Every finding on record at Palm Terrace Care Center

Based on interview and record review, the facility failed to ensure the physician was notified when the blood sugar (BS) was above 250 mg/dl (milligram/deciliter - unit of measurement) according to the physician's order, for one of three residents reviewed (Resident 3). This failure had the potential for Resident 3's blood sugar to be uncontrolled and could result to complications. Findings: On July 10, 2026, at 11:21 a.m., an unannounced visit to the facility was conducted to investigate quality-of-care issues. On July 13, 2026, Resident 3's record was reviewed. Resident 3's Face Sheet, indicated the resident was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (DM - abnormal blood sugar). A review of Resident 3's Order Recap Report, included a physician's order, dated May 15, 2025, which indicated, .FINGERSTICK BLOOD SUGAR CHECK BID (twice a day). CALL MD (medical doctor) IF BG (blood glucose) GREATER THAN 250 OR LESS THAN 70 . A review of Resident 3's Medication Administration Record, for the month of May 2025, indicated Resident 3's blood sugar was above 250 mg/dl on the following dates and times: -May 27, 2025, at 4:30 p.m. 251 mg/dl; and -May 28, 2026, at 6:30 a.m.; 284 mg/dl. Further review of Resident 3's record indicated the physician was not notified of the blood sugar above 250 mg/dl on the above dates. On July 13, 2026, at 10:30 a.m., a concurrent interview of review of Resident 3's record was conducted with the Director of Nursing (DON). the DON stated when a resident is admitted to the facility and has diagnosis of DM with no diabetic medications, the facility would initiate an order to check the BS twice a day and refer to the physician if the BS is below 70 mg/dl or above 250 mg/dl. The DON stated Resident 3's BS was above 250 mg/dl on May 27 and 28, 2025. The DON stated the physician was not notified when Resident 3's BS was above 250 mg/dl. The DON stated the physician should have been notified of the BS above 250 according to the physician's order. A review of the facility's undated policy and procedure titled, Diabetes Management in the Post-Acute and Long-Term Care Setting, indicated, .When to Call the Practitioner .A systematic facility approach to diabetes management can streamline day-to-day care and reduce the frequency of episodes of hypoglycemia (low blood sugar), hyperglycemia (high blood sugar), and other acute metabolic complications .Facility may consider implementing the following .Standing orders for BGM (blood glucose monitoring) and practitioner notification that are approved by the primary care practitioner when the patient is admitted .The practitioner should be called as soon as possible when .The patient has 2 (two) or more blood glucose readings higher than 250 mg/dl (milligram/deciliter - unit of measurement) within a 24-hour period if this is accompanied by a new medical problem or a change in condition or functional status and the patient's treatment has not already been initiated or modified .

Based on observation, interview and record review, the facility failed to ensure wound and care and management for pressure injuries (PI - (localized damage to the skin and underlying tissue, caused by prolonged, intense pressure, friction, or shear forces that cut off blood supply to vulnerable areas, typically over bony prominences like the heels, tailbone, and hips) were provided, for two of three residents reviewed (Residents 1 and 2), when: 1.For Resident 2, there was no complete wound assessment conducted when the resident was readmitted back to the facility; and 2.For Resident 1, there was no complete wound assessment conducted on October 22, 2025. In addition, the wound physician (WP)'s treatment recommendation was not carried out as ordered. These failures had the potential for the delay in the care and treatment of the residents' wound, and could affect overall health condition. Findings: On July 10, 2026, at 11:21 a.m., an unannounced visit to the facility was conducted to investigate quality-of-care issues. On July 10, 2026, at 11:34 a.m., during an interview conducted with the Director of Nursing (DON), the DON stated the Treatment Nurse (TXN) works Monday to Fridays and completes wound assessments on admission and weekly thereafter, conducts rounds with the wound consultants (physician or nurse practitioner) weekly and carries out treatment recommendations from the wound consultants. On July 10, 2026, at 12 p.m., during an interview conducted with the TXN, the TXN stated the following: -She would conduct wound assessments on admission and weekly thereafter; -She does rounds with the wound consultants and carry out their recommendations after the rounds; -The wound physician (WP) would come every Wednesdays and looks at major wounds such as pressure injuries (localized damage to the skin and underlying tissue, caused by prolonged, intense pressure, friction, or shear forces that cut off blood supply to vulnerable areas, typically over bony prominences like the heels, tailbone, and hips), diabetic and venous ulcers (open skin sores on the lower limbs caused by different chronic medical conditions); -During the rounds with the WP, she would document in a facility document spreadsheet titled Skin Summary, wound assessments and treatment recommendations; -The Wound Nurse Practitioner (WNP) sees the residents approved by the medical group every Tuesdays, documents the assessments in the residents' electronic health record within 24 hours from visit. The TXN provided a list of current residents with skin breakdown and type of wound present and currently being treated. 1.On July 10, 2026, at 12:37 p.m., a concurrent observation and interview was conducted with Resident 2. Resident 2 was observe lying on a low air loss mattress (a specialized medical mattress featuring microscopic holes that continuously release a gentle stream of air) in bed with head of bed elevated. Present in the room were two family members visiting the resident. In a concurrent interview with Resident 2, she stated, she had been in the facility for about four (4) months for wound management on her buttocks. Resident 2's family member (FM) stated Resident 2 has a pressure wound on from the buttocks to the tailbone, with bone exposure. Resident 2's FM stated the resident was recently readmitted from general acute care hospital (GACH) on July 7, 2026, for continuation of wound management. On July 10, 2026, during a review of Resident 2's record indicated the following: -Initially admitted to the facility on [DATE]; was transferred to GACH on June 27, 2026, and readmitted back to the facility on July 7, 2026, with diagnoses which included quadriplegia (he partial or total loss of motor and sensory function in all four limbs (both arms and legs) and the torso), and osteomyelitis (a painful infection in the bone that causes inflammation, bone damage, and pus buildup); -Minimum Data Set (MDS - a resident assessment tool), dated May 21, 2026, indicated a BIMS (Brief Interview of Mental Status) score of 15, which indicated cognitively intact. The MDS also indicated Resident 2 is totally dependent on most ADLs (Activities of Daily Living); -Treatment order to Stage 4 PI (a severe wound defined as full-thickness skin and tissue loss with directly exposed or palpable fascia [sheets of connective tissue], muscle, tendon [a tough, fibrous cord of connective tissue that firmly attaches muscle to bone] , ligament [a tough, fibrous band of connective tissue in the body that connects bones to other bones or holds organs in place], cartilage [a strong, flexible type of connective tissue that cushions joints, supports body structures, and acts as a shock absorber], or bone) wound on left ischium (the lower and back part of the hip bone); -Progress Notes, dated July 7, 2026, at 6:20 p.m., indicated, .admitted an (resident's age) female from (name of GACH) arrived at 1820 (6:20 p.m.) .Skin assessment done and noted .OPEN WOUND TO BUTTOCK AREA . _Progress Notes, dated July 7, 2026, at 10:06 p.m., documented by the TXN, indicated, .Skin issue .Location: Buttocks - generalized .extending to bilateral upper posterior thighs .PT (patient) NEW ADMIT TO FACILITY .NOTED WITH STAGE 4 PRESSURE ULCER TO LEFT ISCHIUM WOUND TO ISCHIUM NOTED WITH HEAVY SEROPURULENT (a fluid that consists of a mixture of serum and pus) DRAINAGE . -Further review of Resident 2's record indicated there was no complete wound assessment of the stage 4 on the left ischium which included the size of the wound. On July 10, 2026, at 1:55 p.m., during a concurrent interview and review of Resident 2's record conducted with the TXN, the TXN stated Resident 2 was readmitted the night of July 7, 2026. The TXN she conducted wound assessment but failed to include in her documentation the size of the stage 4 wound on the left ischium. The TXN stated there should have been a completed wound assessment which includes the size of the wound to have baseline to see if the wound is improving or worsening. The TXN stated she missed to get the size of the wound. On July 10, 2026, at 3:10 p.m., during a concurrent interview and review of Resident 2's record with the DON, the DON stated a complete wound assessment includes location of the wound, size, wound bed description, and wound drainage. The DON stated it is important to conduct and document a complete wound assessment to have a baseline when it is reassessed if the wound is improving or worsening. 2. On July 10, 2026, during a review of Resident 1's record indicated the following: -The Face Sheet, indicated the resident was admitted to the facility on [DATE], with diagnoses which included left femur (the longest, heaviest, and strongest bone in the human body, commonly known as the thighbone) fracture (break), generalized muscle weakness, and difficulty walking; -Progress Notes, dated October 8, 2025, at 10 p.m., indicated, .Clinical admission .Coccyx (the small, triangular bone located at the very base of your spine, just below the sacrum) .DTI (Deep Tissue Injury - a type of pressure injury which has damage to deep soft tissues beneath the skin, caused by long periods of pressure or sliding force (shear) appearing like a purple or dark red localized area of intact skin, or a small blood-filled blister) Wound was present on admission . -Physician's order, dated October 9, 2025, indicated, ,,,TX (treatment) COCCYX: CLEANSE WITH NS (normal saline), PAT DRY, APPLY MEDIHONEY AND COVER WITH FOAM DRESSING every day shift for STAGE 2 PRESSURE INJURY . -Minimum Data Set, dated [DATE], indicated a BIMS score of 14 (cognitively intact); requires moderate to maximal assistance in toileting and transferring; -Progress Notes, dated October 16, 2025, at 11:47 a.m., indicated, .Skin Check .Coccyx .Stage 2 Pressure ulcer/injury - partial thickness skin loss with exposed dermis (the thick, vascular middle layer of skin located directly beneath the epidermis [the thin, outermost layer of your skin that acts as a protective barrier against germs, locks in body moisture, and gives your skin its color] and above the subcutaneous fat layer). Further review of Resident 1's record indicated there was no complete assessment documented on the wound on the coccyx, which includes size of the wound, wound bed description, and drainage. -Progress Notes, dated October 22, 2025, at 8:13 a.m., indicated, .Coccyx .Stage 2 Pressure Injury .Length (cm - centimeters [unit of measurement]) 1.3 Width (cm): 1.1 Depth (cm) 0.3 .Granulation (new tissue and tiny blood vessels that grow from the base of a wound during the healing process) 10%. Slough (a layer of soft, moist, dead tissue that forms over a wound). Exudate amount: Light . -Progress Notes, dated October 22, 2025, at 11:31 a.m., indicated, .(name of Wound Physician [WP]) in to assess resident, coccyx injury stage 2 1.3 x (by) 1.1 x 0.3 purulent small drainage, 90 slough, 10 gran. DC (discontinue) current tx and start Silvadene and Hydrogel QD (once a day) . -Physician's order, dated October 22, 2025, indicated, .TX: COCCYX PRESSURE INJURY STG 2: CLEANSE WITH NS (normal saline), PAT DRY APPLY SILVADENE CREAM AND HYDROGEL AND COVER WITH DRY DRESSING QD . -Wound Progress Note, dated October 22, 2025, documented by the WP, indicated, .Coccyx .Stage 2 .Slough (blank) .Granulation tissue: 10% granulation 100% red tissue .Dressing Choice .silvadene, foam QD . On July 13, 2026, at 11:51 a.m., during a concurrent interview and review of Resident 1'sd record was conducted with the WP, the WP stated the following: -He comes to the facility to conduct wound care and management every Wednesday at around 6 a.m.; -The TXN would give him a list of residents to see for wound care and the wound assessment and recommendations were being document on a temporary spreadsheet which includes wound assessment of wound location, size, wound bed description, drainage, and treatment recommendations; -Resident 1's wound on the coccyx was initially assessed by him and the previous TXN on October 22, 2025, and was assessed as Stage 2 with 100& red tissue wound bed. The WP stated the documentation on his wound notes, dated October 22, 2025, indicating 10% granulation tissue was a typographically error. The WP stated the wound on Resident 1's coccyx is stage 2 with treatment recommendation of Silvadene cream and cover with foam dressing . -Stated the physician's order transcribed by the previous TXN of Silvadene with Hydrogel was incorrect. The WP stated the treatment order should have been only Silvadene cream and without Hydrogel; -Stated the previous TXN should have documented complete wound assessments which include the location, size, wound bed description, and drainage, to determine if the wound is improving or worsening. A review of the facility's policy and procedure titled, Skin and Wound Monitoring and Management, revised December 2025, indicated, .A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing .Resident Assessment: The nurse responsible for assessing and evaluating the resident's condition on admission and readmission is expected to take the following actions .Skin and wound assessment on admission and readmission .A licensed nurse must assess/evaluate a resident's skin on admission. All areas of breakdown, excoriation, or discoloration, or other unusual findings, will be documented on the Initial admission Record .A licensed nurse will assess/evaluate each pressure injury and/or non-pressure injury that exists on the resident. This assessment/evaluation should align with the scope of practice and include but not limited to .measuring the skin injury .Staging the skin injury (when the cause is pressure) .Describing the nature of the injury .describing the location of the skin alteration .Describing the characteristics of the skin alteration .Ongoing Skin and Wound Assessments .A licensed nurse will assess/evaluate a resident's skin at least weekly .Areas of breakdown, excoriation, or discoloration, or other unusual findings .must be documented in the nursing notes or on the appropriate weekly assessment form .Treatment per physician order, should be documented in the resident's clinical record at the time they are administered .

Based on interview and record review, the facility failed to ensure a toileting program was implemented to address bowel and bladder incontinence (involuntary loss of bladder or bowel control), for one of three residents reviewed (Resident 1). In addition, there was no plan of care developed to address Resident 1's bowel and bladder incontinence. This failure had the potential to place Resident 1 at risk for complications such as urinary tract infections, skin breakdown, or kidney damage. Findings: On July 10, 2026, at 11:21 a.m., an unannounced visit to the facility was conducted to investigate quality-of-care issues. On July 10, 2026, Resident 1's record was reviewed. Resident 1's Face Sheet, indicated the resident was admitted to the facility on [DATE], with diagnoses which included left femur (thighbone - running from hip to knee) fracture (break). A review of Resident 1's Bowel and Bladder (B & B) Evaluation, dated October 8, 2025, indicated the resident is a likely candidate for bowel and bladder re-training (behavioral therapies that help regain control over urinary urgency, leakage, and fecal consistency, including scheduled toileting. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated October 15, 2025, indicated the following: -BIMS (Brief Interview of Mental Status) score of 14 (cognitively intact); -Toilet transfer not attempted due to medical condition; and -Frequently incontinent in bladder (episodes of incontinence with episode of continent voiding). A review of Resident 1's care plans indicated there was no care plan initiated to address Resident 1's B & B incontinence and plan for B & B retraining program as indicated in the B & B evaluation, dated October 8, 2025. Further review of Resident 1's record indicated there was no B & B re-training program implemented to evaluate the resident's potential to regain bowel and bladder continence. On July 13, 2026, at 12:30 p.m., during an interview with the MDS Nurse (MDSN), the MDSN stated B & B evaluation were to be completed on the third (3rd) day of admission. The MDSN stated the MDSN Assistant (MDSNA) was responsible to complete the B & B evaluation and to proceed on implementing a plan of care to address the residents' needs. In a concurrent interview with the MDSNA, she stated the B & B evaluation were to be completed on the 3rd day of admission to evaluate if the resident could benefit on any toileting program to address B & B incontinence. The MDSNA stated the B & B evaluation was done on the day of admission and was not re-evaluated on the 3rd day of admission. The MDSNA stated the B & B evaluation indicated Resident 1 is a likely candidate for B & B re-training, which includes assisting the resident to the bathroom upon waking up, before and after meals, and at bedtime. The MDSNA stated this was not done. the MDSNA stated there was no care plan developed to address Resident 1's B & B incontinence. A review of the facility's policy and procedure titled, Bowel and Bladder Assessment, revised April 2026, indicated, .The purpose of the bowel and bladder assessment is to offer a structured, goal-oriented approach with the intent that the resident attains the highest level of independence in bowel and/or bladder continence. This program will also focus on the residents' ability to improve continence independently .Complete a bowel and bladder evaluation within seventy-two (72H) of admission .The facility shall initiate a bowel and bladder re-training program, once the resident is determined to have a potential for re-training .Resident's care plan will be updated accordingly.

Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported to the facility abuse coordinator timely according to the facility's policy and procedure, for one of three residents reviewed (Resident A).This failure had a potential for a delay in the implementation of the abuse protocol of investigation and protecting the residents from further abuse. Findings:On March 3, 2026, at 10:25 a.m., an unannounced visit was conducted at the facility to investigate a complaint and facility reported incident regarding resident abuse.On March 3, 2026, at 10:30 a.m., during an interview with the Director of Nursing (DON), the DON stated a therapy student (TS) reported to Adult Protective Services (agency) that a Certified Nursing Assistant (CNA) handled a resident in a manner that was not acceptable to the rehab student. The DON stated Resident A had a change of condition when the resident was combative to staff.On March 3, 2026, at 11:30 a.m., an interview with the CNA was conducted. The CNA stated she provided care to Resident A when he came back from the hospital and was being combative during care. The CNA stated Resident A was rubbing his mouth hard with a wash cloth and the side of the resident's mouth bled as it was dry. The CNA stated she reported the bleeding on Resident A's mouth to the licensed nurse. The CNA stated the TS came in to assist the CNA so the TS could start Resident A's therapy. The CNA stated she changed Resident A's shirt and socks before the TS worked with the resident, then she left the room. The CNA stated at around 10 a.m., the Director of Staff Development (DSD) came to inform her that Resident A would be removed from her run as there was a complaint against her. The CNA stated she was counseled by the DON but was not suspended.On March 3, 2026, at 12 p.m., the Director of Rehabilitation (DOR) was interviewed. The DOR stated the TS informed him in the morning of February 18, 2026, that he had reported to APS a concern on abuse toward Resident A by the CNA. The DOR stated he went to the TS clinical instructor and both of them went to the Administrator (Admin) and informed about the abuse allegation.On March 3, 2026, at 12:30 p.m., the TS was interviewed. The TS stated that when he began the therapy of Resident A, the resident kept repeating a mean lady hit him. The TS stated that he worked with Resident A on February 16, 2026 (Monday), and the resident was combative as the resident would not let him put on his socks, he had a lot of food on his shirt, and the clinical instructor wiped the resident's mouth and there was no blood. The TS stated when he and the rehab clinical instructor came back to Resident A's room after about 45 minutes, he heard Resident A yelling No, and the CNA said to the resident, we are not doing this today, and she pulled the resident's sheet and the resident hit the bed railing. The TS stated the CNA was angry at Resident A and was yelling at the resident while putting socks and a new shirt on. The TS stated he informed the Physical Therapy Lead (PTL) and his clinical supervisor on February 17, 2026, then he reported the abuse allegation to APS the night of February 17, 2026. On March 3, 2026, at 1:45 p.m., during a follow up interview with the DOR, the DOR stated he informed the Admin the morning of February 18, 2026, when he found out from the TS that he had filed a report to APS regarding the abuse allegation. The DOR stated the rehab students were educated on to report abuse allegations to their clinical instructor or to the DOR then the DOR would inform the Admin to ensure investigation was initiated. The DOR stated the TS did not follow the chain of command for reporting abuse allegations.On March 3, 2026, at 2:55 p.m., during an interview with the Admin, the Admin stated he received a call from the DOR the morning of February 18, 2026, about an abuse allegation reported by the TS against a CNA toward Resident A. The Admin stated the TS should have reported the abuse allegation to his clinical instructor, then to reported to the Admin to ensure the abuse protocol could be followed.On March 4, 2026, at 8:30 a.m., during an interview with the PTL, the PTL stated the TS came to him either February 16 or 17, 2026, regarding a concern he had on the alleged CAN, and that the TS was upset. The PTL stated he did not ask the TS further what the concern was and he reported it to the DOR. The PTL stated the DOR told him that the DOR would talk to the TS clinical instructor.A review of the facility's policy and procedure titled, Reporting Alleged Violations of Abuse, neglect, Exploitation or Mistreatment, dated April 2025, indicated, .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment.are reported to immediately.The Administrator of the Facility.Ensure that, after receipt of a report of possible abuse.steps are immediately taken to protect the identified resident.

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy, for 67 out 68 residents who eat food from the kitchen, when: 1. Four (4) large metal pans with food debris and dripping water on them were stored and stacked on top of each other on a bottom shelf; and 2. One 50-pound (lb- unit of measurement) bag of instant milk nonfat dry powder was found stored with an open tear in the bag, with food product seeping out and with clear tape covering it. These failures exposed residents' to contaminated food and unsanitary practices, which had the potential to place them at risk of developing a foodborne illness. Findings: 1. On May 12, 2025, at 7:04 a.m., a concurrent observation and interview was conducted with the Dietary Supervisor (DS) in the kitchen. There were three large metal pans, and one large metal perforated pan that had water and food debris on them observed dripping wet and stacked on top of each other and stored under the counter. The DS stated the pans were not clean and had debris on them. The DS also stated that the pans should not have food debris on them and should not be stacked and stored wet. The DS further stated the pans should be clean and dried before storing. On May 16, 2025, at 08:56 a.m., a telephone interview with Registered Dietitian (RD) 2 was conducted. RD 2 stated the expectation of the staff were not to stack and store wet dishes. RD 2 stated that the pans should not have been stored wet. RD 2 also stated the pans should have been stacked individually, then waited until dried and then put away. RD 2 further stated that she expected kitchen staff to identify dishes that had debris, rewashed, and dry properly before using them to cook. RD 2 stated there was the possibility of cross contamination which could make residents sick. According to the 2022 Federal Food Code, Section 4-601.11, titled Cleaning of Equipment and Utensils. Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils.(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch . A review of the facility's policy and procedure titled, Dietary Services Dietary, Sanitation in, dated January 2025, indicated, .It is the policy that the food service area shall be maintained in a clean and sanitary manner .All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair . 2. On May 12, 2025, at 8:37 a.m., a concurrent observation and interview with the DS was conducted in the facility's outside kitchen storage for emergency food. One 50 lb bag of non fat dry powder instant milk was observed with an opened tear in the bag, and was covered with clear tape. In a concurrent interview with the DS, she stated the bag should not have a hole in it. The DS further stated pest could get inside and that would contaminate the food. On May 15, 2025, at 3:42 p.m., a concurrent interview and observation with RD 1 was conducted in the facility's outside kitchen storage for emergency food. RD 1 stated if the packaged food arrived damaged the facility's process was to send it back. RD 1 stated if the packaged food was damaged at the facility, it should not be used and must be discarded. RD 1 further stated the food item could become contaminated and someone could get sick if the food was not sealed properly. According to the 2022 Federal Food Code, section 3-307.00 Miscellaneous Sources of Contamination, indicated, .Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 to 3-306. A review of the facility's policy and procedures titled, Food and Nutrition Services: Food, Dry Storage of, dated January 2025, indicated, .It is the policy of this facility that all non-perishable foods shall be stored utilizing methods which maximize nutrient retention, food appearance, and food quality .Dry goods (i.e. cereal and grains) .shall be stored according to the USDA Food Safety Information on Shelf-Stable Food Safety .

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy, for 67 out of 68 residents who consume food from the kitchen, when pests (a roach, a spider, and ants) were observed in the dry food storage pantry. In addition spiderwebs were also observed inside the kitchen. These failures had the potential to expose residents to contaminated food, that could result in food borne illnesses for all residents who consume food from the kitchen. Findings: On May 12, 2025, at 07:01 a.m., a concurrent observation and interview was conducted in the facility's kitchen dry food storage room with the Dietary Supervisor (DS). The floor had a roach (bug), spiders, and ants on the floor. There was spiderwebbing on the metal carts. The DS stated pests should not be in the dry food storage room. On May 14, 2025, at 12:45 p.m., a follow up interview with the DS was conducted. The DS stated the expectation was for the facility to not have any pests. The DS also stated pests could multiply to more pests and pest droppings or fecal matter could contaminate the food. The DS further stated the residents could get sick that if residents ate the contaminated food. On May 15, 2025, at 3:38 p.m., during an interview with the Registered Dietician (RD 1), RD 1 stated her expectation was to not see pests. RD 1 stated the kitchen should not have pest. RD 1 also stated she expected the staff to alert the supervisor of pest sightings. RD 1 stated pests should not be near the food to prevent contamination. RD 1 further stated the food could get contaminated and the residents could get sick. According to the 2022 Federal Food Code, section 3-307.00 Miscellaneous Sources of Contamination, indicated, .Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 to 3-306. A review of the facility's policy and procedures titled, Food and Nutrition Services: Food, Dry Storage of, dated January 2025, indicated, .It is the policy of this facility that all non-perishable foods shall be stored utilizing methods which maximize nutrient retention .The storeroom shall be maintained free from .insects, rodents, or any potential source of contamination . A review of the facility's policy and procedures titled, Dietary Services: Dietary, Sanitation in, dated January 2025, indicated, .It is the policy of this facility that the food service area shall be maintained in a clean and sanitary manner .All kitchens, kitchen areas, and dining areas shall be kept clean .and protected from rodents, roaches, flies and other insects . A review of the facility's policy and procedures titled, Infection Control: Pest Control dated January 2025, indicated, .It is the policy of this facility to provide an environment free of pest .

Based on observation, interview, and record review, the facility failed to ensure call lights were answered in a timely manner, for six out 68 residents (Residents 10, 27, 37, 55, 56 and 163). This failure had the potential for the residents' emotional, psycho-social, and optimal physical well-being to not be met. Findings: 1. On May 12, 2025, at 9:55 a.m., an interview was conducted with Resident 10 in her room. Resident 10 stated it would take time for the staff to answer her call light during the morning shift. Resident 10 stated she had waited an hour for someone to come during the night shift and it was frustrating. A review of Resident 10's medical record indicated she was admitted on [DATE], with diagnoses which included surgical aftercare following skin and tissue infection. A review of Resident 10's History and Physical, dated April 3, 2025, indicated Resident 10 had the capacity to understand and make decisions. A review of Resident 10's Minimum Data Set (MDS - an assessment and screening tool), dated April 6, 2025, indicated a BIMS (Brief Interview for Mental Status) score of 14 which indicated cognitively intact. On May 13, 2025, at 9:20 a.m., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated she had Resident 10 complained about long waits for the call light at night. CNA 1 stated she reported those complaints to the charge nurse. On May 15, 2025, at 8:40 a.m., an interview with Resident 10 was conducted. Resident 10 stated the staff would sometimes answer the call light and say they would be right back and the staff did not return. Resident 10 stated many times it was a simple request for another blanket or for more water. Resident 10 further stated it did not make her feel good when the staff would walk away because the resident could take a minute or two to remember what she needed due to her memory problems. 2. On May 12, 2025, at 8:30 a.m., an observation and interview with Resident 55 was conducted. Resident 55 stated sometimes he had to wait for someone to answer the call light at different times. Resident 55 stated he had waited longer than 20 minutes, and he would prefer if the staff could come sooner. On May 15, 2025, a review of Resident 55's medical record indicated Resident 55 was admitted on [DATE], with diagnoses which included fractured (broken) lumbar vertebrae (lower back spine bone ), multiple right sided rib fractures, compression fracture thoracic vertebrae (fracture of the spine bones in mid-back) from a fall at home. A review of Resident 55's Initial History and Physical, dated April 24, 2025, indicated Resident 55 had the capacity to understand and make decisions. A review of Resident 55's MDS, dated [DATE], indicated Resident 55 had a score of 14 which indicated cognitively intact. On May 13, 2025, at 10 a.m., an interview with CNA 2 was conducted. CNA 2 stated Resident 55 had informed her he had long waits at night because he felt anxious. On May 15, 2025, at 9:10 a.m. a follow up interview with Resident 55 was conducted. Resident 55 stated he becomes frustrated and anxious when he had to wait more than 30 minutes for a nurse to come. On May 16. 2025, at 8 am., an interview was conducted with the Director of Nursing (DON). The DON stated the facility's goal was to answer call lights in less than 5 minutes. The DON stated it was the expectation for everyone to answer call lights, including administration, so residents should never have to wait long. The DON stated she had received complaints from residents about long call light wait times, especially at night. The DON further stated when the residents' call lights were not answered promptly it could increase the possibility of skin integrity breakdown and the risk of resident's falls. 49113 3. On May 12, 2025, at 6:06 a.m., during an interview with Resident 163, Resident 163 stated he waited a long time for the call light to get answered and felt he was not serviced fast enough. Resident 163 stated he had waited as long as 30 minutes on some occasion. Resident 163 further stated he had complained about it, nothing had been done and it frustrated him. On October 14, 2025, Resident 163's record was reviewed. Resident 163 was admitted to the facility on [DATE], with diagnoses which included urinary tract infections (infection in the bladder), muscle weakness, and dysphagia (difficulty swallowing). A review of Resident 163's MDS, dated [DATE], indicated Resident 163 had a BIMS score of 13 (cognitively intact), and Resident 163 required partial/moderate assistance with toileting hygiene and substantial/maximal assistance with shower/bathe self, personal hygiene, toilet transfer and tub/shower transfer. A review of Resident 163's History and Physical, dated May 8, 2025, indicated Resident 163 had the capacity to make decisions. On May 15, 2025, at 3:55 p.m., during an interview with Registered Nurse (RN) 1, RN 1 stated the call lights would beep and make an audible sound. RN 1 stated the staffing during the night shift was not good and had received complaints regarding the call lights not being answered timely during the afternoon shift (3 p.m. to 11 p.m.). RN 1 further stated the Administrator, Social Services and the Director of Nursing were aware of the complaints about the call lights. RN 1 also stated if residents were left soiled it could their skin integrity and their dignity. RN 1 further stated the expectation was for the call lights to be answered in five to 10 minutes and residents should be checked. 4. On May 12, 2025, at 4:04 p.m., during an interview with Resident 37, Resident 37 stated he had concerns on the night shift with staff answering the call light. Resident 37 stated, it takes 15 to 20 minutes for staff to answer the call light. Resident 37 stated normally he would call for help to get in and out the bathroom and help to get back in bed. On May 14, 2025, Resident 37's record was reviewed. Resident 37 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (lung diseases that block air flow), muscle weakness, and abnormalities of gait and mobility (abnormal walking). A review of Resident 37's History and Physical, dated January 24, 2025, indicated Resident 37 had the capacity to understand and make decisions. A review of Resident 37's MDS, dated [DATE], indicated Resident 37 had a BIMS score of 15 (cognitively intact), and Resident 37 required supervision or touching assistance with toileting hygiene, shower/bathing self/ and toilet transfer. 5. On May 13, 2025, at 10:17 a.m., during an interview with Resident 27, Resident 27 stated on the night shift, it sometimes took an hour for staff to answer the call light. Resident 27 stated it mostly happened on the night shift. Resident 27 also stated he knew the staff was busy, so he tried to catch them when they walked through the hallways. Resident 27 stated he reported his concern to staff, but no one has responded about it. On May 14, 2025, Resident 27's record was reviewed. Resident 27 was admitted to the facility on [DATE], with diagnoses which included spinal stenosis (space inside bones of the spine too small), obstructive and reflux uropathy (blockage and backflow of urine from the bladder), and benign prostatic hyperplasia (enlargement of the prostate). A review of Resident 27's History and Physical, dated February 20, 2025, indicated Resident 27 had the capacity to understand and make decisions. A review of Resident 27's MDS, dated [DATE], indicated Resident 27 had a BIMS score of 15 (cognitively intact), and Resident 27 required supervision or touching assistance with toileting hygiene, shower/bathing self/and lower body dressing and toilet transfer. 6. On May 15, 2025, at 8:14 a.m., during an interview with Resident 56, Resident 56 stated she gets regular assistance to the bathroom except on the night shift. Resident 56 stated that when she feels the urge to go to the bathroom, she would use the call light but she had waited 20-30 minutes for the call light to get answered. Resident 56 further stated it was frustrating. On May 14, 2025, Resident 56's record was reviewed. Resident 56 was admitted to the facility on [DATE], with diagnoses which included orthopedic (bone) care, osteoarthritis (common form of arthritis), parkinsonism (brain condition that causes slow movement) and difficulty walking. A review of Resident 56's History and Physical, dated April 22, 2025, indicated Resident 56 had the capacity to understand and make decisions. A review of Resident 56's MDS, dated [DATE], indicated Resident 56 had a BIMS score of 10 (moderate cognitive impairment), and Resident 56 was dependent for toilet hygiene, lower body dressing, required substantial/maximal assistance with tub and shower transfer, and partial/moderate assist with toilet transfer. On May 16, 2025, at 7:47 a.m., during an interview with the Director of Nursing (DON), the DON stated she expected all staff to answer the call lights in less than five minutes. The DON stated it was the expectation that everyone can answer the call lights, including administration, so residents should never have a long wait. The DON stated she had received complaints from residents about long call light wait times, especially at night. The DON further stated when resident's call lights were not ansered promptly, it could increase the possibility of skin integrity breakdown, and the risks of resident falls. A review of the facility's policy and procedure titled, Call Light, dated January 2025, indicated, .It is the policy of this facility to provide the resident a means of communication with nursing staff .Procedures: answer the light/bell within a reasonable time. A review of the facility's Job Description titled, Certified Nursing Assistant, dated December 17, 2021, indicated, .The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services, in accordance with the resident's assessment and care plan . check each resident routinely to ensure that his/her personal care needs are being met .Answer resident calls promptly. A review of the facility's policy and procedure titled, Dignity and Privacy, dated January 2025, indicated, .It is the policy of this facility that all residents be treated with kindness, dignity and respect .

Based on interview and record review, the facility failed to ensure sufficient staff were provided to meet the needs of the residents when the facility did not meet the required or minimum of Actual Total CNA Direct Care Service Hours for CNA DHPPD (DHPPD - measure the numbers of hours of direct care given to residents in skilled nursing facility) of 2.4 hours for March 1, 2025, of 31 days reviewed and April 5, 2025, of 30 days reviewed. The failure to maintain a the required minimum CNA DHPPD hours had the potential to increase the resident's risk of fall and to meet residents' requests for assistance with activities of daily living. Findings: On May 14, 2025, a concurrent interview and record review of the facility's Census and Direct Care Service Hours Per Patient Day, was conducted with the Director of Staff Development (DSD). The DSD confirmed records of two days in March 2025 and April 2025, indicated the Actual Total CNA Direct Care Service Hours were below the required minimum of 2.4 hours. The Actual Total DCSH hours were below 2.4 hours (hrs) on the following dates: - March 1, 2025 (Saturday) 2.36 hrs (CNA DCSH); and - April 5, 2025 (Saturday) 2.32 hrs (CNA DCSH). On May 15, 2025, at 3 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated there had been a turnover of nightshift CNA's. The DON stated the facility's goal was to consistently meet mandated CNA hours. The DON further stated that when staffed with less than mandated hours, they could decrease resident safety and satisfaction in meeting their needs. A review of the facility's policy and procedure titled Nursing Services Staffing, Adequate, dated January 2025, indicated .this facility to provide sufficient numbers of staff .to provide care and services for all residents .in accordance with .facility assessment .

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. For Resident 24, facility failed to conduct proper screening for the annual tuberculin skin test (TB- tuberculosis [lung disease] test - screening to determine if someone infected with germs that cause tuberculosis); 2. For Resident 213, one 4,000 milliliters (ml - unit of measurement) incentive spirometer (device use to expand lungs) was observed not properly stored in a bag; and 3. For Resident 216, the Physical Therapist (PT) (healthcare provider who performs physical movement) did not wear personal protective equipment (PPE - equipment use to protect against infection or illness) when providing therapy to a resident requiring enhanced barrier precautions (EBP - an infection control intervention to reduce transmission of multidrug-resistant organisms [MDRO - bacteria that have become resistant to multiple antibiotics]). These failures had the potential to result in transmission of infection to an already vulnerable population of residents in the facility. Findings: 1. On May 14, 2025, at 3 p.m., during a concurrent interview and record review with the Infection Preventionist (IP), the IP stated he conducted surveillance of all immunizations which included TB screening to all residents. The IP stated the process of administering TB test included a two-step TB skin test to be administered upon admission of a resident, and a one-step TB skin test would be administered annually thereafter. The IP stated TB test would be read after three days for the result. The IP stated Resident 216's TB test was administered on July 8, 2024, and there was no reading of the TB test result after three days. The IP further stated if there was no reading, the TB test should should have been repeated to complete the annual TB screening. On May 15, 2025, at 9:25 a.m., during an interview with the Director of Nursing (DON), the DON stated she expected the IP to follow the facility's policy on annual TB screening for residents. The DON stated Resident 24's TB screening should have been readministered if the result was not read. The DON further stated the annual TB screening should have been implemented according to facility's tuberculosis control plan. A review of the facility's policy and procedure titled, Tuberculosis Control Plan, dated January 2025, indicated, .It is the policy of this facility that .Each resident admitted to this facility shall be screened for TB, as prescribed by the attending physician .a PPD skin test results, by Mantoux method is recommended and shall be documented on the medication sheet or a PPD form . 2. On May 12, 2025, at 8:30 a.m., during a concurrent observation and interview with Resident 213 in her room, Resident 213's incentive spirometer was observed placed on top of Resident 213's nightstand, and not in a bag. Resident 213 stated she placed the incentive spirometer on top of the nightstand table when not in use. Resident 213 stated she did not have a plastic bag container to use as storage for her incentive spirometer when not in use. On May 12, 2025, at 8:37 a.m., during a concurrent observation and interview with Registered Nurse (RN) 1, RN 1 stated Resident 213 should have a plastic container to store her spirometer when not in use. RN 1 further stated Resident 213 did not have one. On May 14, 2025, at 3:12 p.m., an interview with the IP was conducted. The IP stated the incentive spirometer should have been kept in a plastic bag container between exercises and should have label on it. The IP further stated if the incentive spirometer was not kept in proper storage, Resident 213 could have a respiratory infection. On May 15, 2025, Resident 213's record was reviewed. Resident 213 was admitted to the facility on [DATE], with diagnoses that included pulmonary edema (swelling of the lungs) and chronic obstructive pulmonary disease (lung disease). A review of Resident 213's History and Physical, dated May 6, 2025, indicated Resident 213 was mentally capable of understanding. A review of Resident 213's Order Summary, dated May 12, 2025, indicated, .INCENTIVE SPIROMETER. INSTRUCT PATIENT TO HOLD THEIR BREATH FOR 3 TO 15 BREATHS WITH YOUR SPIROMETER EVERY 4 HOURS .related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE . On May 15, 2025, at 9:16 a.m., an interview with the DON was conducted. The DON stated she expected the staff to follow the facility's infection control policy in the storage of medical devices. The DON stated the incentive spirometer should be kept in a bag with label. The DON further stated if not properly stored in a bag it could lead to respiratory infection. A review of the facility's policy and procedure titled, Incentive Spirometry, dated January 2025, indicated, .It is the policy of this facility that an incentive spirometry device may be used by a resident to assist with maximal lung ventilation .Place the mouthpiece in a plastic storage bag between exercises and label it and the spirometer with the resident's name . 3. On May 14, 2025, at 10:20 a.m., during a concurrent observation and interview with the Physical Therapist (PT) , the PT was observed not wearing PPE when providing therapy to Resident 216 in the rehabilitation room. The PT stated she provided physical therapy such as upper body exercises and stretching to Resident 216 and did not wear PPE. The PT further stated she should have worn PPE to prevent the spread of infection, protect herself and the facility residents from infection. On May 15, 2025, Resident 216's record was reviewed. Resident 216 was admitted to the facility on [DATE], with diagnoses which included muscle weakness and gastrostomy status (surgical opening in the stomach). A review of Resident 216's History and Physical, dated May 12, 2025, indicated Resident 216 was not mentally capable of understanding. A review of Resident 216's Order Summary, dated May 9, 2025, indicated, .ENHANCED BARRIER PRECAUTIONS: PPE required for high contact care activities. Indication: PEG-TUBE (tube inserted into stomach) . A review of Resident 216's Care Plan Report, dated May 12, 2025, indicated, .Has potential/actual impairment to skin integrity r/t (related to) PEG tube site Risk for infection, worsening impairment .Enhanced barrier precautions as ordered . On May 14, 2025, at 11:10 a.m., an interview with the IP was conducted. The IP stated Resident 216 had a PEG tube and was on Enhanced Barrier Precaution. The IP further stated PT should have worn PPE before providing therapy to Resident 216 to prevent the spread of infection to the residents. On May 15, 2025, at 9:20 a.m., during an interview with the DON, the DON stated the expectation was for the staff to follow the facility infection control policy and procedure. The DON further stated the PT should have worn PPE to prevent the spread of infection to Resident 216. A review of the facility's policy and procedure titled, Infection Control, dated January 2025, indicated, .It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions .Standard Precautions are infection prevention practices that apply to the care of all residents .Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities .PPE: the use of gown and gloves for high-contact resident care activities is indicated when .Indwelling medical devices include .feeding tubes .

Based on observation, interview, and record review, the facility failed to ensure an audiology (healthcare specialists in hearing loss, hearing tests, hearing aid selection) consultation was provided, for one of one resident reviewed for hearing (Resident 214). This failure had the potential to result in Resident 214 not receiving the audiology services needed to maintain her highest practicable level of well-being. Findings: On May 12, 2025, at 2 p.m., during a concurrent observation and interview with Resident 214 in the hallway, Resident 214 was observed staring at Certified Nursing Assistant (CNA) 3, while talking to her. Resident 214 stated she was using one hearing aid in her left ear and she was unable to hear CNA 3. Resident 214 further stated, Huuhhh? On May 12, 2025, at 2:20 p.m., during an interview with CNA 3, CNA 3 stated Resident 214 had left hearing aide and still was not able to hear. CNA 3 stated Resident 214's left hearing aide was not working properly. On May 15, 2025, Resident 214's record was reviewed. Resident 214 was admitted to the facility on [DATE], with diagnoses which included hearing loss in the right ear. A review of Resident 214's Initial Admission Record, dated April 24, 2025, indicated Resident 214 had a moderate difficulty in hearing. A review of Resident 214's Order Summary, dated April 24, 2025, indicated, .Audiologist eval (evaluation) and treat PRN (as needed) . A review of Resident 214's Inventory of Personal Effects, dated April 24, 2025, indicated Resident 214 had left hearing aide. A review of Resident 214's Social Service Summary, dated April 29, 2025, indicated, .She wears a left hearing aide only and its here at the facility . A review of Resident 214's Care Plan Report, dated April 25, 2025, indicated, .At risk for a communication problem r/t (related to) HOH (hard of hearing) R (right) ear .Refer to Audiology for hearing consult as ordered . A review of Resident 214's History and Physical, dated May 7, 2025, indicated Resident 214 was mentally incapable of understanding. On May 14, 2025, at 9:10 a.m., during a concurrent interview and record review with Registered Nurse (RN) 1, RN 1 stated Resident 214 was admitted with a left hearing aid and was recorded in Resident 214's inventory sheet on April 24, 2025. RN 1 stated the left hearing aid was not working for Resident 214, so she should be referred to an audiologist. RN 1 further stated if Resident 214 would be unable to hear properly, her mood could be affected, and she could become upset and frustrated. On May 14, 2025, at 9:46 a.m., during an interview with the Social Service Director (SSD), the SSD stated Resident 214 should have been referred to an ear doctor to address the hearing problem. The SSD further stated Resident 214's self-esteem could be affected and cause her to feel frustrated and irritated if Resident 214 would not provided audiology services. On May 15, 2025, at 9:36 a.m., during an interview with the Director of Nursing (DON), the DON stated Resident 214 should have been referred to an audiologist to check the hearing aid and her hearing condition. The DON further stated if Resident 214 would not seen by audiologists, Resident 214 would potentially feel frustrated when she interacts with staff and other residents. A review of the facility's policy and procedure titled, Dental, Optometry, and Audiology Evaluations, dated January 2025, indicated, .It is the policy of this facility that Social Services staff will coordinate Dental, Optometry and Audiology evaluations for residents .Social services will maintain a system to monitor the dental, optometry and audiology evaluations .

Based on observation, interview, and record review, facility failed to provide assistive devices such as a plate divider (equipment to prevent food from falling off the plate), for one of three residents observed during mealtime (Resident 22). This failure had the potential for Resident 22 to not meet the daily nutritional needs, which could lead to weight loss. Findings: On May 12, 2025, at 12:24 p.m., during a concurrent observation and interview with Resident 22 in the dining room, Resident 22 was observed scooping the food onto her plate, but the food fell off the plate. She stated the food was spilling out of the plate and the fork was unable to hold it. The bread and green veggies were observed on the floor. On May 12, 2025, at 12:29 p.m., during a concurrent observation ad interview was conducted with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 22 spilled the food on the side of the plate and on the floor. LVN 1 stated Resident 22 could eat by herself, a plate guard should have been provided to prevent food from spilling. On May 15, 2025, Resident 22's record was reviewed. Resident 22 was admitted to the facility on [DATE], with diagnoses which included Parkinson's disease (disorder that affects movement). A review of Resident 22's History and Physical, dated March 12, 2025, indicated Resident 22 was mentally capable of understanding. A review of Resident 22's Order Summary, dated March 10, 2025, indicated, .NAS (No added salt) diet MECHANICAL SOFT texture . On May 15, 2025, at 9:14 a.m., during an interview with the Director of Nursing (DON), the DON stated Resident 22 should have been evaluated and provided assistive eating devices. The DON further stated if Resident 22 was unable to eat the food properly, Resident 22 might not meet her nutritional needs, which could lead to weight loss. On May 15, 2025, at 11:00 a.m., during an interview with the Director of Rehabilitation (DOR), the DOR stated the nursing staff assigned in the dining room or direct staff that observed resident during meal time should referred to their department to evaluate any adaptive device needed for residents. The DOR further stated Resident 22 should have been referred for evaluation for adaptive device and should have been provided with plate divider. A review of the facility's policy and procedure titled, Adaptive Equipment for dining, dated January 2025, indicated, .It is the policy of this facility to provide adaptive equipment to residents as needed .An occupational therapist is recommended for evaluating needs .The divided plate is an excellent choice for all skilled level dining rooms .

Based on observation, interview, and record review, the facility failed to ensure the resident was treated with dignity and respect, for one of six residents reviewed (Resident 215), when the lunch meal was not served to Resident 215 at the same time as the other residents on May 12, 2025. This failure increased the potential to negatively affect Resident 215's psychosocial well-being. Findings: 1. On May 12, 2025, at 11:55 a.m., during a concurrent meal observation and interview with Resident 215 in the dining room, Resident 215 was observed sitting in a wheelchair together with two other residents at the same table. The staff were observed to serve the food to the other two residents and did not provide the meal to Resident 215. Resident 215 was observed looking at the other residents who were eating and she asked the staff, Where's my food? On May 12, 2025, at 12:12 p.m., a follow up observation of the dining room was conducted. Resident 215 was observed to be still waiting for her lunch tray while the other two residents seated with Resident 215 at the same table were half way through eating their lunch. On May 12, 2025, at 12:25 p.m., the staff was observed to serve the food to Resident 215. In a concurrent interview with Resident 215, she stated Finally I got my food, I thought they forgot me already. On May 12, 2025, at 12:18 p.m., during an interview with the Activity Director (AD), the AD stated Resident 215 received her meal tray after 30 minutes because the tray was prepared and placed in the other cart and was served in Resident 215's room. The AD stated meals should have been served in an organized manner so no residents would be left out. The AD further stated, I would feel upset if that happened to me. On May 15, 2025, Resident 215's record was reviewed. Resident 215 was admitted to the facility on [DATE], with diagnoses which included depression (mood disorder of feeling sad) and diabetes mellitus (abnormal blood sugar). A review of Resident 215's History and Physical, dated May 7, 2025, indicated Resident 215 was mentally capable of understanding. On May 15, 2025, at 12:31 p.m., during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated food should be served at the same time per table. LVN 1 stated the facility should have been more organized when serving food in the dining room. LVN 1 further stated, It's a dignity issue. On May 15, 2025, at 9:12 a.m., during an interview with the Director of Nursing (DON), the DON stated she expected the staff to serve the tray at the same time and no one should be left out. The DON stated the staff should follow the system where they have a list of residents who will eat at a table in the dining room. The DON further stated if the system would not be followed, residents would feel upset because they were not served food as the others at the same time. A review of the facility's policy and procedure titled, Dignity and Privacy, dated January 2025, indicated, .It is the policy of this facility that all residents be treated with kindness, dignity and respect .

Based on observation, interview, and record review, the facility failed to provide a comfortable homelike environment, for two of two residents reviewed for environment (Residents 48 and 164), when peeled paint were observed on the wall at the side of Residents 48 and 164's bed and at the bathroom door frame of room [ROOM NUMBER]. These failure had the potential for residents not to experience a comfortable and inviting stay while in the facility. Findings: On May 12, 2025, at 3:56 p.m., Resident 164 was observed sitting up in his bed. A patchy area of peeled paint was observed on the wall at the right side of Resident 164's bed. On May 13, 2025, at 9:43 a.m., Resident 27's was observed sitting in her wheelchair next to her bed. Observed peeled paint on the side of the wall next to Resident 27's bed. On May 15, 2025, at 12:54 p.m., a concurrent observation with the Maintenance Supervisor (MS) was conducted in the bathroom in room [ROOM NUMBER]. Observed areas of peeled paint at the at the door frame in the bathroom. On May 15, 2025, at 4:04 p.m., during an interview with the Maintenance Supervisor (MS). The MS stated he was responsible for keeping the building safe. The MS also stated he had to keep the rooms painted and clean. The MS further stated the walls should be fixed, smooth, and painted so it would look like a homelike environment. On May 15, 2025, 4:21 p.m., the Administrator (ADM) stated the walls should be painted and fixed, further stated, we want it to have a feeling of looking like home. A review of the facility's policy and procedure titled, Homelike Environment, dated January 2024, indicated, .It is the policy of this facility to encourage and provide opportunities for each resident to occupy an area reflecting his/her interests, family, or is made homelike by choosing special decorations .Purpose: To provide a homelike environment for residents .

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a clinical assessment tool) was accurately coded, for one of one resident reviewed for hearing (Resident 214). This failure had the potential to cause inaccuracy in identifying Resident 214's care and support needs, and cause delay of needs being met. Findings: On May 14, 2025, Resident 214's record was reviewed. Resident 214 was admitted to the facility on [DATE], with diagnoses which included hearing loss of the right ear. A review of Resident 214's inventory sheet dated April 24, 2025, indicated, .1 hearing aide (L) . A review of Resident 214's Initial Admission Record, dated April 24, 2025, indicated Resident 214 had a moderate difficulty in hearing. A review of Resident 214's MDS, dated [DATE], indicated Resident 214 was not using a hearing aid and the hearing ability was adequate. A review of Resident 214's Social Service Summary, dated April 29, 2025, indicated, .She wears a left hearing aide only and its here at the facility . On May 14, 2025, at 9:23 a.m., during a concurrent interview and record review with MDS Nurse, the MDS Nurse stated Resident 214 was admitted to the facility on [DATE], with a hearing aid in her left ear. The MDS Nurse stated Resident 214 was moderately impaired in hearing and should have been reflected on MDS section B. The MDS Nurse further stated the MDS assessment was not accurate. On May 15, 2025, at 9:36 a.m., the Director of Nursing (DON) was interviewed. The DON stated the MDS assessment for Resident 214 should have been coded as moderately impaired with hearing and it should have been reflected to the actual status of the resident. The DON further stated Resident 214 needs, care, and support would not be met if the MDS assessment would not be accurately coded. A review of the facility's policy and procedure titled, Accuracy of Assessment, dated January 2024, indicated, .It is the policy of this facility to ensure that the assessment accurately reflect the resident's status .An MDS Nurse must conduct or coordinate each assessment with the appropriate participation of health professionals . A review of the facility's manual version 3.0 titled, RESIDENT ASSESSMENT INSTRUMENT (RAI), dated October 2024, indicated, .The purpose of this manual is to offer clear guidance how to use the Resident Assessment Instrument (RAI) correctly and effectively to help provide appropriate care .the care plan becomes each resident's unique path toward achieving or maintaining their highest practical level of well-being .

Based on observation, interview, and record review, the facility failed to ensure a dental consultation was provided, for one of one resident reviewed for dental (Resident 24). This failure had the potential to result in Resident 24 not to receive the dental services needed to maintain his highest practicable level of well-being. Findings: On May 12, 2025, at 11:38 a.m., during a concurrent observation and interview with Resident 23 in his room, Resident 24 was observed with some missing upper and lower teeth. Resident 24 stated he wanted to have dentures, and he was not seen by the dentist. Resident 24 further stated it was hard for him to chew solid food. On May 15, 2025, Resident 24's record was reviewed. Resident 24 was admitted to the facility on [DATE], with diagnoses which included facial weakness. A review of Resident 24's Order Summary, included a physician's order, dated July 9, 2022, indicated, .MAY HAVE DENTAL CONSULT WITH FOLLOW UP TREATMENT AS NEEDED . A review of Resident 24's Impressions Mobile Dentistry, dated February 28, 2024, indicated, Resident 24 had multiple missing teeth and root tips, and treatment was recommended as needed. A review of Resident 24's History and Physical Note, dated August 20, 2024, indicated Resident 24 was mentally capable of understanding. A review of Resident 24's Minimum Data Set (MDS - a resident assessment tool), dated April 5, 2025, indicated Resident 24 had a BIMS (Brief Interview of Mental Status) score of 15 which indicated cognitively intact. On May 14, 2025, at 10:07 a.m., during an interview with the Social Service Director (SSD), the SSD stated Resident 24 should have been referred to a dentist to have dentures. The SSD further stated Resident 24 would not be able to eat properly and could lead to weight loss if Resident 24 was not provided dental services. On May 15, 2025, at 9:31 a.m., during an interview with the Director of Nursing (DON), the DON stated she expected the nurses and SSD to follow facility's policy and procedure for dental services. The DON stated Resident 24 should have been referred to the dentist. The DON further stated, if Resident 24 would not receive dental services, he would not eat food properly and could lead to weight loss. On May 15, 2025, at 11:20 a.m., during an interview with the Facility Dentist (FD), the FD stated he received a dental referral from SSD, and he would check all the residents that were listed. The FD stated Resident 24 should have been seen right away to prevent complications. The FD further stated, I'm always available, and I come right away. A review of the facility's policy and procedure titled, Dental, Optometry, and Audiology Evaluations, dated January 2025, indicated, .It is the policy of this facility that Social Services staff will coordinate Dental, Optometry and Audiology evaluations for residents .Social services will maintain a system to monitor the dental, optometry and audiology evaluations .

Based on observation, interview, and record review, the facility failed to ensure the dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. Food service workers did not follow the facility's cleaning procedure to clean food preparation surfaces and stationary equipment. (Cross referred F 812) This failure had the potential to cause foodborne illness for 64 of 64 sampled residents who received food from the kitchen. 2. [NAME] (CK) 1 served chunky pasta for 10 of 10 sampled residents who had a physician prescribed pureed diet (food that has been ground, pressed and/or strrained to a soft smooth consistency like pudding) during lunch on May 8, 2024. (Cross referred F 805) These failures had the potential to place the residents at risk of aspiration (accidentally inhaling food or liquid into the lungs), choking, and decreased meal intake. Findings: 1. On May 8, 2024, at 10:54 a.m., an observation was conducted with CK 1. CK 1 cleaned the prep table surface and blender base with sanitizer after preparing mechanical soft chicken. On May 8, 2024, at 11:10 a.m., an interview was conducted with CK 1. She stated she used sanitizer to clean the prep table surface and blender base. On May 8, 2024, at 11:11 a.m., an interview was conducted with the Dietary Supervisor (DTR). She stated the dietary staff used sanitizer to clean the prep table surface and stationary equipment after use. On May 9, 2024, at 11:24 a.m., interviews were conducted with CK 2 and CK 3. CK 2 and CK 3 were asked how to clean the prep table surface and stationary equipment after use. Both stated, they use sanitizer to clean the prep table surface and stationary equipment. During a review of the facility Procedure title, SHELVES, COUNTERS, AND OTHER SURFACES INCLUDING SINKS (HANDWASHING, FOOD PREPARATION, ETC.), indicated, .Remove any large debris and wash surface with a warm detergent solution .Rinse with clear water using a clean sponge or cloth. Wipe dry with a clean cloth. 3. Spray with a sanitizer . During a review of the facility's Policy and Procedure titled, SANITATION, indicated, .The Food and Nutrition Services Director (Dietary Supervisor) is responsible for instruction employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques . During a review of the job description Cook, indicated, .The primary purpose of your job position is to prepare food in accordance with current applicable federal, state, and local standards, guidelines and regulations, with our established policies and procedures .in accordance with sanitary regulations . 2. On May 8, 2024, at 10:38 a.m., an interview was conducted with CK 1. She stated she finished preparing all pureed food items (chicken, noodles, and vegetable) for lunch. On May 8, 2024, at 1:05 p.m., a test tray (to evaluate the quality of a meal during a meal service and identify any areas for improvement) was conducted with the DTR. The DTR stated the pureed noodles had chunks and did not have a smooth consistency. On May 9, 2024, at 2:39 p.m., an interview was conducted with Registered Dietitian (RD) 2. She stated a pureed diet should be smooth in consistency with no chunks. The RD 2 further stated her expectation was for the cooks to follow the puree diet menu and recipe. During a review of the job description Cook, indicated, .Prepare food for therapeutic diets in accordance with planned menus .Prepare food in accordance with standardized recipes and special diet orders .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Food service workers did not follow the facility's cleaning procedure to clean food preparation surfaces and stationary equipment. (Cross reference 802); 2. [NAME] (CK) 2 did not cover his mustache; 3. Five cracked tiles were found on the kitchen floor; 4. There was missing grout found in the kitchen dirty area; 5. There was peeling paint and holes found on the wall; 6. Four of four storage shelves in the dry storage room were rusted; 7. There was grease buildup found on the fire hoods; 8. The microwave had buildup; 9. The grid divider was covered with dust in the pot and pans area; 10. The ice machine pipes had buildup; and 11. Seven out of eleven white storage shelves in reach-in refrigerator had chipped paint. These failures had the potential to increase the risk of cross-contamination and exposure to microorganisms that harbor foodborne pathogens, resulting in foodborne illness (stomach illness acquired from ingesting contaminated food) for 64 out of 64 sampled residents who received food from the kitchen and are medically compromised. Findings: 1. On May 8, 2024, at 10:54 a.m., an observation was conducted with CK 1. CK 1 cleaned the prep table surface and blender base with sanitizer after preparing mechanical soft chicken. On May 8, 2024, at 11:10 a.m., an interview was conducted with CK 1, she stated she used the sanitizer to clean the prep table surface and blender base. On May 8, 2024, at 11:11 a.m., an interview was conducted with the Dietary Supervisor (DTR). She stated the dietary staff used sanitizer to clean the prep table surface and stationary equipment after use. On May 9, 2024, at 11:24 a.m., interviews were conducted with CK 2 and CK 3. CK 2 and CK 3 were asked how to clean the prep table surface and stationary equipment after use. Both stated, they use sanitizer to clean the prep table surface and stationary equipment. On May 9, 2024, at 2:39 p.m., interviews were conducted with Registered Dietitian (RD) 2, RD 3 and the DTR. RD 3 stated the proper procedure for cleaning the prep table surface and stationary equipment was to wash, rinse, and sanitize after use. RD 2 and DTR stated not following the proper cleaning procedure could result in potential cross-contamination of the preparation areas and equipment. During a review of the facility Procedure titled, SHELVES, COUNTERS, AND OTHER SURFACES INCLUDING SINKS (HANDWASHING, FOOD PREPARATION, ETC.), indicated, .Remove any large debris and wash surface with a warm detergent solution .Rinse with clear water using a clean sponge or cloth. Wipe dry with a clean cloth. 3. Spray with a sanitizer . 2. On May 7, 2024, at 10:19 a.m., CK 2 was observed to not have his mustache covered during meal preparation. On May 7, 2024, at 1:08 p.m., an interview was conducted with the DTR. She stated CK 2 should have had his mustache covered while in the kitchen. On May 9, 2024, at 2:39 p.m., an interview was conducted with RD 2. She stated CK 2 should have had his mustache covered while working in the kitchen to prevent cross-contamination. During a review of the facility Policy and Procedure titled, DRESS CODE, dated 2023, indicated, .If applicable, beards and mustaches (any facial hair) must wear beard restraint . 3. During the initial kitchen tour conducted on May 7, 2024, at 9:15 a.m., a concurrent observation and interview was conducted with the DTR. She stated there were five broken tiles found in the kitchen in the following areas: i) Under the dish machine ii) In front of the dish machine iii) In the dirty area iv) In front of the pot and pan area On May 9, 2024, at 2:39 p.m., an interview was conducted with RD 2. She stated cracked tiles need to be replaced in order to have a smooth surface that is easily cleaned. 4. On May 7, 2024, at 10:43 a.m., a concurrent observation and interview was conducted with the DTR in the dirty area of the kitchen. There was missing grout on the floor. The DTR stated the missing grout should be filled. On May 9, 2024, at 2:39 p.m., an interview was conducted with RD 2. She stated the missing grout should be filled in order to have a smooth surface that is easily cleaned. During a review of the U.S. Food and Drug Administration's (FDA) Food Code 2022, Annex 3: Section 6-201.12 Floors, Walls, and Ceilings, Utility Lines, indicated, .Floors that are of smooth, durable construction and that are nonabsorbent are more easily cleaned .Requirements and restrictions regarding floor coverings, utility lines, and floor/wall junctures are intended to ensure that regular and effective cleaning is possible and that insect and rodent harborage is minimized . 5. On May 7, 2024, at 10:43 a.m., a concurrent observation and interview was conducted with the DTR in the dirty area of the kitchen. The DTR stated there were 2 holes and chipped paint on the wall. On May 9, 2024, at 2:39 p.m., an interview was conducted with RD 2. She stated the walls should not have chipped paint or holes and should have a smooth surface that is easily cleaned. During a review of the facility policy and procedure titled, WALLS, CEILINGS, AND LIGHT FIXTURES, dated 2023, indicated, .Walls .must be free of chipped and /or peeling paint .It is important to repair peeling paint areas as soon as they appear . 6. On May 7, 2024, at 11:08 a.m., a concurrent observation and interview was conducted with the DTR and the Maintenance Supervisor (MTD) in the dry storage area. Four out of four silver storage shelves had brown grime. The DTR stated all four silver storage shelves had brown grime. The MTD stated the brown grime was rust. On May 9, 2024, at 2:39 p.m., an interview was conducted with RD 2. She stated the storage shelves need to have a smooth surface that is easily cleaned. RD 2 further stated the rusted storage shelves should be replaced. During a review of the facility policy and procedure titled, SANITATION, dated 2023, indicated, .All .shelves .shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas . 7. On May 7, 2024, at 10:38 a.m., a concurrent observation and interview was conducted with the DTR in front of the stove in the kitchen. There was black grease buildup on the fire hood pipes. The DTR stated the black grease buildup on the fire hoods could potentially drop into food while the cooks prepared food on the stove. On May 9, 2024, at 2:39 p.m., an interview was conducted with RD 2. She stated the fire hood pipes above the stove should be kept clean. During a review of the facility policy and procedure titled, HOODS, FILTERS, AND VENTS, dated 2023, indicated, .Hoods must be free of dust and grease . During a review of the U.S. Food and Drug Administration's (FDA) Food Code 2022, Annex 3: Section 4-204.11 Ventilation Hood Systems, Drip Prevention, indicated, .The dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms . 8. On May 7, 2024, at 9:17 a.m., a concurrent observation and interview was conducted with the DTR regarding the microwave in the kitchen. There was brown grime buildup inside the microwave. The DTR stated the microwave had buildup. On May 9, 2024, at 2:39 p.m., an interview was conducted with RD 2. She stated the microwave should not have buildup and should have been kept clean. During a review of the facility policy and procedure titled, SANITATION, dated 2023, indicated, .All .equipment shall be kept clean . 9. On May 7, 2024, at 9:48 a.m., a concurrent observation and interview was conducted with the DTR and RD 1 in the pot and pan area of the kitchen. The grid divider was covered with brown debris and black grime buildup. The DTR stated the brown debris was dust, and RD 1 stated there should not have been any grime, debris or dust on the grid divider. On May 9, 2024, at 2:39 p.m., an interview was conducted with RD 2. She stated the grid divider should be kept clean to prevent cross-contamination. During a review of the facility policy and procedure titled, SANITATION, dated 2023, indicated, .All .equipment shall be kept clean . 10. On May 7, 2024, at 11:10 a.m., an interview was conducted with the DTR regarding the ice machine in the kitchen. The DTR stated there is one ice machine used for the facility. On May 7, 2024, at 11:10 a.m., a concurrent observation and interview was conducted with the MTS regarding the ice machine in the kitchen. Inside the ice machine under the ice maker, there was brownish buildup on the pipes. The MTS stated there was brownish buildup on the pipes and he did not clean the ice machine pipes. On May 9, 2024, at 2:39 p.m., an interview was conducted with RD 2. She stated the pipes under the ice maker were not supposed to have buildup and should be kept clean. During a review of the facility policy and procedure titled, SANITATION, dated 2023, indicated, .All .equipment shall be kept clean .Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner . During a review of the facility policy and procedure titled, ICE MACHINE CLEANING PROCEDURES, dated 2023, indicated, .The internal components cleaned monthly or per manufacturer's recommendations .Information about .cleaning and care of the ice machine can obtained from owner's manual . During a review of the document titled, Ice Machine Owner's Manual, indicated, .Clean and sanitize the ice machine a minimum of once every six months for efficient operation .If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment . 11. On May 7, 2024, at 11:54 a.m., a concurrent observation and interview was conducted with the DTR regarding Reach-in refrigerator number (#) 3. Seven of eleven white storage shelves inside the Reach-in refrigerator had chipped paint. The DTR stated the white storage shelves had chipped paint. On May 9, 2024, at 2:39 p.m., an interview was conducted with RD 2. She stated the white storage shelves in the Reach-in Refrigerator # 3 should not have chipped paint and should be replaced. RD 2 further stated the white storage shelves need to have a smooth surface to be easily cleaned. During a review of the facility policy and procedure titled, SANITATION, dated 2023, indicated, .All .shelves .shall be kept clean, maintained in a good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas .

Based on observation, interview, and document review, the facility failed to ensure medications in emergency medication supply containers (EKITs) were safely stored, with individual medications placed in its own space to distinguish one from others. Two EKITs contained multiple different unit-dose medications in each compartment. This failure had the potential for delay in locating and administering the needed medication, and to increase medication errors. Findings: On May 7, 2024, at 11:10 a.m., during an inspection of the medication room with the Registered Nurse Supervisor (RNS), it was noted there were two EKITs, one EKIT contained 48 different medications and the other contained 40 different medications. The EKIT labeled, Nonantibiotic EKIT #1 (A-L), had 13 compartments for 48 different medications, each compartment containing multiple different medications in manufacturer's unit dose packaging, mixed together. The EKIT labeled, Nonantibiotic EKIT #2 (M-W), had 17 compartments for 40 different medications, each compartment containing multiple different medications in manufacturer's unit dose packaging, mixed together. The medications were alphabetically placed in the compartments and medications that sounded similar to each other were placed in the same compartment. Observed in one compartment placed together, were citalopram, carvedilol, and carbidopa/levodopa. On May 10, 2024, at 11:25 a.m., during an interview, the Consultant Pharmacist (CP) stated, medications in EKITs should be compartmentalized, with each medication stored separately in its own compartment. The CP agreed that having one medication per compartment would be safer for picking the right medication in the EKIT. The facility's policy and procedure titled, Medication Storage in the Facility Storage of Medications, dated December 12, 2023, indicated, .Medications and biologicals are stored safely .Medication storage areas are .free of clutter . According to the Institute for Safe Medication Practices (ISMP- a nationally recognized organization devoted entirely to preventing medication errors,) indicated, .ISMP's List of Confused Drug Names contains look-alike and sound-alike (LASA) name pairs of medications that have been published in the ISMP Medication Safety Alert!(R) Acute Care, the ISMP Medication Safety Alert!(R) Community/Ambulatory Care, and the FDA and ISMP Lists of Look-Alike Drug Names with Recommended Tall Man Letters .Use this list to determine which medications require special safeguards to reduce the risk of errors and minimize harm . According to ISMP article titled, Adopt Strategies to Manage Look-Alike and/or Sound-Alike Medication Name Mix-Ups, dated June 2, 2022, indicated, .Store medications with problematic, error-prone, look-alike and/or sound-alike names in separate physical locations away from each other .

Based on observation, interview, and record review, the facility failed to ensure the appropriate food texture was provided for 10 of 10 sampled residents (Resident 6, 11, 13, 32, 39, 62, 63, 219, 170 and 369) who had a physician-prescribed pureed diet (food the has been grounded, pressed and/or starined to a soft smooth consistency like pudding) received chunky noodles during lunch on May 8 2024. This failure had the potential to place the residents at risk of aspiration (accidentally inhaling food or liquid into the lungs), choking, and decreased meal intake. Findings: (Cross reference 802) On May 8, 2024, at 1:05 p.m., a test tray (to evaluate the quality of a meal during a meal service and identify any areas for improvement) was conducted with the Dietary Supervisor (DTR). The surveyor tried one teaspoon of the pureed noodles and observed the pureed noodles had chunks and did not have a smooth consistency. The DTR stated the pureed noodles were not smooth and contained chunks. The DTR further stated, the potential risk for the residents on pureed diet who consumed the chunky noodles were choking and aspiration. On May 9, 2024, at 2:39 p.m., an interview was conducted with Registered Dietitian (RD) 2. She stated pureed diet should be smooth in consistency with no chunks. RD 2 further stated residents who had a physician order for a pureed diet and were served chunky noodles could experience difficulty chewing and swallowing which could lead to choking and aspiration. During a review of the Physician Prescribed Diet Orders, indicated, .Residents 6, 11, 13, 32, 39, 62, 63, 219, 170 and 369 .on pureed diet . During a review of recipe, PUREED STARCH (Rice, Pasta, Potatoes), undated, indicated .Puree should reach a consistency slightly softer than whipped topping . During a review of the document tiletd, Regular Pureed Diet Definition from Diet Menu, dated 2023, indicated, .The pureed diet is a regular diet that has been designed for residents who have difficulty chewing/or swallowing .The texture of the food should be of a smooth and moist consistency .

Based on interview and record review, the facility failed to ensure a copy of the Advance Directive (AD - written statement of a person's wishes regarding medical treatment) was available in the resident's record and accessible to staff, for one of three residents reviewed for AD (Residents 15). This failure had the potential to make Resident 15's AD not readily retrievable by the staff and the physician, leaving them unaware of and unable to honor the residents' wishes regarding their medical treatment. Findings: On May 8, 2024, Resident 15's record was reviewed. Resident 15 was admitted to the facility on [DATE]. A review of Resident 15's History and Physical dated March 1, 2024, indicated, .has the capacity to understand and make decisions . A review of Resident 15's Minimum Data Set (an assessment tool), dated February 29, 2024, indicated Resident 15 had a Brief Interview of Mental Status (a tool used to screen and identfy the cognitive condition of residents) Score of 12 (moderate impairment in cognition). A review of Resident 15's Advance Directive Acknowledgement Form, dated February 29, 2024, indicated, .I do have an Advance Directive . There was no documented evidence a copy of the AD was provided in Residents 15's medical record. On May 9, 2024, at 08:47 a.m., during a concurrent interview and review of Resident 15's record with the Social Service Director (SSD), the SSD stated she is responsible for AD formulation and follow-up. The SSD further stated if the resident has an AD, copy of the AD is obtained and place in the resident's record. The SSD stated Resident 15 has an AD, but it was not available in the resident's record. The SSD further stated, Resident 15's AD should have been available and accessible to the staff and physician. The facility Policy and Procedure titled, Advance Directives, dated December 2023, indicated, .Prior to, upon, or immediately after admission, the facility staff will ask residents, and/or their family members about the existence of any advance directives .Should a resident indicate that he or she has issued advance directive about his/her care and treatment .a copy of such directives be included in the medical records .