restorative nursing programs prior to 01/28/2026. On 01/29/2026 at 12:00PM during interview and record review with V29 and V3 (Director of Nursing), R1's point-of-care tasks included restorative for active/passive ROM and restorative bed mobility program with revision date of 01/28/2026, and with documented 15 minutes implementation of the programs within the past 14 days. During this review with V29 and V3, R1's restorative care plan for AROM/PROM and bed mobility were created on 01/28/2026. V3 asked V29 for any other possible place the restorative aides might have documented the implementation of the restorative nursing programs, and V29 stated that the point-of-care tasks is the only place to document it. Review of R1's Order Summary Report dated 01/28/2026 indicated R1 was admitted on [DATE] with diagnoses of not limited to other cervical disc regeneration, subsequent encounter for displaced intertrochanteric fracture of left femur, generalized muscle weakness, abnormal posture and rhabdomyolysis. Review of facility's policy entitled Restorative Nursing Programs dated 10/01/2025 indicated the following:Policy: Restorative nursing programs is to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level.Definition: Restorative nursing program refers to the interventions that promote the resident's ability to adjust to live independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning.Procedure:6. Residents may receive restorative nursing services upon admission when not a candidate for specialized rehabilitation services, when restorative needs arise during the course of a longer-term stay, in conjunction with specialized rehabilitations therapy, or upon discharge from therapy.9. A resident's restorative nursing plan will include but not limited to:a. Problem, need, or strength that the restorative tasks are to addressb. The type of activities to be performedc. Frequency of activitiesd. Duration of activitiese. Measurable goal and target date10. The discharging therapist, restorative nurse, or designated nurse will communicate to the appropriate restorative or nursing staff the provisions of the resident's restorative nursing plan, providing any necessary training to carry out the plan.11. The nursing staff, restorative aides, or designee will implement the plan for a designated length of time, performing the activities, and documenting the record of the resident12. The restorative nurse, or designated nurse, will provide oversight of the restorative aide activities or nursing staff's, review the documentation as needed, and evaluate the effectiveness of the plan and document accordingly.

Based on interview and record review, the facility failed to initiate the Level II PASRR (Preadmission Screening and Resident Review) process for residents identified with mental illness. This deficient practice affected 1of 3 residents (R220) reviewed for PASRR within a total sample of 36 residents.Findings include:R220's face sheet documents her admission date into the facility was 3/10/2020 with medical diagnoses including Parkinsons Disease without dyskinesia onset date 12/01/2023, unspecified dementia unspecified severity with other behavioral disturbances onset date 12/24/2022, unspecified psychosis onset date 3/10/2020, major depressive disorder single episode onset date 12/31/2021, anxiety disorder onset date 3/10/2020, major depressive disorder recurrent mild onset date 3/10/2020, type 2 diabetes mellitus with diabetic polyneuropathy onset date 3/3/2023.On 1/29/2026 at 2:10PM V26 (admission Director) stated, V26 is in charge of receiving residents OBRAs / PASARR prior to residents being admitted into the facility. V26 stated the social workers in the facility complete the follow up for OBRA (Omnibus Budget Reconciliation Act)/PASARR when needed. V26 stated there was only one OBRA in the file for R220.On 1/29/2026 at 1:56 PM V27 (Social Worker) stated she has been working at the facility for 8 months and had no clue she was supposed to follow up with residents OBRAS / PASARRS. V27 stated she was unaware she needs to make a referral to the state designate authority when a resident has a newly evident or possible serious mental disorder is identified.Record review of R220s OBRAS-1 Initial Screen, provided by the V2 (Assistant Administrator), documents date of screening 3/10/2020, determination of Need Score:65, date of admission to facility on R220s OBRA is blank, the OBRA documents screening is valid for 90 days from date of screening. R220s OBRA 1 Initial Screen reads: Based upon all information and data available to me for this person there is a reasonable basis for suspected DD (developmentally disabled) or MI (mental illness), no was marked.R220s Medication Review Report Documents Duloxetine (Anti-Depressant) Capsule (Cap) 60mg (milligrams), give 1 capsule orally one time a day related to major depressive disorder recurrent mild, start date 5/18/2021. Divalproex (anticonvulsant/mood stabilizer) Cap 125mg give 2 capsules orally two times a day related to unspecified psychosis not due to a substance or known physiological condition, start date 5/18/2021. Mirtazapine (Anti-Depressant) Tab 15mg give 1 tablet orally at bedtime related to major depressive disorder recurrent mild, start date 5/18/2021.R220s progress notes for psychiatry follow up visit dated 1/27/2026 documents R220 was being seen for a follow up for mood, behavior and medication management. NP documents per staff documentation, R220 still with behavioral issues, refusing medications, poor appetite.On 1/29/2026 V3 (Director of Nursing) presented the facility's policy Titled PASRR and OBRA screening.Policy statement: The facility shall follow Illinois Department of Human Services requirement for PASRR and OBRA screenings. All residents are required to go through this screening process and copy of the screenings shall be maintained in the residence record. Policy reads: Resident who are appropriate for long-term care placement with special needs (e.g. DD) and/or serious mental health issues shall be assessed for needs and an individualized plan of care shall be developed and implemented.

Based on observation, interview and record review, the facility failed to follow their restraint free environment policy by preventing a resident sitting in a wheelchair from rising independently during breakfast for one resident (R228) reviewed for physical restraint in a sample of 36 residents. Findings Include:On 1/27/2026 at approximately 8:30am, R228 was sitting in her wheelchair while waiting for breakfast. R228 attempted to rise out of her chair independently three times but was prevented by her table, a wall to her left side, and a wall behind R228's wheelchair.On 1/27/2026 at 8:40am, V6 Licensed Practical Nurse (LPN) stated R228 is confused, is a fall risk and that staff were in the middle of passing trays. V6 stated that, R228's wheelchair should not be touching the back wall and the left wall there by preventing R228 to be able to stand freely. V6 was later observed at 8:45am removing R228 two feet away from the back wall and one foot away from the table.On 1/29/26 at 2:30pm, V3 DON (Director of Nursing) stated the facility is a restraint free facility, and a furniture should not be used to prevent a resident from moving freely.R228's care plan dated 1/20/2026 reads, The resident has the potential for falls due to current medical condition. Facility policy titled Restraint Free Environment reads. Policy. It is the policy of the facility that each resident shall attain and maintain his or her highest practicable well-being in an environment that prohibits the use of physical or chemical restraints for discipline or convenience and limits restraints used to circumstances in which the resident has medical symptoms that warrant the use of social restraints. Definition: Physical Restraint refers to any manual method of physical or mechanical device, material, or equipment attached or adjacent to the residence's body that the individual cannot remove easily, which restricts freedom of movement or normal to one's body. Physical restraints may include, but are not limited to: Placing a resident in a chair that prevents the resident from rising independently. Placing a chair or bed close enough to a wall that the resident is prevented from rising out of the chair or voluntarily getting out of bed.

Based on observation, interview, and record review, the facility failed to keep a resident's respiratory inhaler and nasal spray in a secured storage for one of one resident (R74) reviewed for medication storage in a sample of 36. Findings include:R74's Order Summary Report dated 01/28/2026 indicated R74 was admitted in the facility on 01/14/2026 with diagnoses of not limited to acute and chronic respiratory failure with hypercapnia and hypoxia, and chronic obstructive pulmonary disease. On 01/27/2026 at 8:41AM R74 had an Albuterol (steroid inhalation medication) inhaler and Fluticasone (corticosteroid) nasal spray at R74's bedside. R74 stated that R74 had asked the nurse to reorder them because it is almost gone. On 01/27/2026 at 9:45AM during unit rounds with V4 (Infection Preventionist), R74 still had the unboxed albuterol inhaler and fluticasone nasal spray bottle at bedside. On 01/27/2026 at 9:45AM during interview with V4, V4 stated that R74 should not have any medication at bedside unless there was an order and that she is safe to self-administer the inhaler and nasal spray. At 10:30AM, V4 stated that R74 had no physician order for fluticasone nasal spray, so they will call R74's doctor to inform him. Review of facility's policy entitled Resident Self-Administration of Medication dated 10/01/2025 indicated the following: Policy: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Procedure: 8. All staff of the facility are required to report to the nurse on duty on any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the nurse to return to the family or the responsible party. Families or responsible parties are reminded of policy and procedures regarding residents self-administration when necessary.

Based on observation, interviews and record review, facility failed to implement fall precautions to prevent falls with injuries. This applies to 2 out of 3 residents (R2, R3) reviewed for fall precautions.The findings include:1.On 8/19/25 at 10:25 AM, R2 was lying in bed. R2's left arm was in a bandage. R2 was alert with some confusion. Bed was at average height and not at its lowest position. There were no landing pads next to the bed. R2's call light was tied to the grab bar and was hanging downwards. R2 searched for her call light and stated she cannot find her call light. R2's table was towards the lower half of her body and she could not reach her cup of water. On 8/19/25 at 10:40 AM V6 (LPN-Licensed Practical Nurse) verified R2's bed was not in the lowest position and her call-light was out of her reach. On 8/19/25 at 11:30 AM V10 (CNA- Certified Nursing Assistant) observed and stated R2's water was out of her reach and bed was not in lowest position. On 8/20/25 at 8:45 AM, R2 was lying in bed. R2's bed was at average height and not at the lowest level. R2's call light was under her upper back. R2 stated she is not able to find her call light and stated the call light should have been where she can reach for it.On 8/20/25 at 10:00 AM, V13 (PTA-Physical Therapy Assistant) and V4 (Director of Rehab) stated R2 need two people to transfer from bed to wheelchair and R2 can move her legs out of the bed, not her upper body. V13 and V4 stated it is recommended for R2 to have her bed in lowest position and have call lights within reach. R2's 6/9/25 fall risk evaluation showed a score of 19 with a scale that showed a score of 10 or higher means at high risk for falls. R2's care-plan dated 7/25/25 showed to ensure R2's personal items and call light were within reach and to use her call light when assistance is needed. R2's care-plan showed R2 had falls in the facility on 11/15/24, 12/21/24, 6/3/25 and 7/5/25. On 8/19/25 at 2:42 PM V3 (Restorative Nurse) stated one of the post fall interventions for R2 was to keep bed at lowest position. On 8/20/25 at 10:10 AM, V5 (NP - Nurse Practitioner) stated R2 had the potential to fall again as R2 does not follow the nursing instructions. V5 stated R2 must have her call light within reach, her bed in the lowest position, and have landing pads to minimize injuries. 2.On 8/20/25 at 9:27 AM, R3 was sitting on her bed with her feet on the floor on the left side of the bed. R3 stated she wanted to use the bathroom and then go to the dining room for breakfast and needed to call for help, but her call light is out of her reach. R3's call light was tied to the grab bar on the right side of the bed and hanging to the floor. V9 (CNA) verified R3's call light was out of her reach.On 8/19/25 at 9:50 AM, V8 (RN-Registered Nurse) and V12 (RN) stated fall precautions include keeping bed at lowest position, having the call light and other personal items near resident, and frequent monitoring/rounding.On 8/19/25 at 10:40 AM V6 (LPN-Licensed Practical Nurse) stated anyone with history of previous falls must have their beds in the lowest position and their call lights within their reach.

Based on observation, interview, and record review, the facility failed to follow their Water Management Program, failed to follow their policy for PPE (Personal Protective Equipment) during care of a resident in contact isolation, and failed to follow their policy for hand hygiene and glove use during provisions of care. This applies to all 206 residents residing in the facility. The findings include: 1. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated December 16, 2024, by V1 (Administrator) showed there were 206 residents residing in the facility. On December 17, 2024, at 8:57 AM, V14 (Maintenance Director) said for the facility's Water Management Program for legionella, the facility receives a yearly water report from the village. V14 continued to say a monthly water quality test is performed with a TDS (Total Dissolved Solids) probe. V14 said sometimes while performing the monthly TDS test, he does a chemical test of the water but V14 does not document those test results. V14 said the facility submitted water samples for testing for legionella on December 4, 2024. V14 said the facility does not have documentation to show any legionella testing was performed prior to December 4, 2024. V14 said housekeeping flushes the water in resident rooms on a weekly basis. The instruction manual for the facility's TDS probe showed TDS is short for Total Dissolved Solids. TDS is not a measure of harmful substances or pollutants. It is simply a measure of all substances dissolved in water. Purified water has a TDS of 0 to 1 PPM (Parts Per Million). The ocean has a TDS of over 10,000 PPM. Neither water sources are harmful. TDS is a good tool for monitoring the general quality of a known source of water . 4. TDS and Tap Water: a high TDS of tap water usually indicated a high level of calcium and magnesium (hard water) and other salts. This water is probably corrosive to plumbing fixtures, pipes and appliances, the water may taste bad too. Due to high mineral content, a professional water treatment company will be able to advise you on specific actions to take to correct the situation. The United States Environmental Protection Agency sets the standards for drinking water in the United States. The maximum TDS in drinking water is 500 PPM . The manual does not show the TDS probe can test for chlorine levels. On December 17, 2024, at 2:46 PM, V1 said the facility's Water Management Program's attachment number three cannot be located. V1 continued to say V14 should be following the control measures that are listed in the facility's Water Management Program. The facility's Water Management Program dated 10/18 showed Policy: The facility will implement the Water Management Program to reduce the risk for Legionnaire's disease associated with the building water system and devices, reduce the growth and spread of Legionella bacteria in the facility to identify areas or devices in the facility where Legionella might grow or spread to people so that the facility can reduce that risk . Procedure: 1. The Water Management Program Team: a. The following but not limited to are the members of the Water Management Program Team: i. Owner of the building; ii. Building Manager/Director of Environmental Services; iii. Administrator; iv. Assistant Administrator; v. Medical Director; vi. Infectious Disease Specialist/Physician; vii. Director of Nursing; viii. Assistant Director of Nursing; ix. Interdisciplinary Team of the facility representative; x. Contractors/consultants; xi. State and local health officials; xii. Representative from the Governing Body. b. The following but not limited to are the duties of the Water management team: i. Oversee the program. ii. Identify control locations and control limits. iii. Communicate regularly about the program. iv. Monitor and document the performance of the program. v. Identify and take corrective action as needed . 3. The facility water systems: a. The Director of Environmental Services has to describe the facility's water system using a Flow Diagram and in a Text document. (Attachment number two). b. Once completed, identify areas where legionella could grow and spread. Decide where control measures should be applied and how to monitor them. Establish ways to intervene when control limits are not met. (Attachment number three). 4. Control measures and Corrective actions: .b. With the use of the diagram (Attachment number two), the facility identified and implemented a process in monitoring control measures. Control limit monitoring includes but not limited to checking water temperature weekly and PRN (Pro Re Nata/As Needed) and disinfectant levels weekly and PRN at different areas of the facility. c. The following but not limited to are the areas routinely checked: i. Quality of Water: On a weekly and PRN basis, the quality of the water will be measure throughout the system to ensure that changes that may lead to legionella growth (such as a drop in chlorine levels) are not occurring . v. Unoccupied room or unit closed to public use: if a room or floor will be unoccupied or closed to public use for a longer period of time which could be due to renovations, constructions or just plainly due to low census, this may cause a temporary hazardous condition because the water usage will decrease, which means stagnation is possible, therefore the following course of action should be implemented: a) Daily flushing of the sinks and fixtures with hot and cold water in several rooms including those at the end of the hall, which are farthest from the vertical pipe serving that floor (riser). b) Continued to monitor the water temperature and increase the frequency on monitoring the chlorine levels of the floor/unit/area that is closed from weekly to daily . On December 18, 2024, at 10:58 AM, V32 (Admissions Director) said a resident room on the second floor had been unoccupied since October 18, 2024. V32 continued to say she checked the facility's census from June 1, 2024, to present and the room next door had been unoccupied since before June 1, 2024. The facility does not have documentation to show daily flushing, water temperatures, or chlorine levels were monitored daily for the unoccupied rooms. The facility does not have documentation to show weekly water temperatures or weekly disinfectant levels were monitored. 29562 2. On December 17, 2024, at 9:30 AM V11 (Nurse) prepared and administered medications to R144. There was a sign outside R144's bedroom which showed Contact Precaution. V11 went in and out of R144's bedroom twice, first to administer the intravenous antibiotic medication and then to administer all the oral medications to R144. V11 only used a pair of gloves, however she did not use an isolation gown. When asked about what contact precaution R144 has, V11 was not sure of it. 3. On December 17, 2024, at 4:35 PM, V18 assisted R58 to the bathroom. After R58 used the toilet, V18 wiped R58's perineum, then she pulled the incontinence brief and pants back in place, assisted R58 to transfer from toilet to wheelchair while wearing the same soiled gloves. V18 used one set of gloves all throughout the provision of care. 4. On December 18, 2024, 10:23 AM, V17 (CNA) assisted R24 to the toilet. R24 voided, afterwards V17 assisted R24 to stand up, provided peri-care, pulled the incontinence brief and pants back in place, and assisted R24 to sit down on the wheelchair while wearing same soiled gloves. V17 changed her gloves without performing hand hygiene and continued to assist R24. On December 18, 2024, at 4:02 PM, V2 (Director of Nursing/DON) stated it is the facility's practice to follow standard infection control process such as hand hygiene and donning of complete PPE (Personal Protective Equipment) which include glove and gown for resident on contact isolation. The staff should perform hand hygiene and change gloves in between tasks to prevent spread of infection. R144 is on contact precaution for MRSA (Methicillin-resistant Staphylococcus aureus) of the wound. Facility's Hand Washing/Hygiene Policy with revision date of November 2017 shows: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation: 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use and alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: f. Before moving from one contaminated body site to a clean body site during resident care. g. after contact with a resident's skin. j. After removing gloves. 8. The use of gloves does not replace handwashing/hygiene. Facility's Transmission Based Precautions dated June 21, 2023, shows: Contact Precautions: b. Wear a gown and gloves for all interactions with the patient or potentially contaminated areas in the patient's or resident's environment. Donning personal protective equipment (PPE) upon room entry and discarding it before exiting the patient room.

Based on observation, interview, and record review, the facility failed to provide incontinence care, oral care, and grooming to residents who depend on the facility for care. The facility also failed to shave female and male resident's long facial hair and trim and clean resident's long fingernails. This applies to 13 of 13 residents (R16, R21, R42, R61, R77, R80, R106, R115, R134, R160, R167, R190, R199) reviewed for ADL (Activities of Daily Living) in the sample of 35. The findings include: 1. R160's face sheet showed him to be a [AGE] year old male admitted to the facility on [DATE] with diagnoses that include Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Left Dominant side, Dysphagia, Anxiety Disorder, Seizures, and Dementia with Moderate Agitation. R160's Minimum Data Set (MDS) section C dated November 12, 2024 showed R160 to be severely cognitively impaired. The same MDS section GG showed R160 to be dependent or require substantial/maximal assistance for self-care activities. On December 16, 2024 at 10:14 AM, R160 was lying in his room and his finger nails were long and there was a black substance under the nails. On December 17, 2024 at 1:49 PM, V4 (CNA) and V25 (CNA) came in to perform incontinence care for R160. R160's incontinence brief was visibly soiled from the front. When V4 opened R160's incontinence brief, it was heavily saturated with urine soiled from mid front and went all the way up his back. Under the brief there was a yellow pad that had a brown ring around the wetness on the pad. R160 had stool that was dry, pasty and stuck to resident's inter-gluteal cleft and buttocks, because of this, V4 had to use almost a full pack of large wipes to clean R160. The fitted sheet that was underneath the yellow pad, was also wet with brown tinged urine. When V4 removed the socks, there was a copious amount dead skin that fell on to R160's bed. R160's feet were extremely dry, scaly and flaky. R160's finger nails were still overgrown, with black substance under his nails. R160's skin care plan shows the following: Keep skin clean and dry. May apply lotion or moisturizer cream as part of daily skin care. 2. R61 Face Sheet documents a [AGE] year old female admitted to the facility on [DATE] with diagnoses that include Parkinson Disease, Encounter for Attention to Gastrostomy, Dysphagia, Congestive Heart Failure, and Dementia. Minimum Data Set (MDS) section C dated October 22, 2024 showed R61 to be severely cognitively impaired. The same MDS section GG showed R61 to be dependent or require substantial/maximal assistance for self-care activities. On December 16, 2024 at 10:47 AM, R61 was sitting in the dining room and has long facial hair above her upper lip and at the corners of her mouth. R61's finger nails were long with brown substance underneath the nails. On December 17, 2024 at 1:30 PM and 1:45 PM R61, was sitting in the dining room displaying curly facial hair on the upper lip and below her lower lip. R61 also had long fingernails with chipped nail polish and black brown substance underneath her nails. 29562 3. Face sheet shows that R21 is [AGE] years-old who has multiple medical diagnoses which include dementia, lack of coordination, and need for assistance for personal care. MDS (Minimum Data Set) dated November 6, 2024, shows that R21 is totally dependent on staff for dressing, and grooming and hygiene. On December 16, 2024, at 10:54 AM, R21 was sitting in the dining room along with other residents. R21 was unkempt and disheveled. His clothes have flaky substances all over from his top down to his pants, he displayed overgrown fingernails with black/brown substances underneath, his nail beds have yellowish/brownish discoloration, hair was uncombed, unkept overgrown mustache and beards, and he had overgrown hairs in the ears and nostrils which was sticking out. R21's ADL (activities of daily living) care plan with revision date of March 25, 2024, showed R21 had an ADL self-care performance deficit related to diagnoses which include Vascular Dementia. The goal was to meet R21's ADL daily. This same care plan shows R21 is totally dependent on staff for dressing, and to check nail length, trim, and clean on bath day and as necessary, 4. Face sheet shows that R190 is [AGE] years-old who has medical diagnoses which include Alzheimer's disease. MDS October 18, 2024, shows R190 requires maximum assistance with grooming/hygiene. On December 17, 2024, at 4:45 PM, R190 was sitting in the dining room displaying facial hair and long fingernails which has chipped nail polish and black/brown substance underneath the nails. R190 touched her face and felt her long facial hair on the upper lip and chin, then she looked at her fingernails. R190 stated that she would like her facial hair shaven, and fingernails clipped. 36567 5. R16's face sheet included diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, arthropathy. R16's quarterly MDS dated [DATE] showed that R16 had impairment on both sides for range of motion on upper extremities and was dependent on staff for personal hygiene. On December 16, 2024 at 10:52 AM, R16 was lying in bed sleeping and both of her arms appeared deformed with very dry skin. R16 had both hands with fingers formed into fists and therefore the finger nails were not visible. V8 CNA (Certified Nursing Assistant), who was in the vicinity, stated that R16 is dependent on staff for ADLs. On December 17, 2024 at 9:23 AM, R16 was lying in bed with arms tucked under the blankets and was unable to respond coherently to queries. V6 (Restorative CNA) who was in the room assisting R16's roommate was requested to remove the blanket from R16's arms. R16's fingers on both hands were curled into fists and on opening them by V6, it was noted that R16's right hand and left hand pinky and middle fingers had very long and hardened finger nails that were curled in. R16's care plan initiated on October 19, 2021 showed that R16 has an ADL self-care performance deficit related to weakness secondary to above stated diagnoses. The care plan intervention for personal hygiene included that the resident requires (extensive assistance) by (1) staff with personal hygiene. 6. R42's face sheet included diagnoses of Parkinson's disease without dyskinesia, without mention of fluctuations, unspecified dementia, unspecified severity, with other behavioral disturbance, dysphagia, oropharyngeal phase, anorexia, unspecified protein-calorie malnutrition. R42's quarterly MDS dated [DATE] showed that R42 was moderately impaired in cognition for decision making and dependent on staff for oral hygiene and personal hygiene. On December 16, 2024 at 10:30 AM, R42 was propped up in bed and did not respond to queries but only smiled. R42's upper teeth that were visible were coated with extensive debris. R42's CNA (V8) stated that she provides cup and water set up only to R42 to brush her teeth and that R42 does not brush her teeth properly. R42's thumb nail on left hand was very long (about 1/2 inch) with blackish substance underneath. R42's right hand was contracted and holding paper towels that were crumpled up. On request R42's right hand fingers were opened by V9 (LPN, Licensed Practical Nurse) and R42's middle finger nail on right hand was also very long with blackish substance underneath. V8 and V9 were notified that R42's nails need to be trimmed. On December 17, 2024 at 9:25 AM, R42 was propped up in bed. R42's teeth remained with extensive debris built up and R42's middle finger nail on right hand and thumb nail on left hand remained long with blackish substance underneath. V8 was notified again about the observations. R42's care plan revised March 12, 2024 included that R42 has ADL self care performance deficit related to weakness with interventions showing that R42 requires extensive assistance by one staff for personal hygiene and oral care. R42's care plan initiated June 7, 2021 also included to check mouth after meal for pocketed food and debris and report to nurse and to provide oral care to remove debris. 7. R134's face sheet included diagnoses of primary generalized (osteo)arthritis, adult failure to thrive, dorsalgia, gastro-esophageal reflux disease without esophagitis. R134's Admission MDS dated [DATE] showed that R134 is moderately impaired in cognition and is dependent on staff for personal hygiene. On December 16, 2024 at 12:05 PM, R134 was seated in dining room for lunch meal and noted to have several very long chin hairs and stated that she would like it removed. On December 16, 2024 at 1:57 PM, R134 was seated in common activity room on first floor and the long chin hairs remained on her chin. This was relayed to V2 (Director of Nursing) who stated that the CNAs are supposed to provide grooming assistance per request or as needed. R134's care plan initiated November 1, 2024 included that R134 has an ADL self-care performance deficit related to activity Intolerance. 8. R199's face sheet included diagnoses of cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery, difficulty in walking, not elsewhere classified, need for assistance with personal care, other reduced mobility. On December 16 2024 at 10:37 AM, R199 lying in bed with hair and beard overgrown, and finger nails very long with blackish substance underneath. R199 stated that that he returned to facility in October, 2024. R199 stated that he wanted his hair cut and beard and nails trimmed and did not know if the facility offers these services. R199 remarked My hair is usually not this long. My nails are longer than I have ever had. On December 17 2024 at 9:21 AM, R199 was lying in bed and his hair, beard and nails remained long and this was relayed to V9 (LPN) who stated that R199 needs assistance with ADL care. R199's care plan revised on October 1, 2024 included that R199 has ADL self-care performance deficit related to above listed diagnoses with a goal that ADL needs will be met on a daily basis until next review. 15845 9. Face sheet, dated December 2024, shows R77, a [AGE] year-old female resident with diagnoses that includes bipolar disorder, psychoses, Alzheimer's disease, arteriosclerotic heart disease, dementia, osteoarthritis, and right wrist drop. R77 was admitted to the facility on [DATE]. MDS (Minimum Data Set), dated October 24,2024 shows R77's cognition was severely impaired and required extensive to substantial assistance from staff for personal hygiene/grooming. R77's care plan dated October 24,2024 showed R77 was dependent on staff for assistance with ADLs. On December 16,2024 at 11:00 A.M., R77 was in the dining room on the third floor designated Memory Unit. R77 was attending recreational activity. R77 was observed with long chin hair approximately 2 inch long. R77 was also had long, jagged fingernails with black substance under the nails. During this time, V21 (Memory Care Coordinator) was present and said that the residents in the designated Memory Care Unit were low functioning residents and their cognition were severely impaired. At 12:30 P.M., R77 was still in the same dining room, eating her lunch. R77's hygiene and grooming were remained the same with long soiled nails and long chin hair. V20 (RN/Registered Nurse) was present during this observation. On December 17,2024 at 12:20 P.M., R77 was in the memory unit dining groom eating her lunch. R77's hygiene and grooming were not maintained, with long soiled jagged nails, and an unkempt chin hair. V20 (RN/Registered Nurse) was again present during this observation and was R77's assigned nurse. 10. Face sheet, dated December 2024, shows R80, a [AGE] year-old female resident with diagnoses that includes type 2 diabetes mellitus, dementia, heart disease, chronic kidney disease, bipolar disorder and major depressive disorder. R80 was admitted to the facility on [DATE]. The MDS dated [DATE] shows R80's cognition was moderately impaired, and she required substantial/maximum assistance from staff for ADLs including hygiene and grooming. The care plan dated December 3,2024 shows that R80 was dependent on staff for assistance with ADLs. The POS (Physician Order Sheet) for the month of December 2024 shows Special Instructions: **Extensive assistance - one+ person physical. On December 16, at 10:50 A.M., R80 was in the dining room on the third floor designated Memory Unit. R80 was attending recreational activity. R80 was observed with long chin hair approximately 2 inch long. R80 was also had long, jagged fingernails. V20, the assigned nurse for R80 said that R80 was a total care for all ADLs. On December 17,2024 at 1:04 P.M., R80 was in the dining room on the third floor designated Memory Unit. R80 was eating her lunch. R80's personal hygiene remained unkempt, with long jagged fingernails, black substance under nail bed and chin hair that was unbecoming for a female resident. V20, was present during this observation. 11. The Face Sheet for the month of December 2024 show that R106, a [AGE] year-old female resident with diagnoses that includes dementia, Alzheimer's disease, major depressive and anxiety disorder. R106 was admitted to the facility on [DATE]. The MDS dated [DATE] shows R106's cognition was severely impaired and required maximum/dependent on staff for assistance with ADLs. The care plan dated March 19, 2024 showed R106 be aided with ADLs. On December 16, at 1:34 P.M., R106 was in the dining room on the third floor designated Memory Unit. R106 was eating her lunch. R106 was observed with long chin hair approximately 2 inch long. R106 was also had long, jagged fingernails V20, the assigned nurse for R106 said R106 was a total care for all ADLs. On December 17,2024 at 1:10 P.M., R106 was in the dining room on the third floor designated Memory Unit. R106 was eating her lunch. R106's personal hygiene remained unkempt, with long jagged fingernails, black substance under nail beds and chin hair that was unbecoming for a female resident. V20, was present during this observation. 12. The Face Sheet for the month of December 2024 shows that R115, an [AGE] year-old female resident with diagnoses that includes Alzheimer's disease, schizophrenia and hypothyroidism. R115 was admitted to the facility on [DATE]. The MDS dated [DATE] shows R115's cognition was severely impaired and required maximum/dependent on staff for assistance with ADLs. The care plan dated November 22, 2024 showed R115 be aided with ADLs. The POS for the month of December 2024 Special Instructions: POS *Extensive assistance - one+ person physical assist* On December 16,2024 at 12:30 P.M., R115 was in the dining room on the third floor designated Memory Unit. R115 was eating her lunch. R115 was observed with long chin hair approximately 2 inch long. R115 was also observe with long, jagged fingernails V20, the assigned nurse for R115 had said that R115 was a total care for all ADLs. On December 17,2024 at 1:15 P.M. R115 was in the dining room on the third floor designated Memory Unit. R115 was eating her lunch. R115's personal hygiene remained unkempt, with long jagged fingernails, black substance under the nails and chin hair that was unbecoming for a female resident. V20, was present during this observation. 13. The Face Sheet for the month of December 2024 shows that R167, a [AGE] year-old female resident with diagnoses that includes multiple sclerosis, dementia, obstructive hydrocephalus, urinary tract infection, anxiety disorder, depression, psychosis and type 2 diabetes mellitus. R167 was admitted to the facility on [DATE]. The MDS dated [DATE] shows R167's cognition was severely impaired and required maximum/dependent on staff for assistance with ADLs. The care plan dated November 8, 2024 showed R167 needed help with ADLs. The POS for the month of December 2024 Special Instructions: POS *Extensive assistance - one+ person physical assist* On December 16,2024 at 12:40 P.M. R167 was in the dining room on the third floor designated Memory Unit. R167 was eating her lunch. R167 was observed with long chin hair approximately 2 inch long. R167 was also observed with long, jagged fingernails V20, said R167 was a total care for all ADLs. On December 17,2024 at 12:42 P.M., R167 was in the dining room on the third floor designated Memory Unit. R167 was eating her lunch. R167 hygiene and grooming remained unkempt. R167 was touching her food with her bare hands and her fingernails were long, jagged and black substance under nail bed. On December 18, 2024, at 3:46 PM, V2 (Director of Nursing/DON) stated the facility's practice is to ensure that residents are well groomed. Hygiene is provided including nail, facial hair, and incontinence care. Ensure that residents are wearing appropriate, comfortable, and clean clothing. The facility's policies for ADLs were as follows: -Care of Fingernails/Toenails: dated October 2010 shows: Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin -Shaving the Resident: dated October 2010: Purpose The purpose of this procedure is to promote cleanliness and to provide skin care. -Urinary Continence and Incontinence date March 2020: Policy Statement: The staff and practitioner will identify and manage individuals with urinary continence or incontinence. .6. The staff is to assist the resident with his or her toileting needs at least every 2 hours and as needed. Assistance may include but is not limited to checking and changing if incontinent or assisting the resident to the toilet as needed .9. If the individual requires assistance from more than one person to transfer to the toilet, the staff will address his or her mobility problems before attempting a toileting assistance trial. 10. Incontinence care should be individualized at night to maintain comfort and skin integrity and minimize sleep disruption. 11. Prompted voiding is not helpful at night (e.g., between the hours of 10 p.m. and 5 a.m.) and has been shown to disrupt sleep. 12. If the resident is incontinent, provide incontinent care or check and change the resident at least every 2 hours and PRN. 13. If the resident does not respond and does not try to toilet, or for those with such severe cognitive impairment that they cannot either point to an object or say their name, staff will use a check and change strategy. 14. A check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments.

Based on observation, interview, and record review, the facility failed to label and date medication to determine the expiration date once it was opened and failed to ensure narcotic medications were accounted for. This applies to 9 of 11 residents (R4, R11, R18, R36, R38, R89, R90, R134, R136) reviewed for medication storage and labeling in the sample of 35. The findings include: On December 18, 2024, inspections of 6 of the facility's 11 medication carts and 2 of their 3 medication rooms were conducted with each of the assigned staff nurses (V10, V11, V24, V29, V31, V32). The following was observed: 1. On December 18, 2024, at 1:26 PM, there was a Basaglar Kwik Pen (insulin solution) in the 4th floor center 1 medication cart that was unlabeled, opened, and not dated. The pharmacy recommendation shows to discard this medication 28 days after it was opened. R4's Lorazepam (antianxiety) 1 milligram (mg) tablet card/container had a seal broken and taped over for number 30. In addition, there were three water cannister or tumblers stored inside this medication cart. V29 stated that all three belonged to her. 2. On December 18, 2024, at 1:35 PM, the narcotic medications on the 4th floor East medication cart were counted with V10. R136's Lorazepam 0.5 mg tablet showed there were 16 tablets in the bingo card/container. However, it was documented on the narcotic log/sheet that there were 17 tablets remaining. R36's Hydrocodone/APAP (pain medication) 5-325 mg showed 14 tablets, but the documented narcotic sheet showed 15 tablets. R38's Alprazolam (antianxiety) 0.5 mg tablets showed 18 tablets, the documented narcotic sheet showed 20 tablets remaining. R89's Lorazepam 1 mg tablet, showed 10 tablets, the documented narcotic sheet showed 11 tablets remaining. R134's Hydrocodone/APAP 10-325 mg showed 13 tablets, the documented narcotic sheet showed 14 tablets remaining. R18's Hydrocodone/APAP 5-325 mg showed 7 tablets, the documented narcotic sheet showed 8 tablets remaining. On December 18, 2024, at 1:59 PM V28 (Assistant Director of Nursing/ADON) stated the moment the staff administer the narcotic medication to the resident, the staff must sign it out on the narcotic sheet to have accurate count and ensure that it was given. 3. On December 18, 2024, at 2:08 PM, the 3rd floor medication room was inspected with V30 (Nurse). R90's Ozempic 2mg/3 ml was stored in the refrigerator, it was opened and not dated. The pharmacy recommendation shows to discard this medication 56 days after it was opened. 4. On December 18, 2024, at 2:24 PM, the narcotic medications on the 2nd floor [NAME] medication cart were counted with V31. R11's Hydrocodone/APAP 5-325 mg showed 18 tablets, but narcotic sheet/log shows 19 tablets remaining. 5. December 18, 2024, at 2:45 PM, the 2nd floor East medication cart as checked with V11. There was a vial of Insulin Lispro that was unlabeled, opened and not dated. The pharmacy recommendation shows to discard this medication 28 days after it was opened. On December 18, 2024, at 3:40 PM, V2 (Director of Nursing/DON) stated that it is the facility's practice to document on the narcotic sheet/log to ensure accuracy of dispensing and administration of the narcotic medication. V2 added, that it is also the facility's practice to ensure all medications mentioned above are labeled and stored to ensure that potency and expiration date of the medications are monitored. V2 also stated Staff's personal belongings should not be stored in the medication cart. The facility's policy and procedure for Storage of Medication dated March 2020, shows: Policy Statement: The facility shall store all drugs and biologicals safely, securely, and orderly. 6. Antiseptics, disinfectants, and germicides used in any aspect of resident care must have legible, distinctive labels that identify the contents and the directions for use and shall be stored separately from regular medications. Medications that are in bottles, vials, and pens should be dated when opened and discarded according to the manufacturer's guidelines.

Based on observation, interview, and record review, the facility failed to assess and treat a resident with a contracture of the left hand and failed to apply a splint in accordance with physician orders. This applies to 2 of 6 residents (R117 and R160) reviewed for range of motion in the sample of 35. Findings include: 1. R160's face sheet showed him to be a [AGE] year old male admitted to the facility on [DATE] with diagnoses that include Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Left Dominant side, Dysphagia, Anxiety Disorder, Seizures, and Dementia with Moderate Agitation. R160's Minimum Data Set (MDS) section C dated November 12, 2024 showed R160 to be severely cognitively impaired. The same MDS section GG showed R160 to be dependent or require substantial/maximal assistance for self-care activities. On December 16, 2024 at 10:14 AM, R160's left hand was contracted closed,with fingers touching the palm, and no splint or positioning device was in his hand. On December 17, 2024 at 1:49 PM, while V4 (Certified Nursing Assistant/CNA) and V25 (CNA) were providing care and R160 left hand remained without a positioning device or splint. On December 17, 2024 at 3:00 PM, V22 (Restorative Nurse) stated that she was not aware that R160 had any contractures, but she would assess him and have occupational therapy assess him also. V22 stated that R160 does not wear any kind of splint. On December 18, 2024 at about 9:20 AM, V22 stated that her assessment showed that R160 could benefit from a splint. On December 18, 2024 at 11:30 AM, V26 (CNA) and V23 (Licensed Practical Nurse/LPN) attempted to open R160's left contracted hand and R160 screamed in pain. On December 18, 2024 at 12:49 PM, V27 (Occupational Therapist) stated that she assessed R160 this morning because the staff was concerned with changes to his left arm. V27 stated that R160's left hand 3rd and 4th fingers Interphalangeal (IP) joints were contracted. V27 stated she recommended that R160 have a resting hand splint and occupational therapy. V27 stated, the resting hand splint was the best option for R160 because it would leave his hand in a neutral position, will not cause him to clamp down, and will prevent more deterioration. R160's Occupational Therapy Evaluation & Plan of treatment dated December 18, 2024, showed the following: Assessment Summary: Clinical impression/Reason for Skilled Services: Patient currently presents for skilled Occupational Therapy with changes to the proximal interphalangeal (PIP) joint and the distal interphalangeal (DIP) joints of digits 3 and 4 on the left hand, as well as mild changes in the metacarpophalangeal (MP) Joints (The knuckles) of all left digits. Patient will benefit from skilled (OT) to address range of motion, hand pain/stiffness, and possible splinting needs. Recommend splinting trials and range of motion with skilled OT. 48308 2. R117 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis due to cerebral infarction affecting the right dominant side, chronic obstructive pulmonary disease, essential hypertension, and dysphagia. R117's physician order summary showed an order initiated on November 5, 2024, apply R hand splint ON 9 AM and OFF PM. Check for integrity. continue to re-direct and motivate resident to participate in PROM and splint application. Monitor for pain. R117 was observed on December 16, 2024, at 10:50 AM, lying in bed. R117 was not wearing a right hand splint. R117 was not able to answer questions and only responded by opening her eyes. On December 17, 2024, at 11:42 AM, R117 was observed sitting in the dining room in a reclining wheelchair, not wearing a splint on her right hand. V5 (LPN MDS Coordinator) observed R117, and stated at 11:52 AM, R117 was not wearing a splint on her right hand. At 12:12 PM, V7 (CNA ) stated she had gotten R117 dressed and transferred her to the reclining wheelchair around 9:00 AM that morning and forgot to put on R117's right hand splint. The Facility's policy titled Application of splints or braces , dated November 2015, showed Policy: Adaptive devices will be used as ordered by the physician to prevent deformities or further contractures or to maintain an alignment on a limb or extremity .2. The splints or braces shall be applied according to physician's orders.

Based on interview and record review, the facility failed to follow their policy to offer residents the pneumococcal vaccine. This applies to 3 of 5 residents (R63, R79, and R118) reviewed for immunization in the sample of 35. The findings include: 1. The EMR (Electronic Medical Record) showed R63 was admitted to the facility on [DATE], with multiple diagnoses including dementia, Alzheimer's disease, chronic bronchitis, chronic obstructive pulmonary disease, and hypertension. On December 17, 2024, at 2:26 PM, V3 (Infection Preventionist Nurse) said the facility offers the PCV20 (20-valent Pneumococcal Conjugate Vaccine) to eligible residents. V3 continued to say R63 had only received the PCV13 (13-valent Pneumococcal Conjugate Vaccine) and had not been offered the PCV20. V3 said R63 should had already been offered the vaccine. R63's Immunization Audit Report dated December 17, 2024, at 2:50 PM, showed R63 received the PCV13 on March 19, 2022. The report did not show R63 had been offered or refused another pneumococcal vaccine. As of December 17, 2024, at 2:50 PM, the facility does not have documentation to show R63 was offered an additional pneumococcal vaccine. 2. The EMR showed R79 was admitted to the facility on [DATE], with multiple diagnoses including chronic atrial fibrillation, chronic obstructive pulmonary disease, asthma, and hypertension. On December 17, 2024, at 2:26 PM, V3 said R79 received the PCV13 on March 29, 2022. V3 continued to say R79 had not been offered the PCV20. V3 said R79 should had already been offered the PCV20. R79's Immunization Audit Report dated December 17, 2024, at 2:56 PM, showed R79 received the PCV13 on March 29, 2022. The report did not show R79 had been offered or refused another pneumococcal vaccine. As of December 17, 2024, at 2:56 PM, the facility does not have documentation to show R79 was offered an additional pneumococcal vaccine. 3. The EMR showed R118 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes mellitus, chronic kidney disease, and peripheral vascular disease. December 17, 2024, at 2:26 PM, V3 said R118 received two PCV13, one in 2018 and a second in 2019. V3 said R118 should had been offered the PCV20. R118's Immunization Audit Report dated December 17, 2024, at 2:54 PM, showed R118 received the PCV13 on October 12, 2019. The report did not show R118 had been offered or refused the PCV20. As of December 17, 2024, at 2:54 PM, the facility does not documentation to show R118 was offered or refused the PCV20. On December 17, 2024, at 2:26 PM, V3 said the facility follows CDC (Centers for Disease Control and Prevention) guidelines for pneumococcal vaccine timing. The CDC's Pneumococcal Vaccine Timing for Adults dated October 2024, showed adults [AGE] years of age or older who have only received the PCV13 should receive the PCV20 after one year of receiving the PCV13. The facility's policy titled Pneumococcal Vaccine revised November 2017, showed Policy Statement: Residents in the facility will be offered a pneumococcal vaccine to air in preventing pneumococcal infections. Policy Interpretation and Implementation: .6. Administration of the pneumococcal vaccine or re-vaccinations will be made by current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination .

Based on observations, interview and record review, the facility failed to provide double protein portion as ordered by the physician. This applies to 2 of 2 residents (R95 and R168) observed for dining in the sample of 35. The findings include: 1. On December 17, 2024 at 12:05 PM, during tray line service on the 4th floor, V12 (Dietary Aide) was platting the food and V13 (Dietary Manager) was checking meal trays. R168's meal ticket showed regular consistency, double protein and he received one serving portion (2 oz (ounces) with #16 scoop) of mechanical soft polish sausage and V13 was notified of the same. R168's diet order on POS (Physician Order Summary) showed LCS (Low Concentrated Sweets) diet, Regular texture, Regular/Thin consistency, double protein at lunch. R168's care plan initiated March 6, 2024 included that R168 requires a therapeutic diet and interventions included to provide ordered therapeutic diet. 2. On December 17, 2024 at 12:22 PM, R95 received one serving portion (2 oz with #16 scoop) of mechanical soft polish sausage. The facility diet order listing showed double protein at lunch for R95. When V13 was asked, why R95 only received one portion, V13 stated that the meal ticket only shows one portion of the same. V13 was notified at a later time that the diet order on POS shows double protein at lunch, and V13 responded that he will update the meal ticket. R95's diet order on POS showed LCS diet, Mechanical Soft texture, Regular/Thin consistency, double protein at lunch. R95's care plan revised January 22, 2024, included that R95 has nutritional problem or potential nutritional problem of weight changes related to disease process of Depression, Bipolar disorder, Dementia, Anxiety disorder. Intervention included to serve diet as ordered. On December 18, 2024 at 12:41 PM, V15 (Dietitian) stated that she recommended double protein for R168 related to his request for the same as a food preference. V15 added that R95 was recommended double protein for lunch as he has had a history of weight loss. Diet spreadsheet for lunch (week 4 Tuesday) included kielbasa [polish sausage] (1 portion=2 oz/ounce protein). The same spreadsheet also included portion serving size of 2 oz protein +1 oz broth of ground kielbasa for mechanical soft diet. Facility serving scoop equivalent chart showed that #16=2 oz portion.

Based on observation, interview, and record review, the facility failed to provide safe transfer and feeding supervision to residents who required assistance for activities of daily living care. This applies to 3 of 4 residents (R24, R42, R58) reviewed for safety during ADL assistance in the sample of 35. The findings include: 1. Face sheet shows R58 is [AGE] years-old who has multiple diagnoses which include displaced fracture of base of neck of left femur, subsequent encounter for closed fracture with routine healing, Parkinson's disease, unspecified fall, reduced mobility, needs for assistance with personal care. On December 17, 2024, at 4:35 PM, V18 (Certified Nursing Assistant/CNA) assisted R58 to the bathroom. V18 propelled R58 to the bathroom, R58 held onto the grab bar as she was standing up unsteadily while V18 supported her by holding on to the waistband of her pants. After R58 completed toileting, R58 stood up while V18 cleaned her perineum, and was assisted back to the wheelchair without use of a gait belt. R58's care plan with initiated date of May 2022 showed R58 has an ADL self-care performance deficit related to weakness and current medical condition which include radiculopathy of lumbar region, disorder of muscle, and Parkinson's disease. This same care plan shows R58 requires extensive assistance by two staffs to move between surfaces and as necessary. Use of gait belt by all staff whenever transferring. R58's fall assessment dated [DATE], showed R58 was at risk for fall. 2. Face sheet shows R24 is [AGE] years-old who had multiple medical diagnoses which include morbid obesity, Alzheimer's disease, abnormalities of gait and mobility, lack of coordination, and need for assistance with personal care. On December 18, 2024, at 10:23 AM, V17 (CNA) assisted R24 to the toilet. R24 was assisted to stand up and transfer from wheelchair to the toilet without a gait belt. After R24 used the toilet, she stood up and held on to the grab bar, while V17 provided peri-care, and was assisted back to the wheelchair without the use of gait belt. R24's active ADL care plan shows R24 has an ADL self-care performance deficit related to weakness and current medical condition including dementia, morbid obesity, and osteoarthritis. This same care plan shows R24 requires extensive assistance by two staffs to move between surfaces and the use of gait belt at all times especially during transfers and repositioning. R24's fall assessment October 15, 2024, shows R24 scored 13 which means she was at risk for fall. On December 18, 2024, at 4:10 PM, V2 (Director of Nursing/DON) stated the standard of practice for transferring resident who can stand up is for staff to apply gait belt to resident who requires assistance to ensure safety. Policy Statement Residents in the facility will be transferred safely from one location to another using the proper transfer technique. 36567 3. R42's face sheet included diagnoses of Parkinson's disease without dyskinesia, without mention of fluctuations, unspecified dementia, unspecified severity, with other behavioral disturbance, dysphagia, oropharyngeal phase, anorexia, unspecified protein-calorie malnutrition. R42's quarterly MDS (minimum data set) dated November 27, 2024 showed that R42 was moderately impaired in cognition. R42's diet order on Physician's order summary included mechanical soft texture, regular/thin consistency, no rice/beans, feeding assist alternate consistencies, small bites/sips, no straw. On December 16, 2024 at 12:34 PM, R42 was propped up in bed at around 45 degree angle and received a lunch tray set up on a bedside table. Set up for lunch meal was provided by V8 CNA (Certified Nursing Assistant) and V8 left the room. V8 stated that R42 is resistive to feeding assistance. R42 was observed attempting to eat some of the ground meat and dessert with her left hand that was unsteady. R42's right hand appeared contracted. R42's meal ticket showed mechanical soft diet, feeding assist, alternate consistencies, small bites/sips, and no straw. On December 17, 2024 at 11:11 AM, R42 was propped up in bed with bedside tray with disposable cup (4 oz/ounce) of water with a straw in the cup. V8 stated that she gave R42 the water and put the straw in the cup. On December 17, 2024 at 12:43 PM, R42 was propped up in bed at around 45 degree angle and was attempting to eat lunch that was placed in front of her on a bedside table. R42 also had the disposable cup (4 oz) of water with a straw in it. No staff was present in the room. R42's meal ticket showed mechanical soft diet, feeding assist alternate consistencies, small bites/sips, no straw. R42 was seen eating some of the bread and then sucked up all of the dessert directly from the bowl with her mouth. V10 (Licensed Practical Nurse) who was in the hallway was notified of the directions listed on the meal ticket. R42's care plan initiated June 7, 2021 included that R42 has a swallowing problem related to swallowing assessment results secondary to diagnoses of dysphagia. Interventions for the same included alternate small bites and sips. Use a teaspoon for eating. Do not use straws. On December 18, 2024 at 12:16 PM, V16 (Speech Language Pathologist) stated that she last saw R42 in March, 2022 and at the time of discharge she recommended mechanical soft /ground meat, thin liquids, small sips, small bites and to alternate consistencies during meals. V16 stated that she recommended direct supervision at meals for safety of intake and carryover of swallow strategies and also for encouragement of oral intake. V16 also added that direct supervision is beneficial as R42 has Dementia and needs cueing and has also has tremors related to Parkinson's. V16's discharge progress notes dated March 11, 2022 included as follows: Recommendations discussed with patient/staff include mechanical soft/thin diet with aspiration precautions (upright for meals, slow rate, small bites, alternating consistence's, tray set up, offer alternate food options. The same summary also included direct supervision during meals to encourage intake.

Based on interview and record review, the facility failed to safeguard and properly store a medication that led to a confused resident ingesting that medication. This failure resulted in R1 being hospitalized for drug overdose, fast heartbeat, and altered mental status. This applies to one out of seven residents (R1) reviewed for medication storage. Findings include: On 1/9/2024 at 12:50 PM, V4 (ADON-Assistant Director of Nursing) said an incident occurred on 12/17/2023 between the hours of 4:30 AM to 5:00 AM. He said V19 (RN-Registered Nurse) received a delivery from pharmacy on 12/17/23 at 1:13 AM. Soon after delivery, V19 left the medications on top of V20's (RN) medication cart which was inside a locked unit without informing V20 of the delivery. R1 was noted holding one bingo card of Chlorpromazine (Antipsychotic) 25 mg (milligrams) with 30 tablets. It was noted that 18 tablets were missing. R1 was noted to have a whitish substance on her mouth. R1 was brought to her room and was assessed. R1's heart rate was 116 beats per minute. R1 became lethargic and she was sent to a local hospital where admitting diagnoses were drug overdose, tachycardia and altered mental status. On 1/9/2024 at 10:12 AM, V7 (RN) said the incident could have been avoided if the medications were secured. On 1/9/2024 at 12:19 PM, V17 (NP-Nurse Practitioner) said R1 would not have accidentally ingested unknown amounts of Chlorpromazine 25 mg and became lethargic if medications were properly stored. On 1/9/2024 at 12:30 PM, V4 (ADON) said R1 would not have accidentally ingested 10 tablets of Chlorpromazine 25 mg if the medication was properly stored. On 1/9/2024 at 12:50 PM, V3 (DON-Director of Nursing) said the incident would have been avoided if the medications were secured in the medication cart or the medication room as she expects the nurses to do. She said she expects the nurses to store all medications in the medication cart or the medication room for safety and security reasons and so nobody, including residents, staff, or visitors, could get access to the medications. Facility's Storage Medication Policy revised on March 2020 states the following: . Policy Statement: The facility shall store all drugs and biologicals safely, securely, and orderly.Locked Compartments .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observations, interviews and record reviews, the facility failed to supervise a resident that ingested another resident's medication. This failure resulted in R1 being hospitalized for drug overdose, fast heartbeat, and altered mental status. This applies to one out of seven residents (R1) reviewed for supervision with medication. The findings include: On 1/9/2024 at 12:50 PM, V4 (ADON-Assistant Director of Nursing) said an incident occurred between the hours of 4:30 AM to 5:00 AM. He said V19 (RN-Registered Nurse) received a delivery from pharmacy on 12/17/2023 at 1:13 AM. Soon after delivery, V19 left the medication on top of V20's (RN) medication cart which was inside a locked unit. V19 did not inform V20 of the delivery. Around 4:30 AM, V21 (CNA-Certified Nurse Assistant) saw R1 walking around the unit and holding a bingo card of medication (Chlorpromazine 25 mg (Milligrams), 30 tablets). The medication she was holding was for another resident. V21 noticed that 18 tablets were popped. V21 found 8 tablets on the floor. Ten tablets were not found. R1 was noted to have a whitish substance on her mouth. R1 was brought to her room and was assessed. R1's heart rate was 116 beats per minute. R1 became lethargic and she was sent to a local hospital where admitting diagnoses were drug overdose, tachycardia and altered mental status. R1's Admission Records showed her original admitted was on 11/10/2022. R1 was discharged to a local hospital on 12/17/2023 and was readmitted on [DATE]. Diagnoses include accidental poisoning by unspecified drugs, medications and biological substances and dementia. R1's MDS (Minimum Data Sheet) dated 11/10/2023 documented R1's cognition as moderately impaired and needed supervision or touching assistance with ambulation. R1's MDS dated [DATE] documented R1's cognition as severely impaired and needed supervision or touching assistance with ambulation. On 1/9/2024 at 10:12 AM, V7 (RN) said the incident could have been avoided if the medications were secured and if staff were aware that R1 was walking around the unit at that time. On 1/9/2024 at 12:19 PM, V17 (NP-Nurse Practitioner) said R1 accidentally ingested unknown amounts of Chlorpromazine 25 mg and became lethargic that is why she was sent to a local hospital for further evaluation. She said Chlorpromazine is very sedating and caused R1 to be lethargic. She said if medications were properly stored and if staff saw R1 walking around, the incident would not have happened. On 1/9/2024 at 12:30 PM, V4 (ADON) said R1 would not have accidentally ingested 10 tablets of Chlorpromazine 25 mg if the medication was properly stored and if R1 was supervised while walking around the unit. On 1/9/2024 at 1:21 PM, V18 (Psychiatric NP) said side effects of Chlorpromazine includes lethargy and dizziness, EPS (Extra Pyramidal Symptoms). She said Chlorpromazine causes tachycardia. She said R1 was sent to the hospital so she can be closely monitored after accidentally ingesting Chlorpromazine. On 1/11/2024 at 9:18 AM, V3 (DON-Director of Nursing) said R1 would not have accidentally ingested Chlorpromazine if she was being supervised while walking around the unit. R1's Hospital Records dated 12/18/2023 at 7:30 AM documented R1 came to ER (emergency room ) due to altered mental status and drug overdose. Upon arrival to ER, R1 was very somnolent and arousable only to painful stimuli. Diagnosis was altered mental status and drug overdose. Facility's Policy titled Safety and Supervision of Residents revised in March 2020 stated the following: . Policy Statement: The facility strives to make the environment as free from accident hazards as possible. Resident safety supervision and assistance to prevent accident is a priority. 7. Resident supervision is a core component of the system's approach to safety.

Based on interview and record review, the facility failed to assist a resident to the toilet, resulting in the resident transferring herself and falling. The fall resulted in a fractured left hip which required surgical repair. This applies to 1 of 3 (R4) residents reviewed for falls. Findings include: On May 9, 2023, at 10:03 AM, R4 was observed in bed with a surgical incision on her left hip. The hospital records dated April 27, 2023, at 1:31 PM show a history and physical documenting the following: [R4] is complaining of [left] hip pain after the fall. In the ED [Emergency Department], she is noted to have [left] hip femoral neck fracture. Plan is for OR (Operating Room). On May 9, 2023, at 10:40 AM, V16 (RN/Registered Nurse) said she was assigned to R4 on April 26, 2023. V16 said R4 was a high fall risk. V16 said she had toileted R4 and gotten her back to bed when R4 said she wanted to use the restroom again. V16 said R4 would often say her bladder was still full after urinating and would request to be taken back to the toilet or commode. V16 said she instructed R4 to urinate in her incontinence brief and left the room. V16 said she was later called by another staff member as R4 was found on the floor between her bed and bedside commode. V16 said there was urine in the bedside commode. V16 said R4's fall was not witnessed and R4 complained of pain on her left side. V16 said at baseline, R4 had no issues with her mentation and would insist on using the bedside commode. On May 9, 2023, at 10:55 AM, V32 (Activity Aide) said on April 26, 2023, she was doing her rounds and saw R4 on the floor on the left side of her bed. V32 said she notified V16 (RN) that R4 had a fall. On May 9, 2023, at 12:33 PM, V32 said R4 does not like urinating in her incontinence brief and preferred to go to the toilet in the bathroom or on the bedside commode. V32 said all the staff taking care of her know she does not like to urinate in the incontinence brief. On May 9, 2023, at 11:55 AM, V30 (PT/Physical Therapist) said R4 prefers using the toilet and would not go in the brief. On May 9, 2023, at 11:56 AM, V31 (OT/Occupational Therapist) said if R4 was just toileted and requested to be toileted again, she would have taken the resident to the toilet or bedside commode, as R4 required assistance with toileting and ambulating. On May 9, 2023, at 10:14 AM, V28 (NP/Nurse Practitioner) said R4 had an unwitnessed fall on April 26, 2023, at 4:30 PM, and resulted in R4 requiring surgery for a fracture of the left hip. V28 said R4 did not have any injuries prior to the fall. When R4's progress notes were reviewed, a stricken-out progress note written by V16 on April 26, 2023, at 10:35 PM showed: received resident in bed in her room. She requested assistance for her to use bedside commode but explained that she can urinate in her diaper and will change her in the room. Resident insisted to stand and use bedside commode. Upon assessment resident was conscious and coherent, however resident verbalizes pain whenever her extremities were examined. Resident was lying on the floor until 911 arrived. On May 9, 2023, at 4 PM, V1 (Administrator) said if a resident needed to go to the toilet, the staff has to take the resident to the toilet. The hospital records dated April 26, 2023, at 3:46 PM documents the following: [AGE] year-old female to ED [Emergency Department] via EMS [Emergency Medical Services] from [facility] with complaints of left hip pain after unwitnessed fall from commode. [Patient] was on commode in room when staff heard a fall and walked in to find [patient] awake and alert on floor. [Patient] has complaints of left hip pain and cannot straighten out left leg. An X-ray of the left hip showed the X-ray was indicated due to the fall, and the impression was Displaced subcapital fracture of the left femoral neck. The EMR (Electronic Medical Record) showed R4 was admitted to the facility on [DATE]. R4 had multiple diagnoses including osteoarthritis of both knees, spinal stenosis, spondylosis, chronic kidney disease, need for assistance with personal care, difficulty in walking, and reduced mobility. R4's April 3, 2023, MDS (Minimum Data Set) showed R4 was cognitively intact, required extensive assistance for bed mobility, transferring, dressing, toileting, and personal hygiene. The MDS showed R4 was occasionally incontinent of urine and always continent of bowel. The facility's Urinary Continence and Incontinence revised March 2020 shows the staff is to assist the resident with his or her toileting needs at least every 2 hours and as needed. The assistance may include but is not limited to checking and changing if incontinent or assist the resident to the toilet as needed.

Based on observation, interview, and record review the facility failed to ensure a resident with a current UTI (Urinary Tract Infection) had orders for an indwelling catheter and failed to change the indwelling catheter. This resulted in R26 experiencing chronic UTIs with the need for IV (intravenous) antibiotic treatment. The facility failed to provide incontinence care in a manner to meet professional standards. These failures apply to 2 of 7 residents (R26, R95) reviewed for catheter and bladder care in the sample of 35. The findings include: 1. On 1/24/23 at 11:09 AM, R26 was lying in bed with an IV antibiotic connected to the IV site in his right hand. R26 had an indwelling catheter. The tubing of the catheter was hazy, and it was difficult to visualize the urine in the tubing. R26's catheter drainage bag was draining dark, amber urine with copious amounts of white sediment. On 1/25/23 at 2:39 PM, V5 (Wound Care Coordinator) and V13 (Wound Care Nurse) were providing incontinence care and wound care to R26. During this process, R26's indwelling catheter appeared stiff and dirty from the meatus to halfway down the catheter. R26's catheter was draining dark, amber urine with sediment. R26's Face Sheet dated 1/26/23 showed diagnoses to include, but not limited to stroke; disorders of kidneys and ureters; sepsis; CHF (Congestive Heart Failure); diabetes; dementia; bladder-neck obstructions; need for assistance with personal care; kidney stones; BPH (Benign Prostatic Hyperplasia); microcephaly; reduced mobility; ESBL (Extended Spectrum Beta Lactamase) Resistance of the urine; diabetes; and unspecified intellectual disabilities. R26's Physician Order Sheet (POS) dated 1/26/23 did not contain an order for R26's indwelling catheter to include size, type, balloon size, and diagnosis for the indwelling catheter. R26's POS did not include an order to change R26's catheter or drainage system. The only order for R26's indwelling catheter on the POS was, Foley catheter care q (every) shift and PRN (as needed) - notify the physician of changes and/or irritation at the site . R26's Medication Administration Record (MAR) for November 2022, December 2022, and January 2023 showed R26 did not have orders for his catheter or for changing the catheter or drainage system. R26's Progress Notes were reviewed from November 2022 to January 25, 2023. There were no notes that showed R26's catheter or drainage system had been changed. The surveyor requested the facility provide documentation of R26's most recent catheter change. The facility was unable to provide documentation. R26's Provider's Progress Note dated 1/23/23 at 9:17 AM, showed, Patient is a poor historian due to cognitive/psychiatric impairment. Chief Complaint/Reason for Visit: UTI, recent adynamic ileus, leukocytosis, debility, anemia, hypertension, and CHF. HPI (History and Physical Information) relating to this visit: pt (resident) with recent + urine cx (culture), started on IV atb (antibiotics) . On 10/11/22 pt was sent to [local hospital] with vomiting and abd (abdominal distension) . Seen by ID (Infectious Disease) and was s/p (status post) IV atb treatment. Hospital course complicated by urine retention, failed Foley trial catheter was reinserted on 10/22/22 with plans to f.u. (follow-up) with urology in 2-4 weeks . On 10/27/22 pt was sent to ED (emergency department) with fever and anemia. Limited records available for review. pt admitted for Sepsis 2/2, GB (gallbladder) fossa abscess/phlegmon. Followed by ID and antibiotic course completed .Medications/Allergies: . Meropenem (antibiotic) Intravenous Solution Reconstituted 1 GM (gram) intravenously every 8 hours for UTI for 7 days . Review of systems: .Fever, + Gen (generalized) weakness . Awake, alert, no acute distress, calm, cooperative, appears comfortable . Decreased mobility, poor strength . Laboratory 1/2/23 urine cx = .ESBL 50-100,000 colonies/ml . 1/18/23 .ESBL GREATER THAN 100,000 COLONIES/ML . Assessment/Plan: UTI - Urinary Tract Infection: Recurrent on 12/9/22 urine cx Pseudomonas aeruginosa GREATER THAN 100,000 COLONIES/ML - completed Cipro at that time. 1/2/23 urine cx = .ESBL 50-100,000 COLONIES/ML - now to completed macrobid per sensitivities. 1/15/23 urine cx collected and resulted. 1/18/23 = .ESBL GREATER THAN 100,000 COLONIES/ML = discussed with [physician] per sensitivities will start Meropenem IV, pharmacy to dose . F/U (Follow-up) with urology as directed 2/17/23 .Acute retention of urine: see by [doctor] at hospital. Foley. To follow up with urology as otpt (outpatient) for bilateral renal stones . The surveyor requested R26's most recent Urology Visit Note. The facility was unable to provide documentation. On 1/26/23 at 9:35 AM, V3 (Director of Nursing/DON) said there is an order set for residents that require an indwelling catheter. V3 stated, The order set includes the type and size of the catheter. I'm not sure that the order shows the diagnosis for the catheter. Does the diagnosis have to be part of the order? It's under the diagnosis section. The order set also includes the orders to change the catheter and the drainage system. If the doctor doesn't specify a time, then it is based on nursing assessment of the catheter. They should look to see if the catheter is intact and flowing. Hazy drainage tubing should be changed. That would just require a drainage system change. The catheter should not be stiff or dirty. I would have to look at it, but it sounds like the catheter should also be changed. If the staff are not changing the catheter or drainage system, then the resident's risk for UTI increases. The surveyor asked V3 to find documentation that R26's catheter had been changed and the most recent urology visit. The facility was unable to provide that information. On 1/26/23 at 11:44 AM, V19 (Licensed Practical Nurse/LPN) said she was the nurse for R26. V19 said R26 was dependent on staff of all care. V19 said R26 was on IV antibiotics for a UTI. V19 was not sure when R26's catheter had been changed last. The facility's Use of an Indwelling Urinary Catheter Policy (dated 2013) showed, .The facility is responsible for the assessment of the resident at risk for urinary catheterization and/or the ongoing assessment for the resident who currently has a catheter. This is followed by implementation of appropriate individualized interventions and monitoring for the effectiveness of the interventions. The facility's Catheter Care Policy (dated 2013) showed, Daily catheter care will be done to prevent infection. A physician's order is required . 34891 2. R95's Face Sheet dated 1/25/23 showed diagnoses including but not limited to dementia, psychotic disturbance, mood disturbance, and anxiety. R95's facility assessment dated [DATE] showed severe cognitive impairment and staff assistance required for bed mobility, transfers, toilet use, and personal hygiene. The same assessment showed R95 is frequently incontinent of urine and bowel. On 1/24/23 at 12:39 PM, R95 was in bed and lying on a cloth incontinence pad. The pad had a brownish/yellow dried ring of urine on it. V14 (Certified Nurse Aide/CNA) stated R95 wets a lot and needs to be checked every few hours for incontinence. At 1:15 PM, V14 and V17 (CNAs) provided incontinence care for R95. Both CNAs donned gloves and rolled R95 to the side. R95's incontinence brief was heavily soaked through with urine. R95's bed pad and gown were saturated with urine. V14 stated incontinence checks should be done every few hours and the resident changed if they are wet. Bed pads and linens need to be changed if urine or stool are on them. V14 and V17 rolled R95 from side to side wearing gloves and removed the wet brief and wet linens. V14 wiped R95's buttocks and repeatedly used the contaminated gloves to reach into the peri wipe container. V14 wore the same gloves while touching the room curtain, new brief, new fitted sheet, new bed pad, new gown, and resident's body. V14 and V17 put a fresh incontinence brief on R95 and taped it closed. At no time was cleansing done to R95's front vaginal area. At 1:32 PM V17 (CNA) stated We need to change our gloves when they are soiled and after wiping incontinent residents. I knew I should have changed my gloves after wiping the urine, but I was busy holding R95. At 1:37 PM, V14 (CNA) stated Urine-soaked skin needs to be cleaned to prevent skin tears and urinary tract infections. It is an infection control thing. I just forgot to clean her front area and change my gloves. On 1/26/23 at 9:25 AM, V3 (Director of Nurses) stated pericare always involves cleansing the front and back of a urine-soaked resident. Urine left on the skin can burn and cause breakdown. Gloves need to be changed when soiled or contaminated. Aides should stop and get fresh gloves before touching anything to control the spread of germs. The facility's Perineal Care policy, revision dated 10/2010, states under the steps in procedure section: 9. For a female resident .b. Wash perineal area, wiping from front to back. (4). Gently dry perineum. The same policy states: 12. Remove gloves and discard into designated container. Wash and dry your hands thoroughly.

Based on observation, interview, and record review the facility failed to administer tube feedings to a resident in a manner to prevent aspiration and failed to administer a tube feeding according to the physician orders for 3 of 6 residents (R224, R111, R45) reviewed for tube feedings in the sample of 35 and 1 resident (R137) outside the sample. These failures resulted in a significant weight loss for R224. The findings include: 1.R224's face sheet showed a [AGE] year-old male with diagnoses of pneumonitis due to inhalation of food and vomit, dysphagia, cerebral infarction, sepsis, diabetes, hypertension, spinal stenosis, gastrostomy and myocardial infarction. On 01/24/23 at 11:34 AM, R224 was lying flat in bed. R224 was receiving a tube feeding at 90 milliliters (ml)/hour (hr) through a pump. The tube feeding container's label showed the solution was started at 3:00 AM. At 01:16 PM, R224 was supine in bed. The tube feeding pump was off and the tubing was still attached to R224. There was tube feeding solution in the tubing. On 01/25/23 at 09:58 AM, R224 was lying flat in bed. R224 was receiving a tube feeding 1.5 at 51 ml/ hr. The feeding solution label showed the tube feeding was started at 3:40 AM. On 01/26/23 at 09:26 AM, V3 (Director of Nursing/DON) said A resident receiving a tube feeding should be in an upright position to prevent aspiration. No one with aspiration precautions should receive a tube feeding while lying flat in bed because I don't want them to choke. On 01/26/23 at 11:24, V11 (Dietician) said The staff doesn't contact me regularly about consults or weight loss trends. I see residents as soon as significant weight change noted. When I see them (the residents), I put recommendations directly in the orders so everyone can see. If I order it, then I'm expecting every one to be done. I do the calorie recommendations. They don't have the types of feedings that I want to use, so they are having to do substitutions. As long as the resident is receiving a higher calorie content feeding (1.5 is > 1.2) then it is fine to stay at the same rate. There wouldn't be a problem. But if they substitute for a lower calorie feeding, then the rate would need to be adjusted to meet the calorie needs. I expect the substitutions to be temporary. I order a certain formula because that is what is best for the resident. If the facility cannot obtain that specific formula, then they should tell me. I will need to do additional calculations for the feeding available. I expect the tube feedings to run at the rate I have ordered. The rate is determined by the calorie needs of the residents. If it is running slower, then the resident is not getting all the necessary calories required. This could lead to weight loss and be detrimental to wound healing. The rate and timing of the tube feeding is all determined by the calorie calculations. I would expect that the residents received their tube feedings at the appropriate times to ensure they are getting adequate nutrition. A resident on tube feeding should not be malnourished. If the tube feeding is not hung at the appropriate times, then that would be a problem. They should be following the schedule. And if they are not, then I should be notified. R224's physician order sheet (POS) showed a 1/17/23 order for {Name brand} 1.2 at 90 ml/hr, on at 10:00 AM and off at 7:00 AM. R224's weight record showed a December 12/7/22 weight of 162.8 pounds. R224's 1/6/23 weight was 150 pounds, a significant weight loss of 12.8 pounds. R224's care plan showed a significant weight loss of 7.9% in one month. There were no new care plan interventions after the significant weight loss was recorded. R224's 1/9/23 facility assessment showed moderate cognitive impairment. This assessment showed he was totally dependent for bed mobility, transfer, dressing, eating, toilet use, personal hygiene, and bathing. R224's care plan initiated 12/13/22 showed the resident needs the head of the bed elevated 45 degrees during and 30 minutes after tube feed. The facility's 12/2011 Enteral Nutrition Policy documents Adequate nutritional support through enteral feeding will be provided to residents as ordered. Risk of aspiration will be assessed and addressed in the individual care plan. Risk of aspiration may be affected by diminished level of consciousness, moderate to severe swallowing difficulties, and improper positioning of the resident during feeding. 34491 2. R137's Admission Record printed by the facility on 1/26/23 showed she had diagnoses including hemiplegia and hemiparesis following a cerebral infarction (paralysis and weakness affecting one side following a stroke), dysphagia (difficulty swallowing foods or liquids), following cerebral infarction aphasia (a disorder that affect how you communicate. It can impact your speech, as well as the way you write and understand both spoken and written language), and gastrostomy status (g-tube). R137's facility assessment dated [DATE] section C does not show a BIMS (Brief Interview for Mental Status) score. The assessment showed R137 had modified independence with her cognitive skills for daily decision making. The assessment also showed R137 was dependent on staff for eating (includes intake of nourishment by tube feeding). R137's Order Summary Report, provided by the facility on 1/26/23, showed Enteral Feed Order every shift {Name brand} 1.2 at 77 cc/hr (cubic centimeter an hour-cc measurement is the same as ml measurement) x 21 hours. R137's care plan initiated on 11/4/22 showed she requires tube feedings of {Name brand} 1.2 related to dysphagia. The care plan showed Provide GTF (g-tube feedings) as ordered. The care plan also showed RD (Registered Dietitian) to evaluate quarterly and PRN (as needed). Monitor caloric intake, estimate needs . R137's cognition care plan initiated on 11/5/21 showed she had impaired cognitive function/dementia or impaired thought processes related to difficulty making decisions, disease process cerebral infarction, impaired decision making. R137's Weights and Vitals Summary, provided by the facility on 1/26/23, showed a 3.4 pound weight loss from 1/20/22-12/15/22. R137's most recent Registered Dietitian (RD) assessment was requested three times. R137's last name was spelled when requested two of the times. The RD assessment for two different residents were provided. R137's RD assessment was not provided. On 1/24/23 at 1:52 PM, R137's tube feeding showed it was started at 4:00 AM. The container was a 1,500 ml (milliliter) container. The pump that delivers the tube feeding showed it was running at 70 ml/hr (milliliters an hour). The container still had 1,320 ml in the bottle. V33 (Licensed Practical Nurse/LPN) verified the bottle showed it was started at 4:00 AM. V33 said it is a 1500 ml container running at 70 ml/hr. V33 said the order is 70 ml/hr continuous for 21 hours. V33 said the bottle showed 1,320 ml were still in the bottle. V33 said the feeding is stopped during R137's bed bath, when flushing the g-tube and when giving medications. V33 was not able to explain why there was such a discrepancy in the amount that should have already been delivered (if three hours was subtracted, due to being ordered for 21 hours, that would still leave six hours and 52 minutes that should have been delivered. 7 times 70 equals 490 ml. 1500-490 equals around 1,010 ml that should be left in the bottle). On 1/26/23 at 11:04 AM, R137's tube feeding bottle showed {Name brand} 1.5 running at 70 cc/hr. The bottle showed it was started on 1/25/23 at 11:00 PM. 560 ml of feeding was still left in 1,000 ml bottle. (If started at 11:00 PM on 1/25/23 and three hours is subtracted for down time, that leaves 9 hours the feeding should have been delivered. 9 x 70 ml/hr = 630 ml that should have been delivered. The bottle showed only 440 ml had been delivered since 11:00 PM on 1/25/23). 3. R111's Admission Record, provided by the facility on 1/26/23, showed she had diagnoses including dementia, Alzheimer's disease, dysphagia (difficulty swallowing foods or liquids), protein-calorie malnutrition, and gastrostomy status (g-tube). R111's facility assessment dated [DATE] showed she had severe cognitive impairment and was dependent on staff for eating (includes intake of nourishment by tube feeding). R111's care plan initiated on 12/20/21 and last updated on 10/8/22 showed R111 requires tube feedings of {Name brand} 1.2 at 65 ml x 21 hours. The care plan documented R111 is dependent with tube feeding and water flushes. The care plan also showed RD (Registered Dietitian) to evaluate quarterly and PRN (as needed); monitor caloric intake, estimate needs, make recommendations for changes to tube feeding as needed. R111's RD assessment dated [DATE] showed Tube feeding {Name brand} 1.2 at 65 ml/hr x 21 hours a day. On at 10:00 AM, off at 7:00 AM. The assessment showed R111's current enteral (tube) feeding provides 1,430-1,716 kcal/ml fluid per day (kcal is short for kilocalories, which is another word for calories). R111's Order Summary Report, printed by the facility on 1/26/23, showed an order for Enteral Feed Order every shift administer feeding. Formula {Name brand} 1.2. Rate 65 ml per hour x 21 hours a day. Off at 7:00 AM. On at 10:00 AM. On 1/24/23 at 11:05 AM, R111 was lying in bed with head of bed up. The tube feeding bottle showed she was receiving {Name brand} 1.5 at 65 ml/hr. The container showed it was started at 4:00 AM. 890 ml were left in the 1,000 ml container. V16 (Nurse) verified {Name brand} 1.5 container showed it was started at 400 AM on 1/24/23. V16 verified that there was 890 ml in the container at that time and the pump was running at 65 ml/hr. V16 said it should have less in the container if it was started at 4:00 AM and it is now 11:05 AM. V16 said it should have delivered 260 ml. V16 said it should have about 760 ml in the container. On 1/25/23 at 9:41 AM, R111's tube feeding was {Name brand} 1.5. The machine was off. The bottle showed it was started at 1:47 AM. There were 840 ml left in the 1,000 ml bottle. (If started at 1:47 AM and stopped around 7:00 AM, that would be around 5 hours. 5 x 65 = 325 ml that should have been provided. The bottle showed only 160 ml were delivered). On 1/26/23 at 11:24 AM, V11 (Registered Dietitian) said she does the calorie recommendations. V11 stated They don't have the types of feedings that I want to use, so they are having to do substitutions. As long as the resident is receiving a higher calorie content feeding (1.5 is > 1.2) then it is fine to stay at the same rate. V11 said she expects the tube feedings to run at the rate she has ordered. The rate is determined by the calorie needs of the residents. If it is running slower, then the resident is not getting all the necessary calories required. This could lead to weight loss and be detrimental to wound healing. The rate and timing of the tube feeding is all determined by the calorie calculations. V11 said she would expect that the residents received their tube feedings at the appropriate times to ensure they are getting adequate nutrition. If the tube feeding is not hung at the appropriate times, then that would be a problem. They should be following the schedule. V11 said if they are not, then she should be notified. Facility Enteral Nutrition policy, with a revision date of December 2011, showed Adequate nutritional support through enteral feeding will be provided to residents as ordered. 39537 4. On 1/24/23 at 11:19 AM, R45 was lying in bed with his tube feeding running at 65 ml/hr by pump. The tube feeding bottle was dated 1/24/23 at 3 AM. R45's lips and oral mucous membranes appeared dry and crusty. On 1/26/23 at 10:18 AM, V20 (Licensed Practical Nurse) stated R45's tube feeding is on hold right now, but I believe it was running at 65 ml/hr. I can go check. V20 entered R45's room and turned the feeding pump on. The tube feeding was set at 65 ml/hr. The surveyor asked V20 why R45's Medication Administration Record (MAR) showed two different rates (65 ml/hr and 80 ml/hr). V20 replied, I'm not sure, I would have to look. V20 opened the MAR, saw both orders, but did not clarify the answer any further. R45's face sheet printed 1/25/23 showed diagnoses to include, but not limited to acute respiratory failure, aspiration pneumonia, sepsis, diabetes, unspecified convulsions, iron deficiency anemia, schizoaffective disorder, dementia, reduce mobility, need for assistance with personal care, severe protein-calorie malnutrition, osteoarthritis, dysphagia, stroke, and muscle wasting and atrophy. R45's facility assessment dated [DATE] showed he had moderate cognitive impairment; was totally dependent on staff for bed mobility, transfers, toilet use, and personal hygiene; was always incontinent of bowel and bladder; and pressure ulcers. R45's Weight and Vitals Summary printed 1/25/23 showed on 1/17/23 R1 weighed 140 pounds. R45's Braden Scale for Predicting Pressure Sore Risk dated 1/13/23 showed R45 was at High Risk, with a score of 11. R45's Physician Order Sheet showed an order on 1/17/23 of {Name brand formula} 1.2 at 80 ml/hr x 21 hours. R45's January 2023 MAR showed, Enteral Feed Order every shift {Name brand} 1.2 at 65 ml/hr x 21 hours/day (start date - 1/13/23). This entry was signed out as administered as ordered. However below this entry, the MAR showed, Enteral Feed Order every shift {Other Name brand} 1.2 @ 80 ml/hr (Start date 1/17/23). This order was only signed out on 1/25/23 and once for the day shift of 1/26/22, by V20 (LPN). V20 could not explain why. On 1/26/23 at 11:24 AM, V11 (Dietician) said she uses the weights and the residents current tube feeding order to determine if the resident is receiving adequate calories and nutrition. V11 stated I expect the tube feeding formula and rate to be correct. If it's not, then the resident is not receiving the nutritional needs that I assessed. If the rate is running too slow, then the resident is not getting all the calories needed. This could lead to weight loss and be detrimental to wound healing. The rate and timing of the tube feeding are determined by the residents' caloric needs. If the facility is not following the orders, then they should be notifying me. This is very frustrating.

Based on observation, interview, and record review the facility failed to prevent severe unplanned weight loss, failed to ensure weights were performed as ordered, and failed to implement interventions after a significant weight loss for 6 of 7 residents (R205, R56, R143, R99, R124, R35) reviewed for nutrition in the sample of 35. These failures resulted in R205 sustaining a severe 20.33% weight loss over 6 months and R56 sustaining a severe 16.18% weight loss over 2 months. The findings include: 1. R205's face sheet printed on 1/26/23 showed diagnoses including dementia with behavior disturbance, anxiety, depressive disorder, and psychosis. R205's facility assessment dated [DATE] showed moderate cognitive impairment and staff assistance needed for setup during eating. The same assessment showed a 5% or more weight loss in the last 6 months and R205 not on a physician-prescribed weight-loss regimen. R205's weights were reviewed for the last six months. The weight summary report showed on 8/18/2022 a weight of 164.8 pounds and on 1/26/2023 at weight of 131.3 pounds (loss of 20.33% in six months.) R205's physician orders showed an order start dated 11/22/22 for daily weights. R205's weights were reviewed from 11/3/22 to 1/26/23 and showed only 7 days those weights had been taken. R205's nutrition/dietary note dated 11/16/22 showed an identified significant weight loss in October of 6.9% and a continued significant weight loss of 10.2% in November. The note stated downward weight trend noted. Goal is for weight maintenance. On 1/26/23 at 11:27 AM, V11 (Dietician) stated any resident with a 10% or more weight loss in 6 months is considered a significant weight loss and nutritional supplements should be added right away. Supplements and/or fortified foods should be ordered, and a physical assessment is needed. The resident should be assessed for the ability to eat alone, as well as laboratory and skin assessments done. The assessments and interventions should be implemented right away to prevent further weight loss. Weights should be done as ordered to catch further weight loss. If weights are not done as ordered there is no way the dietician can review the report and start additional weight loss interventions. R205's care plan was reviewed for nutrition and showed a focus area of risk for malnutrition as indicated by the nutritional assessment done on 9/14/22. The focus area addressed the October and November significant weight loss triggers, however the interventions did not. The last nutritional intervention was on 6/20/22 (same month as admission to the facility). The facility Nutrition (Impaired)/Unplanned Weight Loss policy revision dated 5/12/22 states under the assessment and recognition section: 1. The nursing staff will monitor and document the weight and dietary intake of resident in a format which permits readily available comparisons over time. 3. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .6 months-10% weight loss is significant; greater than 10% is severe. 31615 2. R56's admission sheet documents she was admitted to the facility on [DATE] with a primary diagnosis of multiple sclerosis (MS). The facility assessment of 11/8/22 shows R156 to have severe cognitive impairment. The order summary sheet for active orders of January 2023 shows R56 to have a monthly weight. The weights and vitals summary shows a documented weight of 158.9 pounds in January 2022, March and April 2022 she was 148. 6 pounds. No further weights were documented until August 2022, and R56 was 144.8, and the next weight was November 2002 and R56 was down to 136 pounds. No further weight was documented. On 1/26/23, V22 and V23 (Restorative Nurses) said the restorative department was responsible for monthly weights and monitoring. V22 said the restorative aides do the monthly weights and if there is a daily weight, nursing will complete those weights. V22 said For new admits we do the initial weight and the first 4 weekly weights. V23 said Every resident should be weighed every month with or without a physician order. The dietician will review the weights every month, then she will let us know if a re-weight needs to be done. The restorative aides will get those weights. The weights are documented in the computer under the weights and vitals. V22 said weekly weights would be done by nursing, and the order would be on the MAR/TAR (Medication Administration Record/Treatment Administration Record). V22 said R56 was weighed yesterday and she weighed 114 pounds. V22 said R56 has MS and now needs to be fed by staff. V22 said the last weights were done in November because the restorative aides were pulled to work on the floor, so the weights do not get done. V22 and V23 said they both get pulled off restorative duties to work on the floor as well. V22 said no weights were done for September or October. The nutrition/dietary note of 1/26/23 shows V11 documented a note for weight loss. The progress note shows R56 to be 62 inches in height and weighed 114.4 lbs, low for her age. The note shows a 15.9% weight loss over 2 months. On 1/25/23 at 9:00 AM, V24 was observed sitting at R56's bedside feeding her breakfast. V24 said R56 used to be able to feed herself but now she needed to be fed by staff. R56 was lying in bed with the head of the bed elevated. R56 appeared to have a flat affect and did not respond to verbal conversation. R56's care plan shows R56 to be at risk for malnutrition related to disease process of MS, dementia and comorbidities. The interventions include notify the physician/RD of weight change greater than 5% in one month time and weigh the resident daily or monthly as needed. 3. R143's admission record shows she was admitted to the facility on [DATE] with a primary diagnosis of dementia. The 1/11/23 facility quarterly assessment shows R143 to have severe cognitive impairment. The same assessment shows her to be 60 inches in height and weighing 98 pounds. The assessment shows a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months, and she is not on a physician-prescribed weight-loss regimen. R143's weights and vitals summary documents weights January thru May 2022, the next weight was September 2022 at 107.2 pounds, and R143 was not weighed again until November, and she was down to 97.6 pounds, a 9% weight loss. R143 was seen by her primary physician on 1/14/23 and ordered nursing to obtain a weekly weight. The order was acknowledged by the RN on duty. The weight and vitals summary and progress notes were reviewed and show no weights were obtained after the physician order for weekly weights. On 1/26/23 at 10:34 AM, V3 (Director of Nursing/DON) said the restorative department is responsible for obtaining weights, including all weekly and monthly weights. She said they will they take the weights and give a copy to her and dietary. The RD will review as well. On 1/26/23 at 9:30 AM, V22 said weekly weights would be done by nursing. 4. The admission record for R99 shows she was admitted to the facility on [DATE]. The order summary sheet shows 2 active orders for weights. Both orders were placed on 12/9/22. One order is to obtain daily weights. Notify MD if weight gain of more than 2 lbs (pounds) per day or more than 5 lbs in one week. The second order is to weigh the guest weekly for 4 weeks. R99's weights and vitals summary shows she was weighed on 12/12/22, and 1/19/23. No weights were documented for a daily weight or weekly weight as ordered. 35175 5. R124's face sheet showed a [AGE] year-old male with diagnoses including severe protein calorie malnutrition, sepsis, malignant neoplasm of the anus and rectum, gastrostomy, colostomy, and metabolic encephalopathy. R124's weight record showed a 11/3/22 weight of 112 pounds. This record showed he was 70 inches (5 foot 10 inches) tall. R124's 12/2/22 weight was 103 pounds, and 8% weight loss in one month. There was no January weight on record. R124's nutritional care plan showed no new interventions since it was initiated on 10/23/22. Interventions included weigh at the same time of day monthly and as needed and record. 39537 6. On 1/24/23 at 10:49 AM, R35 was lying in bed on his back with his feet crossed. R35 had contractures to his bilateral upper extremities at his elbows, wrists, and hands. R35 appeared frail and the outlines of his bones were prominent. R35 had thickened water and orange juice on his bedside table. R35 said he had to drink thick liquids because he choked and ended up with pneumonia. R35's catheter drainage bag contained dark amber urine. R35's face sheet dated 1/25/23 showed diagnoses to include, but not limited to Parkinson's Disease; influenza; RSV (respiratory syncytial virus); sepsis; COPD (chronic obstructive pulmonary disease); CHF (congestive heart failure); osteoarthritis; depression; anxiety; need for assistance with personal care; dementia; and insomnia. R35's facility assessment dated [DATE] showed he was cognitively intact; was setup and supervision for eating; and had a Stage III pressure ulcer. R35's Weights and Vitals Summary printed 1/25/23 showed on 10/17/22 he weighed 141.3 pounds and on 11/14/22 he weighed 135 pounds (demonstrates a 4.46% weight loss in 1 month). R35's weight summary showed that his weight was trending down over the last year. R35 did not have any weights entered after 11/14/22. R35's Physician Order Sheet dated 1/25/23 showed he had orders for nectar thick liquids; a frozen nutritional treat BID (2 times a day) at lunch and dinner; and nutritional shake supplement TID to support weight gain. R35's Care Plan (initiated 7/7/21) showed, The resident is at risk for malnutrition per Mini Nutrition Assessment score of 9. Potential for weight changes d/t (due to) disease processes of Parkinson's Disease, dementia, and major depressive disorder. On nectar thick liquids secondary to dysphagia . Reviewed 11/23/22 . Interventions: Assist with feeding resident as needed . Monitor weight monthly or per facility protocol . R35s 11/23/22 Dietary Assessment showed he was at risk for malnutrition and underweight. A gradual weight loss and fluctuation is noted . On 1/26/23 at 11:24 AM, V11 (Dietician) said she just started covering the facility on 1/17/23. V11 stated, I saw a lot of problems at the facility and missing weights. The weight trends are based on the information entered in to the EMR (Electronic Medical Record). If a weight was not done, then the weight trends will not be accurate. I usually print a report when I go the facility. If I notice that weights haven't been done, then I follow-up with emails and phone calls to management. Sometimes the weights get done and sometimes they don't. It's been difficult to get weights at the facility. It's very frustrating. I can't calculate appropriate dietary recommendations for the resident without appropriate weights and resident information. The EMR calculates the weight loss and will show a trigger when significant weight loss occurs. It doesn't notify me or the staff of weight loss, but it will show up when you print the report. The facility staff does not regularly contact me about weight loss. The front-line staff are the most valuable source of information related to a residents' intake and weights. I try to see residents with significant weight changes as soon as possible. If the resident hasn't had a weight done in 2 months, then I would have no way of knowing if they have experienced a significant weight loss. I enter my recommendations directly into the EMR and I expect those interventions to be completed.

Based on interview and record review the facility failed to ensure medication for the treatment of [REDACTED]. This applies to one of three residents (R1) reviewed for a change in condition. Facility's failure to identify R1's worsening respiratory condition and [MEDICAL CONDITION] status resulted in R1's transfer to the hospital for acute care of the resident, who died shortly afterward. According to the death certificate the contributing factor for R1's death was [MEDICAL CONDITION]. Findings include: Record review on nursing progress note dated on [DATE] at 11:13 AM document that R1 was observed with weakness, having hard time verbalizing needs, cough, and congestion and had hard time standing up. Record review on physician order sheet indicates that V1 (attending physician) ordered immediate (stat) chest X-ray on [DATE] at 10:41 AM. Record review on medical diagnostic service document stat X-ray was done at 1:56 PM. Record review on nursing progress note entered on [DATE] at 7:29 AM (Late entry) document that stat X-ray results got delayed and facility received result after 13 hours on [DATE] at 3:00 AM. On [DATE] at 2:20 PM V2 (Director of Nursing) stated, The X-ray results for R1 ordered on [DATE] was delayed because of something going on with X-ray company that I had no control over it. On [DATE] at 2:35 PM V1 stated, Stat X-ray results are expected as soon as possible (ASAP). Record review on Diagnostic imaging indicates [MEDICAL CONDITION] and right lung pneumonia. V1 was notified on this diagnostic result and V1 ordered [MEDICATION NAME] 500 milligram (mg) oral and O2 inhalation 3 litter per minute. No interventions were ordered for [MEDICAL CONDITION] as shown on X-ray. Record review on physician order sheet document that R1 was not on any diuretic for [MEDICAL CONDITION]. Record review on nurse's progress note entered on [DATE] at 3:16 PM (Late Entry) indicates that R1 noted with crackles upon auscultation and congestion at around 10:30 AM on [DATE]. V1 was notified again on [DATE] at 11:30 AM to update on R1's worsening condition. V1 discontinued [MEDICATION NAME] due to antibiotic reaction and ordered [MEDICATION NAME] 250 mg daily and 500 milliliter (ml) intravenous fluid (D5W) at 60 ml per hour (due to dehydration). On [DATE] at 3 PM, facility contacted V1 again to inform the worsening condition and family's preference to transfer to another hospital. R1 was picked up at 4:15 PM by ambulance to transfer to local hospital. On [DATE] at 8:50 AM, V1 stated, Yes, yes I did everything from my ethical stand point to save R1. He had weak heart and infection and we treated him with antibiotic. I gave verbal order for [MEDICATION NAME] for his fluid overload. Record review on physician order sheet indicate that there was no physician order for [REDACTED]. On [DATE] at 9:30 AM V2 stated, We didn't have any [MEDICATION NAME] order from V1. We have many patients with congestion and shortness of breath. R1 didn't have any [MEDICAL CONDITION] or worsening [MEDICAL CONDITION] symptoms to send him out to hospital immediately. Facility presented policy on emergency transfer or discharge (dated on ,[DATE]) policy statement document: Our facility shall make an emergency transfer or discharge when it is in the best interest of the resident. Record review on emergency room (ER) records indicate that R1 had oxygen saturation 81% and chest x-ray indicates severe [MEDICAL CONDITION] and fluid overload. Death certificate indicates that R1 expired on [DATE] in the local hospital due to [MEDICAL CONDITION] and ventricular [MEDICAL CONDITION].