Every finding on record at Pearl River Co Nursing Home

Based on interviews, record review, and facility policy review, the facility failed to implement a comprehensive person-centered care plan by failing to provide the care-planned assistance of two staff members during a resident transfer for one (1) of five (5) residents reviewed for transfers. (Resident #1).Findings include: A review of the facility's policy titled, Using the Care Plan, revised August 2006, revealed, Policy Statement: The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident .A record review of Resident #1's admission Record revealed the facility admitted the resident on 06/03/26, with an initial admission date of 10/15/24, with diagnoses including cellulitis of the right lower limb.A record review of the Order Summary Report, as of 08/07/26, revealed an order dated 04/25/25 requiring extensive assistance of two (2) staff members for transfers.A record review of Resident #1's Care Plan Report revealed a focus area for an Activities of Daily Living (ADL) self-care performance deficit related to requiring assistance with ADLs, multiple sclerosis, and a history of falls, revised on 01/20/25. Interventions included extensive assist times two (2) with transfers, initiated on 06/11/26, and Hoyer lift as needed for transfers times two (2) assist, initiated on 12/03/25.A record review of the computerized Certified Nursing Assistant (CNA) Kardex revealed that on 08/07/26, Resident #1's transfer status was documented as extensive assistance with two plus persons physical assist.A record review of Nursing Assistant (NA) #1's written statement revealed she was unaware Resident #1 required assistance of two staff members for transfers when she transferred the resident from the wheelchair to the bed on 08/07/26. NA #1 positioned the resident's wheelchair at an angle facing the bed, stood in front of the resident, and assisted the resident to stand and transfer onto the bed. NA #1 then bent down to monitor the resident's catheter. After NA #1 stood back up and moved the wheelchair, she heard a pop and observed blood everywhere.A record review of the facility's Incident Report revealed that on 08/07/26 at 6:15 PM, NA #1 reported that while transferring Resident #1 from the wheelchair to the bed, she heard a pop and observed bleeding from the resident's right lower leg.A record review of the Emergency Department Encounter revealed that on 08/07/26 at 6:38 PM, Resident #1 presented with a right leg injury. The resident and facility staff reported that while the resident was being transferred to the bed with assistance, her legs began to give out, and she struck her right leg on the side rail, resulting in a large laceration. The Emergency Department documented a large laceration across the anterior surface of the right leg with an obvious open fracture. Distal sensation and pulse were intact. Resident #1 was subsequently transferred to another hospital for further evaluation and treatment.A record review of the portable right tibia/fibula X-ray dated 08/07/26 at 6:22 PM revealed, Impression: Marked generalized osteopenia. Significant soft tissue defect along the anterior aspect of the proximal right tibia without evidence of acute bony injury. Postop change otherwise noted.A record review of the Emergency Department Encounter revealed that on 08/08/26 at 1:18 AM, the medical record documented that Resident #1 fell out of the wheelchair, sustaining a laceration to the right proximal tibia/fibula area just below the knee. The laceration to the right lower leg measured 10 centimeters (cm). A record review of the CT Knee Without Contrast RT, dated 08/08/26 at 2:59 AM, revealed, Impression: Acute fracture of the proximal tibia extending into the tibial tubercle and medial tibial plateau.On 08/25/2026 at 10:00 AM, during a telephone interview, NA #1 stated she was unaware Resident #1 required a two-person assist for transfers and did not see the two-person-assist requirement documented on Resident #1's Kardex in the computerized charting system. NA #1 confirmed she transferred Resident #1 from the wheelchair to the bed on 08/07/2026 without assistance from a second staff member.On 08/25/2026 at 10:40 AM, during an interview, Registered Nurse/Minimum Data Set (RN/MDS) #1 stated each resident's comprehensive care plan was individualized based on the resident's assessed needs, functional status, and required level of assistance. RN/MDS #1 confirmed Resident #1's comprehensive care plan identified that the resident required extensive assistance of two staff members for transfers. RN/MDS #1 stated nursing staff, CNAs, and NAs were expected to review and follow each resident's individualized care plan, including the identified level of assistance required for transfers.On 08/25/2026 at 1:00 PM, during an interview, the Director of Nursing (DON) stated nursing assistants were expected to follow each resident's individualized care plan when providing care and confirmed residents' transfer requirements were available to nursing assistants through the Kardex. The DON confirmed NA #1 knew how to access the Kardex to identify residents' transfer requirements. The DON stated three other residents assigned to NA #1 required Hoyer-lift transfers and that NA #1 requested assistance with those transfers. The DON confirmed Resident #1's care plan required assistance of two staff members for transfers and NA #1 did not follow the resident's care plan when she transferred Resident #1 without assistance from a second staff member. The DON stated she expected all staff to follow residents' care-planned transfer requirements.On 08/25/2026 at 1:30 PM, during an interview, the Administrator stated all nursing staff were expected to follow each resident's individualized care plan, including transfer requirements. The Administrator stated staff were expected to review a resident's transfer status before providing assistance and obtain additional staff assistance when required by the care plan. The Administrator confirmed Resident #1's care plan required assistance of two staff members for transfers and that the care plan should have been followed during the transfer on 08/07/26.

Based on interviews, record review, and facility policy review, the facility failed to provide the required level of staff assistance during a resident transfer to reduce the risk of an avoidable accident when one staff member transferred a resident who required assistance of two staff members for one (1) of five (5) residents reviewed for accidents. (Resident #1).Findings include: A review of the facility's policy titled, Accidents/Incidents, revised April 2013, revealed, Policy Statement: Our facility shall provide a safe and secure environment for staff and residents. Therefore, all accidents or incidents occurring on facility premises.while performing their jobs shall be reported and investigated.A review of the facility's policy titled, Safety and Supervision of Residents, revised July 2017, revealed, Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.A record review of Resident #1's admission Record revealed the facility admitted the resident on 06/03/26, with an initial admission date of 10/15/24, with diagnoses including cellulitis of the right lower limb.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/10/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact.A record review of the Order Summary Report, as of 08/07/26, revealed an order dated 04/25/25 requiring extensive assistance of two (2) staff members for transfers.A record review of Resident #1's Care Plan Report revealed a focus area for an Activities of Daily Living (ADL) self-care performance deficit related to requiring assistance with ADLs, multiple sclerosis, and a history of falls, revised on 01/20/25. Interventions included extensive assist times two (2) with transfers, initiated on 06/11/26, and Hoyer lift as needed for transfers times two (2) assist, initiated on 12/03/25.A record review of the computerized Certified Nursing Assistant (CNA) Kardex revealed that on 08/07/26, Resident #1's transfer status was documented as extensive assistance with two plus persons physical assist.A record review of Nursing Assistant (NA) #1's Skills Check Offs competency revealed the competencies were completed and signed off between 06/10/2026 and 07/10/2026, prior to the incident on 08/07/2026. The competency checkoffs included resident transfers, use of mechanical lifts, and use of the computerized charting system/Kardex to identify resident care needs.A record review of NA #1's Continuing Education Earned revealed training was completed between 06/8/26 and 06/23/26. A record review of the facility's Incident Report revealed that on 08/07/26 at 6:15 PM, NA #1 reported that while transferring Resident #1 from the wheelchair to the bed, she heard a pop and observed bleeding from the resident's right lower leg. The nurse entered the room and observed Resident #1 sitting on the bed with blood running from a large laceration to the right lower leg. The nurse applied pressure to the wound with towels, called for assistance, and the resident was transferred to the adjacent emergency room for evaluation and treatment. The Medical Provider, Director of Nursing (DON), and Resident Representative (RR) were notified.A record review of NA #1's written statement, undated, revealed she was unaware Resident #1 required assistance of two staff members for transfers when she transferred the resident from the wheelchair to the bed on 08/07/26. NA #1 positioned the resident's wheelchair at an angle facing the bed, stood in front of the resident, and assisted the resident to stand and transfer onto the bed. NA #1 then bent down to monitor the resident's catheter. After NA #1 stood back up and moved the wheelchair, she heard a pop and observed blood everywhere.A record review of the Emergency Department Encounter revealed that on 08/07/26 at 6:38 PM, Resident #1 presented with a right leg injury. The resident and facility staff reported that while the resident was being transferred to the bed with assistance, her legs began to give out, and she struck her right leg on the side rail, resulting in a large laceration. The Emergency Department documented a large laceration across the anterior surface of the right leg with an obvious open fracture. Distal sensation and pulse were intact. Resident #1 was subsequently transferred to another hospital for further evaluation and treatment.A record review of the portable right tibia/fibula X-ray dated 08/07/26 at 6:22 PM revealed, Impression: Marked generalized osteopenia. Significant soft tissue defect along the anterior aspect of the proximal right tibia without evidence of acute bony injury. Postop change otherwise noted.A record review of the Emergency Department Encounter revealed that on 08/08/26 at 1:18 AM, the medical record documented that Resident #1 fell out of the wheelchair, sustaining a laceration to the right proximal tibia/fibula area just below the knee. The laceration to the right lower leg measured 10 centimeters (cm). A record review of the CT Knee Without Contrast RT, dated 08/08/26 at 2:59 AM revealed, Impression: Acute fracture of the proximal tibia extending into the tibial tubercle and medial tibial plateau.On 08/25/2026 at 10:00 AM, during a telephone interview, NA #1 stated that on 08/07/2026, she was working at the facility as a Nursing Assistant (NA) and was scheduled to test for CNA certification on 08/08/2026. NA #1 stated she was assigned to provide care for six residents and was instructed to ask other CNAs for assistance with transfers, Hoyer lifts, and repositioning residents, as needed. NA #1 stated she was unaware Resident #1 required a two-person assist for transfers and did not see the two-person-assist requirement documented on Resident #1's Kardex in the computerized charting system. NA #1 confirmed she transferred Resident #1 from the wheelchair to the bed on 08/07/2026 without assistance from a second staff member. NA #1 stated she did not observe an injury during the transfer. After moving the wheelchair away from Resident #1, she observed bleeding from the resident's right leg and immediately called for assistance. NA #1 confirmed that prior to the incident, she had received education on the facility's computerized charting system and was aware that each resident had a Kardex containing resident-specific care information. NA #1 further stated she was responsible for providing care to other residents who required Hoyer-lift transfers and confirmed she obtained assistance from other staff members when transferring those residents.On 08/25/26 at 10:20 AM, during a telephone interview, CNA #2 confirmed she worked the same shift as NA #1 on 08/07/26. CNA #2 stated the charge nurse instructed CNAs and NAs to be responsible for their assigned residents during the shift. CNA #2 stated she personally assisted NA #1 with several resident transfers during the shift that required Hoyer lifts and confirmed NA #1 requested and received assistance from other staff when assistance was required.On 08/25/26 at 1:00 PM, during an interview, the DON confirmed that prior to being assigned residents, NAs were required to complete classroom education and skills competency checkoffs, including education on the facility's computerized charting system and how to access the Kardex to identify each resident's care needs and transfer requirements. The DON confirmed NA #1 knew how to access the Kardex to identify residents' transfer requirements. The DON stated three other residents assigned to NA #1 required Hoyer-lift transfers and that NA #1 requested assistance with those transfers. The DON confirmed Resident #1's care plan required assistance of two staff members for transfers and NA #1 did not follow the resident's care plan when she transferred Resident #1 without assistance from a second staff member. The DON stated she expected all staff to follow residents' care-planned transfer requirements.On 08/25/2026 at 1:30 PM, during an interview, the Administrator stated all nursing staff were expected to follow each resident's individualized care plan, including transfer requirements. The Administrator stated staff were expected to review a resident's transfer status before providing assistance and obtain additional staff assistance when required by the care plan. The Administrator confirmed Resident #1's care plan required assistance of two staff members for transfers and that the care plan should have been followed during the transfer on 08/07/26.

Based on observation, staff interview, and facility policy review, the facility failed to discard spoiled food items for one (1) of four (4) days of survey. Findings include:A review of the facility's policy, Storing; Food and Equipment, Food Storage and Equipment, undated, revealed, .Team members must store food in a manner that ensures quality, freshness and safeguards against foodborne illness.On 6/15/26 at 9:43 AM, during an observation and interview with Dietary Manager (DM) #1, there was one (1) box of cucumbers that contained several molded and deteriorating cucumbers at the bottom of the box in Walk-in Refrigerator #1. DM #1acknowledged the cucumbers were deteriorated and removed the entire box from the refrigerator. There was three (3) bags of grapes stored inside a cardboard box that contained molded grapes. DM #1 removed the case, and reported dietary aides were responsible for inspecting fresh produce daily and removing deteriorating items. DM #1 further explained dietary aides were responsible for unloading produce deliveries and checking fresh produce every other day for deterioration.On 6/17/26 at 3:30 PM, in a follow up interview, DM #1 revealed expectations were for staff to remove all rotting, deteriorating, and moldy produce prior to serving. DM #1 reported corrective actions would include assigning staff responsibility for specific storage areas, conducting systematic inspections at the beginning and end of each shift, and ensuring no deteriorating food items remained. DM #1 acknowledged staff had not consistently completed the food storage checklist.On 06/17/2026 at 4:38 PM, in an interview, the Administrator stated that his expectation for the Dietary Department is to ensure staff routinely monitor all fresh produce and promptly remove any moldy, spoiled, or deteriorating produce from refrigerators when identified. He further stated that dietary staff are expected to inspect produce regularly to ensure only wholesome food is available for resident consumption.

Based on observation, staff interview, record review and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the resident's use of a physical restraint, despite the facility's restraint assessment identifying the device as a restraint, for one (1) of (18) residents reviewed for MDS accuracy. (Resident #5).Findings include: A review of facility's policy titled, Comprehensive Assessments and the Care Delivery Process, with a revised date of December 2016, revealed, .Policy Interpretation and Implementation.Comprehensive assessments.involve collecting and analyzing information.Assessment and information collection (assessment).objective of the information collection.to obtain, organize, and subsequently analyze information.a.(1).Gather relevant information from multiple sources.A record review of the admission Record revealed Resident #5 was admitted by the facility on 4/21/22 with diagnoses including Vascular Dementia, Unspecified Severity, With Other Behavioral Disturbance, Hallucinations, Unspecified, Anxiety Disorder, Unspecified, and Restlessness and Agitation.A record review of the Treatment Administration Record (TAR) dated June 2026, revealed Resident #5 had a Physician's Order, dated 5/09/25 for Seat belt with alarm for use when up in wheelchair (w/c) for safety; Release and Reposition every 2 hours and PRN every shift.A record review of the Discharge Return Anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/16/26 for Resident #5 revealed no restraint was coded. Section P Restraints and Alarms, item #P0100, Physical Restraints, was coded 0, indicating the resident had not used a restraint during the look-back period.A record review of Resident #5's Restraint-Physical (Initial Evaluation) form with an effective date 5/09/2025 revealed Resident #5's seatbelt had been identified by the facility as a physical restraint and remained in use during the MDS assessment reference period for the Discharge Return Anticipated with an ARD of 5/16/26.On 06/15/2026 at 11:58 AM during an observation of Resident #5, he was observed sitting up in the wheelchair with a seatbelt latched around his waist.On 06/17/26 at 9:48 AM, during an observation and interview with Licensed Practical Nurse (LPN) #1, Resident #5 was asked to remove the seatbelt that was latched around his waist. The resident was unable to intentionally release the seatbelt upon request. LPN #1 stated Resident #5 frequently unbuckled the seatbelt throughout the day but believed the residents action was habitual rather than an intentional attempt to remove the device.On 06/17/26 at 9:51 AM, during an interview with the Director of Nursing (DON), she stated Resident #5 was unable to independently remove the seatbelt. She further reported the resident frequently fidgeted with the seatbelt throughout the day, causing the alarm to sound. The DON described the resident's action as habitual and not an intentional attempt by the resident to remove the seatbelt.On 06/17/26 at 10:06 AM, during an interview with the MDS Nurse, he stated he is responsible for coding the MDS. He confirmed Resident #5's seatbelt had not been coded as a restraint on the Discharge Return Anticipated MDS with an (ARD of 5/16/26. During the interview, the MDS Nurse reviewed the resident's medical record and confirmed there was no documentation supporting that Resident #5 was able to independently remove the seatbelt during the MDS look-back period. Based on the resident's inability to independently remove the seatbelt, the MDS Nurse confirmed the seatbelt should have been coded as a restraint on the MDS assessment with ARD of 5/16/26.On 06/17/26 at 10:19 AM, during an interview the DON, she stated that she expected the MDS to be coded accurately and in accordance with RAI guidelines.On 06/17/26 at 12:10 PM, during an interview with the Administrator, he stated that he expected that the MDS to be coded accurately.On 06/17/26 at 4:36 PM, during a follow-up interview with the DON, she stated that the use of restraints is communicated to the Interdisciplinary Team (IDT) verbally. She acknowledged that Resident #5's seatbelt was a restraint and confirmed that the Discharge Return Anticipated MDS with ARD of 5/16/26 was not coded to reflect the use of a restraint as required.

Based on observation, interview, facility policy review, and record review, the facility failed to ensure a resident was free from the use of a physical restraint when facility staff loosely wrapped a resident's legs in a sheet to prevent the resident from removing his brief for one (1) of three (3) sampled residents. Resident #1 Findings include: A review of the facility policy, Use of Restraints, revised December 2007, revealed, .Policy Interpretation and Implementation 1. 'Physical Restraints' are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily .4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including .b. Tucking sheets so tightly that a bed-bound resident cannot move . A record review of the Admission Record revealed the facility admitted Resident #1 on 12/17/24 with diagnoses including Parkinson's Disease. A record review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/18/25 revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident's cognition was severely impaired. A record review of the medical record revealed there was no documentation indicating Resident #1 had assessments, interventions, or Physician Orders for the use of a physical restraint. A record review of the Progress Note dated 5/8/25 at 6:18 (AM) revealed: AROUND 5:40 AM ON THIS MORNING 05/08/2025 THIS NURSE ENTERED THIS RESIDENT'S ROOM TO OBTAIN VITALS TO ADMINISTER MEDICATIONS. ONCE IN THE ROOM, THIS NURSE NOTICED THIS RESIDENT TUGGING AT HIS SHEET ON HIS LOWER EXTREMITIES .THIS NURSE FOUND THAT THE RESIDENT'S LEG HAD BEEN BOUND TOGETHER WITH TAPE .THE RESIDENT RESPONDED SAYING THANK YOU . The entry was signed by Licensed Practical Nurse (LPN) #1. A review of the facility's investigation revealed that on 5/8/25, LPN #1 reported to the Director of Nursing (DON) that Resident #1 was found with a sheet wrapped around his legs and secured with tape. Certified Nurse Aides (CNAs) stated the intervention was used because the resident was frequently pulling off his brief and smearing feces. The tape was approximately six (6) inches long and placed mid-calf, over the sheet. The resident's arms and feet were not restricted. A red area was noted by the nurse, which resolved within an hour. On 5/19/25 at 6:15 PM, during an observation, Resident #1 was non-verbal, and was laying in his bed with sheets over his lower extremities. His bed was in the low position with a floor mat next to bed. On 5/20/25 at 10:00 AM, during an interview with LPN #1, she confirmed she found Resident #1 with his legs wrapped in a flat sheet and a piece of tape. She immediately removed the tape and sheet and notified the DON. She confirmed she did not leave the items in place for a witness to observe. On 5/20/25 at 10:20 AM, during an interview with CNA #1, she confirmed that she and CNA #2 attempted to prevent the resident from removing his brief by placing him in a burrito wrap using a sheet and secured it with tape. She confirmed he could move his arms and legs, and the tape was not in contact with his skin. On 5/20/25 at 12:24 PM, during an interview with CNA #2, she explained they wrapped the sheet around the resident's lower body and applied a six (6) inch piece of tape across the sheet to keep him from accessing his brief. She confirmed the intervention was not ordered or approved. On 5/20/25 at 12:30 PM, during an interview with the Director of Nursing, she confirmed the sheet and tape were applied to control the resident's behavior without a physician's order or care plan intervention. She stated the resident retained full movement of upper extremities and feet. There was no injury observed, and there was a reddened area that resolved within one (1) hour. She confirmed the intervention was deemed a violation of policy but not abuse. The CNAs involved received suspensions and re-education. On 5/20/25 at 12:45 PM, during an interview with the Administrator, she confirmed the incident was thoroughly investigated and concluded the resident retained the ability to remove the sheet and tape. She emphasized the action was a policy violation, not abuse, and the CNAs were suspended and retrained. She stated the State Agency would have been notified if criteria for abuse had been met. On 5/20/25 at 1:15 PM, during an interview with Registered Nurse (RN) #1 and the DON present, she confirmed that no bruises, scratches, or skin tears were observed. The healing scabbed area on the right calf had been present before the incident. She confirmed the tape did not touch the skin.

Based on observation, interviews, record review, and facility policy review, the facility failed to serve meals within the 14-hour timeframe without providing a substantial snack for one (1) of four (4) days of survey. Findings included: A review of the facility's policy titled Resident Nutrition Services, revised in July 2017, revealed, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident .7. Nourishing snacks are available to the residents 24 hours a day. The resident may request snacks as desired, or snacks may be scheduled between meals to accommodate the resident's typical eating patterns . A record review of the facility's Meal Serving Schedule, updated on 04/04/2023, revealed that dinner for Station Two (2) starts at 4:00 PM to 4:20 PM, and breakfast is served at 7:15 AM to 7:35 AM, resulting in 15 hours and 15 minutes between dinner and breakfast. The schedule also revealed that dinner for Station One starts at 4:20 PM to 4:40 PM, and breakfast is served at 7:35 AM to 7:55 AM, resulting in 15 hours and 10 minutes between dinner and breakfast. A record review of the facility's Cart Delivery Log, dated 02/25/2025 to 02/26/2025, revealed that Station Two received the dinner meal cart on the floor at 4:06 PM on 02/25/2025 and received the breakfast meal cart on 02/26/2025 at 7:28 AM, resulting in a 15-hour and 22-minute lapse between dinner and breakfast. The log also revealed that Station One received their dinner cart at 4:30 PM on 02/25/2025 and their breakfast meal cart at 7:55 AM on 02/26/2025, resulting in a 15-hour and 20-minute lapse between dinner and breakfast. ON 02/25/25 at 4:00 PM, in an observation, the dinner meal trays on 200 Hall at 4:04 PM. The first tray was served at 4:09 PM. The second dinner cart arrived at 4:16 PM and the diabetic nigh snacks were served in brown bags with resident room numbers on the front. Residents in the Dining Hall received their meal tray at 4:22 PM to residents in Dining Hall. On 02/25/2025 at 4:49 PM, during an interview, Dietary Staff #1 stated that the previous Administrator and Director of Nursing (DON) decided approximately six (6) to seven (7) months ago to stop the snack cart due to residents wanting snack options, such as soup, cereal, and sandwich, instead of chips, crackers, and snack cakes. Now the kitchen supplies the nurses' station with snacks, sandwiches with meat and bread, and residents can request these items. Dietary Staff #1 explained that diabetic residents receive snacks automatically with their dinner trays. Dietary Staff #1 defined a suitable snack as juice, a sandwich, graham crackers, a beverage, or soup. On 02/26/2025 at 7:38 AM, during an interview, Licensed Practical Nurse (LPN) #2 confirmed that there is no documentation indicating who receives a snack. LPN #2 explained that each non-diabetic resident must request a snack, whereas diabetic residents receive snacks automatically with their dinner meal. On 02/27/2025 at 1:23 PM, during an interview, Dietary Staff #2, the newly appointed Dietary Manager, stated that she did not know who set the mealtimes and was unaware that there were more than fourteen (14) hours between the dinner meal and the breakfast meal. She stated that she believed snacks were offered to all residents between 7:00 PM and 9:00 PM but was unaware that residents were not receiving a substantial snack. On 02/27/2025 at 1:31 PM, during an interview, Dietary Staff #3 stated that she was unaware that the meal schedule exceeded fourteen (14) hours between dinner and breakfast. She stated that the three meals served daily met residents' nutritional needs but was unaware that residents were not offered snacks at night. On 02/27/2025 at 1:44 PM, during an interview, the Director of Nursing (DON) stated that she did not know who set the mealtimes, but they had been in place since she started working at the facility. The DON stated she was unaware that residents waited longer than fourteen (14) hours between meals and that snacks were not routinely offered. She confirmed awareness of the resident council's decision to remove the snack cart but was unsure why the decision was made. On 02/27/2025 at 2:05 PM, during an interview, the Administrator stated that he was unaware that residents waited longer than fourteen (14) hours between dinner and breakfast and that residents were not offered snacks at night. The Administrator stated that he expected residents to be offered a substantial snack between meals.

Based on observation, interviews, record review and facility policy review, the facility failed to label and date food items in the refrigerator, freezer, and dry good rooms for one (1) of four (4) observations. Findings included: A review of the facility's Food Preparation policy, undated, revealed, .Discard foods that are not date marked ., TCS (Time/Temperature Control for Safety) foods that was opened or prepared seven (7) days prior . A review of the facility's Labeling policy, undated, revealed .Ensure all food items are labeled. Be especially cautious to label all food items that are not kept in their original containers . Ready -to-Eat TCS food . On 02/24/25 at 09:45 AM, during an observation and interview with the Dietary Manager (DM), there was (1) clear plastic bag of boiled eggs unlabeled without a used by or prepared date. In the freezer, there was an unlabeled box of assorted mini cheesecakes, (1) bag of hushpuppies opened, without product opened date. During tour of dry goods room, there was an opened, exposed, an unlabeled box of graham cracker crumbs, and two (2) sweet potatoes that shows deterioration. The DM confirmed the unlabeled items in the refrigerator, freezer, and dry goods room. On 2/27/25 at 2:56 PM, in an interview with the Administrator, confirmed he was had been informed of the findings in the kitchen.

Based on observation,interviews, facility policy review and record review, the facility failed to ensure residents had access to a call light while in bed for two (2) of 18 residents sampled (Residents #1 and #12). Findings include: A review of the facility's policy, Call Light, Use Of, revised on 05/22/2012, revealed: .position the call light conveniently for the resident to use . Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand . A review of the facility's Resident Rights revealed The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside .the facility. Resident #1 On 02/24/2025 at 03:49 PM, an observation of Resident #1 revealed the resident calling for help from his room. The resident's call light was observed to be draped over the call light box located on the wall. The resident was observed to have an amputated leg. The resident stated he was unable to get out of bed to reach the call light from the call light box on the wall. The resident stated the call light was normally on his bed. On 02/24/2025 at 03:50 PM, an interview with Certified Nursing Assistant (CNA) #1 acknowledged the call light was draped over the call light box and was out of the resident's reach. CNA#1 noted that residents' call lights should always be accessible for their safety and stated everyone is responsible for making sure residents have their call lights within reach. A record review of the facility's Admission Record revealed the facility admitted Resident #1 on 07/16/2021, with diagnoses including Acquired Absence of Left Leg Below the Knee. A record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/2025 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #12 On 02/24/2025 at 03:45 PM, observed Resident #12 calling out for help while in her room. The resident stated she was not able to use her call light because she could not see it. The resident explained that she cannot see very well. The resident's call light was observed on the floor under the head of her bed. The resident stated the call light is usually located on her bed within reach. On 02/24/2025 at 03:47 PM, an interview with Licensed Practical Nurse (LPN) #1, Charge Nurse, acknowledged that Resident #12's call light was out of reach and on the floor. LPN #1 noted that not only CNAs but floor nurses as well should assist in making checks to ensure residents' call lights are within reach. LPN #1 stated her expectation would be that residents' call lights should be within reach at all times. A record review of the Admission Record revealed that the facility admitted Resident #12 on 10/31/2024, with diagnoses including Unspecified Visual Loss. A record review of the quarterly MDS with an ARD of 12/20/2024 revealed Resident #12 had a BIMS score of 06, indicating severe cognitive decline. On 02/26/2025 at 01:50 PM, an interview with the Director of Nursing (DON) acknowledged that the call lights for Residents #1 and #12 were out of reach. The DON stated that call lights should always be within reach for every resident. She further stated that the entire nursing staff is responsible for ensuring residents have access to their call lights. The DON emphasized the importance of residents being able to access their call lights to call for assistance and stated the facility's expectation is that all call lights should be clipped to the bed and within reach. The DON noted that she plans to conduct rounds to ensure residents' call lights remain within reach. On 02/27/2025 at 02:13 PM, an interview with the Administrator acknowledged that the call lights for Residents #1 and #12 were out of reach. The Administrator emphasized the importance of residents having call lights within reach so they can call for help. The Administrator stated that he expects nursing staff to assist residents by ensuring their call lights remain accessible at all times.

Based on observations, interviews, record review and facility policy review, the facility failed to ensure Resident #74 had a safe, clean, and homelike environment for two (2) of four (4) days of facility observations. Findings include: A record review of the Resident Rights, in Section H revealed .1. The facility must provide a safe, clean, comfortable, and homelike environment .2. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior . record review of the Seven-Step Deep Cleaning, revised 2/04/14 revealed that cleaning steps include: Disinfecting all surfaces . disinfecting all furniture . inspection of room . On 02/25/2025 at 02:41 PM, an observation of Resident #74 in bed revealed the bed frame, walls, curtains, and bed rails were stained. Resident #74's room had an odor. The resident stated that his room is cleaned daily. On 02/25/2025 at 02:45 PM, an interview with Certified Nurse Aide (CNA) #3 revealed that Environmental Services is responsible for keeping rooms clean, including wiping walls and bed frames. On 02/25/2025 at 02:50 PM, an interview with Environmental Services (EVS) Worker #1 revealed that staff clean rooms daily. Routine cleaning includes dusting furniture, cleaning the bathroom, taking out the trash, and wiping off bed frames when dirt and debris are visible. On 02/26/2025 at 08:42 AM, a phone interview with the EVS Manager revealed that resident rooms receive detailed cleaning three (3) times per week. Detailed cleaning includes walls cleaned, bed frames wiped off, mattresses wiped (if wipeable), furniture dusted, trash removed, bathrooms cleaned, and bed rails sanitized. The EVS Manager stated that deep or detailed cleaning can occur when residents are out of the room. On 02/26/2025 at 08:48 AM, an observation revealed Resident #74 was in bed. The bed frame, walls, curtains, and bed rails remained stained. On 02/26/2025 at 09:10 AM, an observation of Resident #74's room was made by the State Agency and the EVS Manager. This observation revealed a stained bed frame, walls, curtains, and bed rails. The EVS Manager acknowledged the brown stains on the bed frame, curtains, walls, and bed rails. The EVS Manager stated that she would contact laundering services to remove the curtains and clean them. On 02/27/2025 at 08:14 AM, a phone interview with the EVS Manager revealed that her expectation of EVS staff is to clean rooms according to policy. She stated that nursing staff should inform EVS staff when a resident's room is not clean or needs a deeper cleaning. The EVS Manager acknowledged the stains on the walls, bed rails, bed frame, and curtains and stated that she believed the stains were dried food on the walls, bed frame, curtains, and bed rails. On 02/27/2025 at 01:33 PM, an interview with the Director of Nursing (DON) revealed that EVS staff are expected to clean resident rooms daily. The DON stated that if CNAs observe stains on residents' walls, bed frames, or bed rails, they should clean them between EVS daily cleanings.

Based on record review and facility policy review, the facility failed to have mandatory members of the Quality Assurance Performance Improvement (QAPI) Committee present for (4) four of 12 months reviewed. Findings include: A record review of the facility's QAPI sign in logs revealed the Infection Preventionist (IP) was not present for the meeting on 3/20/24, 5/15/24, 6/19/24, and 7/17/24. On 02/27/25 at 02:37 PM, an interview with Registered Nurse #1/Quality Assurance (QA) nurse revealed the IP was not present for four (4) QAPI meetings in 2024. The QA nurse revealed the purpose of having all required disciplines present is that all ideas can be heard and that the department that is affected by a topic can provide input or receive information. The QA nurse stated the nursing home has had a lot of turnover of staff and going forward she expects all required disciplines to be present. On 02/27/25 at 02:59 PM, during an interview with the Administrator, he acknowledged the IP nurse was not present for four (4) QAPI meetings in 2024. The Administrator revealed the purpose of having all required disciplines present is to provide correct communication between the disciplines regarding patient care issues. The Administrator stated that going forward he expects all required disciplines to be present at the QAPI meetings.

Based on interview, record reviews, and facility's policy review the facility failed to ensure the comprehensive care plan interventions were implemented when a resident was transferred with a mechanical lift without the assistance of two (2) staff members for one (1) of 23 sampled residents. Resident #6 Findings include: Review of the facility's policy, Care Plans, Comprehensive Person -Centered, revised December 2016, revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is . implemented for each resident . Record review of the Comprehensive Care plan, dated 7/6/23, revealed . Category: Seizures . Intervention .Total Assist X 2 for transfers with use of Hoyer Lift (mechanical lift) . On 8/24/23 at 09:00 AM, an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed CNA #1 and CNA #2 had been terminated from the facility for not following the facility policy which required two persons when transferring a resident with a mechanical lift. The DON stated that they re-interviewed both employees and found that CNA #1 had transferred Resident #6 to the shower stretcher without the appropriate number of staff and CNA #2 had transferred Resident #6 from the shower stretcher to her bed without the required number of staff. On 8/24/23 at 11:00 AM, in an interview with Certified Nurse Aide (CNA) #1, she confirmed she transferred Resident #6 to the shower stretcher with a mechanical lift and did not have another staff member to assist. She stated that she had been trained in her CNA class to always have two people when transferring a resident with a mechanical lift. On 8/24/23 at 11:15 AM, with CNA #2, she confirmed she transferred Resident #6 from the shower stretcher to the bed without another staff member assisting. She stated that had been trained to have two staff members when using the mechanical lift. On 08/24/23 at 11:52 AM, during an interview with Registered Nurse (RN)#4, she explained that the purpose of the care plan was for facility staff to understand and know what to do for residents to meet the residents' needs. She stated that all resident care plans are located on the residents' chart at the nurse's station and on the computer. RN #4 reported that she expected the staff to follow the resident's care plan. Record review of the Face Sheet revealed the facility admitted Resident # 6 on 9/05/07 and she had diagnoses including Paraplegia, Multiple Sclerosis, and Osteoporosis. Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/23/23 revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident # 6 was cognitively intact. Further review revealed Resident #6 was dependent upon facility staff for transferring and required two persons to assist with the transfers.

Based on interviews, record review, and facility policy review the facility failed to ensure a resident who was transferred using a mechanical lift was transferred with appropriate supervision for one (1) of three (3) sampled residents transferred with mechanical lifts. Resident #6 Findings include: Review of the facility's policy, Lifting Machine, Using a Portable, revised September 2017, revealed, .The purpose of this procedure is to help lift residents using a manual lifting device .General Guidelines Two (2) nursing assistants are required to perform this procedure . An interview on 8/24/23 at 09:00 AM, with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), revealed Certified Nurse Aide (CNA) #1 and CNA #2 had been terminated from the facility for not following the facility policy which required two persons when transferring a resident with a mechanical lift. The DON stated that during an incident investigation, the CNAs were interviewed again and it was discovered that CNA #1 had transferred Resident #6 to the shower stretcher without using the required number of staff and CNA #2 had transferred Resident #6 from the shower stretcher to her bed without the appropriate number of staff. During an interview on 8/24/23 at 11:00 AM, with CNA #1, she confirmed she transferred Resident #6 to the shower stretcher with a mechanical lift and did get another staff member to assist her. CNA #1 said she showered the resident and took her to her room. During an interview on 8/24/23 at 11:15 AM, with CNA #2, she confirmed she transferred Resident #6 from the shower stretcher to the bed without another staff member assisting. She stated that Resident #6 was on the shower stretcher in her room and she cut the resident's hair and transferred her back to her bed. CNA #2 explained that she was aware that the facility required two (2) staff when using a mechanical lift. Record review of the Face Sheet revealed the facility admitted Resident # 6 on 9/05/07 and she had diagnoses including Paraplegia, Multiple Sclerosis, and Osteoporosis. Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/23/23 revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident # 6 was cognitively intact. Further review revealed Resident #6 was dependent upon facility staff for transferring and required two persons to assist with the transfers.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident rinsed her mouth after the administration of a Metered-Dose Inhaler to prevent possible mouth and throat irritation for one (1) of one (1) resident observed for administration of a Metered-Dose Inhaler. Resident #26 Findings include: A record review of the facility's policy Administering Medications through a Metered Dose Inhaler, revised 10/2010, . The purpose of this procedure is to provide guidelines for the safe administration of inhaled medications . Equipment and Supplies .5. Gargling solutions . On 08/22/23 at 03:50 PM, during an observation of medication administration with Registered Nurse (RN) #1, she administered two (2) puffs of the Flovent inhaler and exited the room without instructing the resident to rinse her mouth. On 08/23/23 at 01:30 PM, during an interview with RN #1, she confirmed that on 08/22/23 while administering the Flovent Inhaler to Resident #26, she did not offer the resident water to rinse and expectorate. RN #1 reviewed the guidelines for the use of the medication and confirmed the resident should have rinsed her mouth after the administration of the Flovent inhaler to prevent thrush and other complications. On 08/23/23 at 01:45 PM, during an interview with the Director of Nursing (DON), she explained she expected the nurses to follow the guidelines for medication administration and confirmed the reason for instructing residents to rinse after the administration of a steroid inhaler is to prevent possible complications. A record review of the Face Sheet revealed the facility admitted Resident #26 on 11/04/2016 with the diagnosis of Chronic Obstructive Pulmonary Disease. A record review of the Physician Orders List revealed Resident #26 had a Physician's Order dated 10/7/2019 for Flovent HFA (Fluticasone Propionate) 0.1 mg (milligram) inhaler. Give two puffs via inhalation four times daily. Allow one minute between inhalations. Rinse mouth with water after use . A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/11/2023, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated she had moderate cognitive impairment. A record review of the Patient Information document for Flovent HFA for oral inhalation use, revised 4/2020, revealed . Rinse your mouth with water without swallowing after each dose of Flovent HFA. This will help lessen the chance of getting a yeast infection (thrush) in your mouth and throat .