Every finding on record at Pickersgill Retirement Community

Based on observation, interview and record review, it was determined the facility failed to:1. Follow professional standards for food service safety, evident for 1 of 1 emergency water supply, and 3 out of 3 food storage bins reviewed. 2. Ensure a drain was maintained sanitarily. This was evident for 1 out of 2 drains located near the facility's dishwasher.Observations made during the surveyor's review of the kitchen task during the facility's recertification survey.The findings include:On 4/7/26 beginning at 8:55AM the surveyor conducted an initial tour of the facility's kitchen.On 4/7/26 at 9:00AM the surveyor conducted a dual observation of three storage bins each separately storing the following loose food items: panko bread crumbs, flour, and sugar, with the facility's Director of Dining Services (DDS) #10. The exterior surface of the bread crumb bin was observed to have an unclean, greasy, crusty appearance with visible tan food debris present on the exterior. Upon the removal of the lid, the interior surface near the top rim of the container was observed with brown food debris present. The exterior surface of the container of flour was observed with a cloudy appearance and crusty food debris present. The exterior surface of the container of sugar was observed with a tan food stain present. At this time, the surveyor shared the concerns with DDS #10 who observed and acknowledged the concerns and reported that the bins would be cleaned.On 4/7/26 at 9:18AM the surveyor observed the kitchen drain near to the dishwasher open with no drain covering with food debris and small pieces of trash present within it. At this time the surveyor shared the concern with DDS #10 who observed and acknowledged the concern and indicated that they would have a drain cover put on.On 4/7/26 at 9:22AM the surveyor observed the facility's emergency water supply with DDS #10 at which time gallons of water were observed to be outdated with no gallons able to be located that were within current date. The surveyor observed several gallons of water in which were damaged with some of the gallons empty with droplets of water present on them, and a gallon from 2025 which was sealed and appeared to be approximately 3/4 of the way full.On 4/7/26 at 9:23AM the surveyor conducted an interview of DDS #10 who stated: No, I wouldn't use the expired water, I'll have more water ordered and have the expired water moved to the wastewater area.On 4/7/26 at 1:29PM the surveyor reviewed kitchen documentation provided by DDS #10 which included photographs of the kitchen food storage bins which they reported had been cleaned.On 4/7/26 1:46PM the surveyor conducted an interview of the facility's Administrator who stated to the survey team: All emergency water was expired. The Administrator additionally reported to the survey team that an order for emergency water supply was placed and they expected to receive that within the next day.04/09/2026 8:48 AM the surveyor shared all concerns with the facility's Administrator who acknowledged and confirmed understanding of the concerns.On 4/9/26 at 12:07PM DDS #10 informed the surveyor that the kitchen drain cover had been replaced.On 4/10/26 at 8:47AM the surveyor conducted another observation of the facility's emergency water supply and after surveyor intervention, the water supply was observed replaced with gallons of water which were observed to have expiration dates in the future and were undamaged in appearance. During the observation, DDS #10 informed the surveyor that they had now added a reminder to the calendar in advance, in order to remind them to replace the facility's emergency water supply prior to the new expiration dates.On 4/10/26 at 8:49AM the surveyor conducted another observation with DDS #10 of the kitchen drain near to the dishwasher at which time the drain was again observed open with no cover present. The surveyor again shared the concern with DDS #10 who observed, acknowledged, and confirmed understanding of the concern and reported to the surveyor that the drain cover would be replaced.On 4/10/26 at 9:33AM the surveyor received and reviewed documentation from the facility's Administrator showing the emergency water supply had been replaced.All surveyor concerns were again reviewed with the facility's Administrator and Executive Director during the exit conference on 4/10/26.

Based on observation, interview and record review it was determined the facility failed to ensure the environment was free from pests. This was evident for 1 out of 1 nursing unit during the surveyor's review of Complaint #2714168 and during the facility's recertification survey.The findings include:On 4/7/26 at 7:35AM the surveyor conducted a review of Complaint #2714168 which documented the complainant's concern for mice pest presence in Resident #13's room located on the facility's nursing unit. During multiple surveyor's subsequent tours of the facility's nursing unit, various pest control devices including bait stations, traps and other methods of pest control were observed to be present. Multiple traps were observed by surveyors to be present in various Resident rooms. On 4/8/26 at 12:22PM the surveyor conducted an interview of Director of Maintenance #11 who acknowledged that the facility has had mice on the long term care unit and also reported that the facility had increased the amount of exterminators and had various methods of pest control in place. On 4/8/26 at 12:43PM the surveyor reviewed the pest sighting log book on the nursing unit which documented the following information:- 4/7/26: Droppings still seen on recliner chair behind door- 4/1/26 mouse running in room, family reported problem- 3/22/26 Snake brown in the storage room on 2nd floor- 3/21/26 Mice swinging from the drape- 3/20/26 Resident does not want mouse trap in their room, s/he prefers other alternate method of eliminating mouse in his/her room- 3/17/26 Dining room under fridge- 3/17/26 mice ran across- 3/1/26 Dining room [ROOM NUMBER] mouse- 2/19/26 2 mice running in hallway- 2/9/26 Mice all over the place, the mice is back. Documentation of mice sightings was observed present dating back to December 2025. On 4/8/26 at 1:03PM during an interview of the facility's Executive Director, the surveyor requested for them to provide copies of all health inspections which addressed pest control problems. Surveyor review of the health inspection reports previously provided by the Director of Dining Services #10 revealed documentation from October 2025 in which mouse droppings was observed at the time of that inspection. During the interview, the Executive Director acknowledged fielding a complaint regarding a mice sighting in the room of Resident #13.On 4/10/26 at approximately 9:00AM the surveyor observed the interior hallway door located near the kitchen was left open to the outside environment.On 4/10/26 at 10:29AM the surveyor began conducting an infection control observation in the main hallway of the nursing unit. On 4/10/26 at 10:31AM the surveyor observed a mouse run across the hallway from near room [ROOM NUMBER] to #435. On 4/10/26 at 10:36AM the surveyor conducted an interview of Resident #31 who spontaneously reported the following information to the surveyor while making a walking motion with their fingers: I did see a mouse today and a couple of days ago. On 4/10/26 at 10:41AM the surveyor informed Housekeeping Supervisor (HS) #12 of the observation and concern at which time they stated Okay, I will let maintenance know. On 4/10/26 at 10:47AM the surveyor observed the pest control service providers and the facility's Director of Maintenance working to address the pest sighting concern in the Resident #31's room. On 4/10/26 at 1:35PM the surveyor shared the concern with the facility's Director of Nursing who acknowledged the concern.All surveyor concerns were again reviewed with the facility's Administrator and Executive Director during the exit conference on 4/10/26. After conclusion of the exit conference, multiple surveyors upon exiting the building on 4/10/26 observed the interior hallway door located near the kitchen was left open to the outside environment.

Based on record reviews and staff interviews, it was determined that the facility failed to provide documentation that indicates that the facility provided the receiving hospital with the resident's information prior to transferring the resident to the hospital. This was evident for 1 (Resident #33) out of 4 residents reviewed during an annual recertification survey for hospitalizations and discharges.The findings include:On 4/8/26 at 1:51 PM, the surveyor conducted a record review. The record review revealed that Resident #33 was hospitalized on [DATE].On 4/9/26 at 9:59 AM, the surveyor interviewed the Director of Nursing (DON) #2. The surveyor asked DON #2 to provide documentation indicating that the facility provided the receiving hospital with Resident #33's information prior to transferring Resident #33 to the hospital. DON #2 indicated that she would check Resident #33's medical record.On 4/9/26 at 10:32 AM, DON #2 stated that when the emergency medical technicians arrive at the facility to transport a resident to the hospital, the facility will provide the emergency medical technicians with a completed SNF to Hospital Transfer Form to provide to the receiving hospital the resident is being transferred to. DON #2 stated that the facility provided the emergency medical technicians with Resident #33's SNF to Hospital Transfer Form at the time Resident #33 was being transferred to the hospital; however, the facility did not keep a copy of Resident #33's SNF to Hospital Transfer Form. The surveyor asked DON #2 if there was a progress note or any other documentation indicating that the facility provided the hospital with Resident #33's SNF to Hospital Transfer Form. DON #2 indicated that she would check resident #33's medical record.On 4/9/26 at 2:55 PM, DON#2 indicated that she was unable to locate documentation indicating that the hospital was provided with Resident #33's SNF to Hospital Transfer Form prior to transferring Resident #33 to the hospital. DON #2 also stated that the expectation is for the facility to document, in a progress note, that they provided the receiving hospital with a copy of the resident's SNF to Hospital Form prior to transferring/discharging the resident to the hospital.

Based on interview and record review it was determined the facility failed to ensure documentation of medication side effect monitoring, and maintain medical records in accordance with accepted professional standards and practices. This was evident for 2 (#9, #17) of 5 residents reviewed for unnecessary medications.The findings include:1. On 4/7/26 at 3:21PM the surveyor conducted an unnecessary medications review for Resident #9 at which time the surveyor reviewed the medical record which revealed the following information: -Resident #9 was admitted to the facility on [DATE] -Resident #9 was observed to have an active medical order dated as beginning on 4/22/25 for Mirtzapine medication for indication of depression. -No side effect or behavior monitoring for psychotropic medications by licensed nursing staff was observed consistently documented in the medical record. On 4/7/26 at 3:33PM the surveyor conducted an interview of the facility's Director of Nursing (DON) and inquired as to how the nursing staff document the side effect monitoring of residents who take antidepressant medications, to which they replied: We have it underneath the treatment administration record for monitoring of side effects, that is listed under our treatment administration record and they check that every shift. When the surveyor further inquired to the DON as to if the monitoring was in the form of a medical order on the treatment administration record in which staff have to check off every shift, they stated: Correct. When the surveyor inquired to the DON as to if there was other ways in which the side effect monitoring was documented, they stated: That is our standard to have it on the medication administration record/treatment administration record. At this time the surveyor shared the concern with the DON that there was no antidepressant side effect or behavior monitoring documentation present for Resident #9. The surveyor offered opportunity for the DON to provide all evidence of side effect and behavior monitoring of the Resident by licensed nursing staff. On 4/7/26 at 3:49PM after surveyor intervention, the DON informed the survey team that there was no side effect monitoring order and that it had now been added for Resident #9. On 4/8/26 at 11:14AM the surveyor shared concerns with the DON who acknowledged and confirmed understanding of the concerns. The surveyor conducted an interview of the DON who confirmed with the surveyor that other than geriatric nursing assistant staff monitoring for behavior, there was no documentation of ongoing behavior monitoring by licensed nursing staff. The DON confirmed with this surveyor that there was no further documentation to provide regarding the concerns. On 4/8/26 at 11:20AM the surveyor reviewed the medical record and noted the following information: -Resident #9's care plan stated the following intervention for use of antidepressant medication: Administer antidepressant medications as ordered by physician; Monitor/document side effects and effectiveness Q-SHIFT (every shift); Date Initiated: 04/21/2025; Monitor/document/report PRN (as needed) adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL (activities of daily living) ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt (weight) loss, n/v (nausea/vomiting), -A medical order dated as beginning 4/7/26 for antidepressant medication side effect monitoring -A medical order dated as beginning 4/7/26 for behavior monitoring. All surveyor concerns were again reviewed with the facility's Administrator and Executive Director during the exit conference on 4/10/26. 2. On 4/9/26 at 3:15PM, during a review of Resident #17's electronic medical record the Surveyor discovered that the Resident had diagnoses of, but not limited to, hypertension, gastro-esophageal reflux disease, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, dementia with behavioral disturbance, and esophageal dyskinesia. Further review revealed physician orders for Diltiazem HCl 30 mg to be given at 2:00pm for esophageal spasms to and Seroquel 50mg to be given at 2:00PM for dementia with behavioral disturbance. On 4/10/26 at 10:00AM, a review of Resident #17's Medication Administration Record (MAR) for February 2026 failed to reveal the Resident received the scheduled 2:00PM dose of Diltiazem HCl and Seroquel on 2/17/2026. A review of the MAR for March 2026 failed to reveal the resident received the scheduled 2:00PM dose of Diltiazem HCl and Seroquel on 3/7/2026. On 4/10/26 at 11:05AM during an interview with the Director of Nursing (DON), the Surveyor expressed the concern that Resident #17's MAR for 2/17/2026 and 3/7/2026 failed to reveal documentation of medication administration of Diltiazem HCl and Seroquel during the scheduled 2:00PM administration time. The DON reviewed the MAR for February 2026 and March 2026 with the Surveyor and confirmed the Surveyor's findings.

Based on observations and interviews, it was determined that the facility staff failed to ensure canned goods and dry food were labeled with expiration dates and failed to label opened food with a used by date. This deficient practice was evident during the kitchen observation and has the ability to impact all residents who receive food from the kitchen. The findings include: On [DATE] at 10:33 AM, during an initial tour of the facility's kitchen with the Director of Dietary Services (DDS) #24 and Dietary Chef #25, the surveyor observed a rack of canned goods without an expiration date. When asked about the process for determining when to discard outdated canned goods the DDS #24 stated they were unsure and deferred the question to the Kitchen Chef #25. The Kitchen Chef #25 explained that can goods are ordered frequently, but the kitchen does not have a process in place to track expiration or best by date for canned goods. Next to the canned good rack, the surveyor along with the DDS #24, and Dietary Chef #25 observed an open cardboard box of Kellogg's Club Crackers containing individual packets. No expiration date was found on either the box or the individual cracker packets. When the surveyor inquired about the date the box was opened and expiration date, the DDS #24 and Dietary Chef #25 were unable to determine when it was opened or when it expired. At 10:40 AM, during a tour of the dairy refrigerator, the surveyor observed an open carton of heavy whipping cream without a label indicating the date it was opened or its discard date. When the surveyor mentioned the finding to the Dietary Chef #25, he immediately discarded the carton and acknowledged that it should have been labeled with both an open and discard date. When asked if labeling dairy products with these dates were the expectation of dietary staff, he confirmed that it was. On [DATE] at 01:54 PM, during a follow up tour of the facility's kitchen with the DDS #24, the surveyor observed that all canned goods were labeled with expiration dates, and the observed open box of Kellogg's Club Crackers had been discarded.

Based on observation and interview, it was determined that the facility failed to ensure residents were treated with dignity and respect. This was evident during observation of 19 rooms on 1 unit (Decker Unit) during the survey. The findings include: On 01/29/25 at 08:16 AM, the initial observation of the facility revealed rooms 406, 413, 416, 418, 419, 420, 421, 422, 424, 425, 426, 427, 428, 429, 430, 431, 432, 434, 435, which had over-the-door organizers on the outside of the doors. The organizers contained various resident care items, including briefs. On 01/31/25 at 08:15 AM, an interview with Resident #28, who resided in room [ROOM NUMBER], revealed that he/she did not know why the organizers were on the outside of the resident room door and was unhappy about it due to a privacy concern. On 01/31/25 at 2:05 PM, at the time of exit, the surveyor reviewed the concern regarding the failure to ensure residents are treated with dignity and respect.

Based on record reviews and interviews, it was determined that facility staff failed to update the residents' (#8) Minimum Data Set to accurately reflect the resident's medical condition, and failed to code the residents' (#16, #31) status accurately on the Minimum Data Set (MDS) assessment. This occurred for 3 (#8, #16, #31) out of 3 residents reviewed during the annual survey. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. The Assessment Reference Date (ARD) is the specific end point of look-back periods of resident status for the MDS assessment process. 1) On 01/31/25 at 7:38 AM, a review of Resident #8's treatment administration record for December 2024 revealed an order to apply Optifoam (foam wound dressing) pad to sacrum topically every day. The treatment order start date was 12/03/2024 at 7:00 AM, and discontinue date was 01/30/2025 5:20PM. On 01/31/25 at 9:07 AM, the surveyor reviewed a wound evaluation note dated 12/31/24 for Resident #8. The evaluation indicated an MDS 3.0 stage 3 wound, and the provider noted wound progress. Review of Resident #8's MDS under the skin condition section on 01/31/25 at 8:42 AM, failed to indicate an unhealed stage 3 pressure ulcer. The assessment reference date (MDS completion) was 01/15/25. On 01/31/25 at 10:10 AM, during an interview with MDS coordinator #14, when asked why a stage 3 pressure ulcer was not captured in the MDS by the ARD of 01/15/25. The MDS coordinator #14 explained that updates to the MDS are based on staff documentation and that Resident #8's pressure ulcer had been documented as healed. The surveyor requested documentation confirming that the pressure ulcer was recorded as healed. On 01/31/25 at 11:14 AM, during an interview with Nurse Unit Manager (UM) #5 the surveyor inquired about the status of Resident#8's pressure ulcer. The UM #5 explained that the wound initially started as a stage 2 pressure ulcer, progressed to stage 3, and was currently healing. The surveyor asked if the pressure ulcer was fully healed, the UM #5 responded, It isn't healed. On 01/31/25 at 11:32 AM, review of wound care progress note dated on 01/14/25 by the physician revealed, Signing off on patient who remains in the facility. Per nursing, the wound continues to heal. Please reconsult if the wound worsens. On 01/31/25 at 12:11 PM, the Director of Nursing (DON) #2 provided the surveyor with a copy of an amended MDS reflecting a correction was made on 01/31/25 in the skin condition section to indicate a pressure ulcer. The DON #2 acknowledged that the pressure ulcer had not been documented in the MDS by the ARD of 01/15/25. 50573 2) On 01/30/25 at 10:21 AM, review of Resident #16's medical record revealed a progress note dated 12/03/25 at 4:40 PM, which indicated the resident had been seen by the wound doctor that day for a left first toe wound. On 01/30/25 at 10:24 AM, review of Resident #16's medical record revealed an assessment titled, Wound Evaluation and Management Summary, dated 12/3/24 which indicated the resident had a wound on his/her left first toe. On 01/30/25 at 10:27 AM, review of section M (skin conditions) of Resident #16's most recent MDS with an ARD of 12/6/24 failed to reveal indication that the resident had a pressure ulcer injury. On 01/31/25 at 10:10 AM, an interview with the Director of Nursing (DON, Staff #2) revealed that Resident #16's toe injury was a pressure ulcer and should have been coded on the MDS with an ARD date of 12/6/24. 3) On 01/29/25 at 08:14 AM, an initial observation of Resident #31 revealed that he/she had an air mattress. An air mattress can eliminate pressure sores and ulcers from forming and existing sores from worsening. On 01/30/25 at 02:33 PM, review of Resident #31's medical record revealed a progress note dated 1/9/25 at 03:14 AM, which indicated that the resident's wound dressing was intact and right heel dressing applied. On 01/30/25 at 02:34 PM, further review of Resident #31's medical record revealed a progress note dated 1/11/25 at 03:32 AM, which indicated there was a new cream medication ordered for multiple skin issues on trunk and arms. On 01/30/25 at 02:36 PM, further review of Resident #31's medical record revealed an assessment titled, Wound Evaluation and Management Summary dated 1/7/25 which indicated the resident had wounds on his/her right lower leg, right upper calf, and right heel. On 01/30/25 at 02:27 PM, an interview with the MDS Coordinator (Staff #14) revealed that staff rely on progress notes and wound assessments to complete section M of the MDS. On 01/30/25 at 02:37 PM, review of section M (skin conditions) of Resident #31's recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/13/25 failed to reveal any indication that the resident had any wounds or skin conditions.

Based on record review and interview, it was determined that the facility failed to ensure there was a system in place to ensure Geriatric Nursing Assistants (GNAs) completed 12 hours of in-service training annually. This was evident for 3 (GNA #7, GNA #19, GNA #21) of 5 GNAs reviewed during the survey. The findings include: 1) On 01/30/25 at 3:19 PM, review of GNA #7's employee file revealed that Staff #7 received 3 hours of in-service training in 2024. 2) On 01/30/25 at 3:21 PM, review of GNA #19's employee file revealed that Staff #19 received 5 hours of in-service training in 2024. 3) On 01/30/25 at 3:24 PM, review of GNA #21's employee file revealed that Staff #21 received 0 hours of in-service training in 2024. On 01/31/25 at 10:10 AM, an interview with the Director of Nursing (DON) revealed that the facility was not in compliance with the 12 hour GNA annual in-service training for Staff #7, Staff #19, and Staff #21.

Based on observation, record review and staff interview, it was determined the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails to identify areas of possible entrapment. This was evident for 2 (Resident #31 and #13) of 2 residents reviewed for accidents hazards. The findings include: Bedrails or side rails are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them. 1) On 01/29/25 at 08:14 AM, during the initial phase of the survey, the surveyor observed Resident #31 in bed with two 1/4 bed rails up on either side of the top end of the bed. 2) On 01/29/25 at 10:05 AM, during the initial phase of the survey, the surveyor observed Resident #13's bed in his/her room which revealed two 1/4 bed rails up on either side of the top end of the bed. On 01/30/25 at 11:17 AM, an interview with the Director of Maintenance (Staff #13) revealed that he would be unable to provide documentation of routine bedrail entrapment assessments completed for Resident #13 and #31. He indicated that maintenance completed routine checks of resident rooms, which did not include risk of entrapment assessments for those residents with transfer bars/bed rails.

Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident was free from a significant medication error. This was evident for 1 (Resident #236) of 5 resident medication administrations observed during the survey. The findings include: On 01/30/25 at 08:02 AM, the surveyor observed Registered Nurse Supervisor (RN) #22 administer 4 medications to Resident #236. On 01/30/25 at 08:15 AM, the surveyor observed RN #22 document the medications, which revealed 5 medications being signed off as administered, which included Bicalutamide 50MG, which was not observed to be prepared or administered to Resident #236. On 01/30/25 at 08:26 AM, review of Resident #236 Medication Administration Record (MAR) revealed 5 medications signed off, including Bicalutamide Tablet 50 MG (A drug used with another drug to treat prostate cancer that has spread to other parts of the body). On 01/31/25 at 12:52 PM, the surveyor obtained a MAR audit for Resident #236, which revealed the exact time that the medication was signed off, which indicated 01/30/25 at 08:16 AM. On 01/31/25 at 12:53 PM, the surveyor reviewed the concern with the DON regarding Resident #236's medication administration observation and MAR audit review. On 01/31/25 at 12:57 PM, the DON completed a pill count of the Bicalutamide medication with the Unit Manager/Staff #5 and the surveyor present. There were 26 pills counted to be in the bottle. On 01/31/25 at 12:58 PM, the surveyor observed a date of 1/27/25 on the pill bottle (which indicated the first date of which a pill was taken out the bottle). On 01/31/25 at 12:58 PM, an interview with the DON who was present during the observation revealed that the date written in would be the date a staff member opened the bottle. On 01/31/25 at 12:59 PM, review of the medication bottle label of Bicalutamide revealed a quantity of 30 pills, which indicated the amount of pills that were in the bottle prior to being opened. On 01/31/25 at 12:59 PM, further review of the medication bottle of Bicalutamide revealed administration instructions that read, take or use this medicine exactly as directed do not skip doses or discontinue unless directed by your doctor. On 01/31/25 at 01:07 PM, an interview with the DON revealed that if medication had been given each day since the bottle was opened on 1/27/25, then there would be a total of 25 pills left in the bottle at the time of the pill count. She was in agreement with the significant medication error finding.

Based on observation, record review, and interview, it was determined that the facility failed to have a medication error rate of less than 5% during medication administration observation. This was evident for 3 (Resident #9, #16, and #236) of 26 medication administration opportunities which resulted in a medication error rate of 11.54%. The findings include: 1) On 01/30/25 at 08:02 AM, the surveyor observed Registered Nurse (RN) Supervisor #22 administer 4 medications to Resident #236. On 01/30/25 at 08:15 AM, the surveyor observed RN #22 document the medications, which revealed 5 medications being signed off as administered, which included Bicalutamide 50MG, which was not observed to be prepared or administered to Resident #236. On 01/30/25 at 08:26 AM, review of Resident #236 Medication Administration Record (MAR) revealed 5 medications signed off, including Bicalutamide Tablet 50 MG (A drug used with another drug to treat prostate cancer that has spread to other parts of the body). On 01/31/25 at 12:52 PM, the surveyor obtained a MAR audit for Resident #236, which revealed the exact time that the medication was signed off, which indicated 01/30/25 at 08:16 AM. On 01/31/25 at 12:53 PM, the surveyor reviewed the concern with the DON regarding Resident #236 's medication administration observation and MAR audit review. On 01/31/25 at 12:57 PM, the DON completed a pill count of the Bicalutamide medication with the Unit Manager/Staff #5 and the surveyor present. There were 26 pills counted to be in the bottle. On 01/31/25 at 12:58 PM, the surveyor observed a date of 1/27/25 on the pill bottle (which indicated the first date of which a pill was taken out the bottle). On 01/31/25 at 12:58 PM, an interview with the DON who was present during the observation revealed that the date written in would be the date a staff member opened the bottle. On 01/31/25 at 12:59 PM, the surveyor obtained the medication bottle of Bicalutamide, which indicated a quantity of 30 pills were in the bottle prior to being opened. On 01/31/25 at 01:07 PM, an interview with the DON revealed that if medication had been given each day since the bottle was opened on 1/27/25, then there would be a total of 25 pills left in the bottle at the time of the pill count. She was in agreement with the medication error finding. 2) On 01/31/25 at 07:20 AM, the surveyor observed Registered Nurse (Staff #23) administer Ophthalmic solution 0.5% carboxymethylcellulose, 2 drops into each of Resident #9's eyes (right and left). On 01/31/25 at 08:02 AM, review of Resident #9's order for Ophthalmic solution 0.5% carboxymethylcellulose revealed, 1 drop into each of Resident #9's eyes (right and left). 3) On 01/31/25 at 07:33 AM, the surveyor observed Staff #23 administer OcuSoft Lid Scrub to Resident #16's left and right eye. On 01/31/25 at 07:59 AM, the surveyor reviewed the MAR for Resident #16 which revealed an order for OcuSoft Scrub to the left eye, which was signed off for the 8:00 AM administration. On 01/31/25 at 12:53 PM, the surveyor reviewed the concern with the DON regarding Resident #9 and #16's medication administration observations.

Based on interview, it was determined that the facility failed to ensure staff received annual performance reviews. This was evident for 4 of 5 GNAs (GNA#7, GNA #19, GNA #21, and GNA #26) reviewed during the annual survey. The findings include: On 01/30/24 at 4:00 PM, the surveyor requested documentation of annual performance reviews for the last two years (2023 and 2024) for GNA #7, GNA #19, GNA #21, and GNA #26. On 01/31/25 at 10:10 AM, an interview with the Director of Nursing (DON) revealed that the facility was unable to provide the documentation requested by the surveyor because the facility was not in compliance with annual performance reviews for GNA #7, GNA #19, GNA #21, and GNA #26.

Based on observation, record review and interview with facility staff, it was determined that the facility failed to obtain informed consent and document alternatives attempted prior to the initiation of bed rails. This was evident for 2 (Resident #31 and #13) of 2 residents reviewed for accident hazards. The findings include: Bedrails or side rails are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them. The facility should obtain a signed consent form before the use of bedrails. 1) On 01/29/25 at 08:14 AM, during the initial phase of the survey, the surveyor observed Resident #31 in bed with two 1/4 bed rails up on either side of the top end of the bed. On 01/30/25 at 09:37 AM, an interview with the Director of Rehabilitation (Staff #16), revealed that Resident #31 was from assisted living and had not been on case load and was unable to indicate why the resident had the transfer bars/bed rails. 2) On 01/29/25 at 10:05 AM, during the initial phase of the survey, the surveyor observed Resident #13's bed in his/her room which revealed two 1/4 bed rails up on either side of the top end of the bed. On 01/30/25 at 07:23 AM, an interview with the Director of Nursing (DON, Staff #2) revealed that verbal consent is obtained for transfer bars/ bed rails, but would double check for documentation. On 01/30/25 at 09:37 AM, an interview with the Director of Rehabilitation (Staff #16), revealed that therapy will assess resident ability and determine whether transfer bars are necessary. The surveyor requested documentation for Resident #13 and #31 of alternatives attempted and the initial assessments completed for the transfer bars/ bed rails. On 01/30/25 at 11:09 AM, the DON indicated to the surveyor that she was unable to provide documentation of alternatives attempted and consent for Resident #13 and #31's prior to initiation of transfer bars/bed rails.

Based on observation and interview with facility staff, it was determined that the facility failed to ensure that a resident receiving oxygen therapy had orders that were being followed and failed to post cautionary signs indicating the use of oxygen. This was evident for 1 (Resident #31) of 1 resident reviewed for respiratory care, and 1 (Resident #9 and #31) of 2 residents observed receiving oxygen. The findings include: 1) On 01/29/25 at 08:14 AM, an initial observation of Resident #31 revealed she/he was on oxygen by nasal cannula. The oxygen level was at 3.5 liters/minute. The nasal cannula was dated 1/27/25. A nasal cannula is a small, flexible tube that fits inside both nostrils, delivering supplemental oxygen directly into your nose. Oxygen liter refers to the amount of oxygen a person receives per minute, measured in liters, and is essentially how much supplemental oxygen is being delivered to them through a piece of oxygen supplying equipment. On 01/29/25 at 02:33 PM, review of Resident #31's medical record revealed an active order dated 1/6/25 which indicated continuous oxygen at 3 liters by nasal cannula. On 01/29/25 at 02:33 PM, further review of Resident #31's medical record revealed an active order dated 1/6/25 which indicated to change the oxygen tubing/nasal cannula tubing every Thursday night shift and to label with the date. On 01/30/25 at 07:12 AM, a second observation of Resident #31 revealed he/she was still on oxygen by nasal cannula, at a rate of 3.5- 4 liters/minute. The nasal cannula was dated 1/17/25. On 01/30/25 at 07:25 AM, an interview with the Director of Nursing (DON, Staff #2) revealed the expectation for residents on oxygen is for the orders to be followed by staff and if the level of oxygen needs to be increased or decreased, that staff should reach out to the provider. On 01/30/25 at 07:28 AM, the surveyor and the DON went to Resident #31's room. The DON read the oxygen level on Resident #31's oxygen supplying equipment and indicated it was at 4 liters/minute. The surveyor also reviewed the concern regarding the tubing dated 1/17/25. 2a) On 01/30/25 at 07:28 AM, an observation with the DON of Resident #31 in his/her room revealed he/she was on oxygen. When the surveyor asked what the expectation was for signage when a resident is on oxygen, she indicated that there would be a red oxygen sign on the resident's door. She indicated that there failed to be one on Resident #31's door, and that she would go and get one. 2b) On 01/30/25 at 12:18 PM, an observation on Decker Unit revealed Resident #9, in room [ROOM NUMBER], who was actively receiving oxygen by nasal cannula, but failed to reveal a sign on the resident's door indicating the use of oxygen. On 01/31/25 at 10:10 AM, the surveyor reviewed the concern with the DON regarding the failure to ensure cautionary signage was posted for Resident #9 and #31.

Based on observation and interview, it was determined that the facility failed to ensure a resident's medical record was protected from public view. This was evident for 1 of 2 medication carts (400 hallway medication cart) observed during the survey. The findings include: On 01/30/25 at 07:57 AM, an observation on the Decker Unit revealed a medication cart on the 400 hallway which revealed a computer screen open with Resident #21's name, date of birth, and Medication Administration Record (MAR). The same medication cart which the computer was on was unlocked, which would allow anyone to open medication cart drawers with several resident medications inside. On 01/30/25 at 08:00 AM, an observation revealed Registered Nurse Supervisor (RN #22) walked up to the medication cart and closed out of the screen which was revealing Resident #21's information and locked the cart. The surveyor approached RN #22 and asked if she was assigned to the medication cart at the time, she indicated yes. On 01/30/25 at 8:00 AM, an interview with RN #22 revealed that the expectation was for nurses to close out of computer screens which reveal resident information and to lock the medication cart whenever they walked away from it. She further indicated that she was pulled away for a resident need and did not lock the cart or close out of the resident revealing computer screen.

Based on record review and staff interview, the facility failed to ensure a resident received care based on professional standards. This was evident for 1 (Resident #16) of 2 residents reviewed for skin conditions. The findings include: On 01/29/25 at 08:18 AM, an initial observation of Resident #16 revealed a small bruise-like area on the his/her left clavicle. On 01/30/25 at 10:21 AM, review of Resident #16's medical record failed to reveal documentation indicating the skin condition was identified. On 01/30/25 12:17 PM, an interview with the Quality Assurance Nurse (Staff #20) revealed that she was assigned to Resident #16. She indicated she was not aware of Resident #16's current skin conditions. The surveyor and Staff #20 walked to the residents room and the surveyor pointed out the area of concern on his/her left clavicle. Staff #20 said that the resident has ecchymosis. On 01/30/25 at 12:20 PM, the surveyor requested documentation of Resident #16's weekly skin checks from Staff #20. On 01/30/25 at 12:27 PM, an interview with the Unit Manager (Staff #5) revealed that the facility switched over from paper to online weekly skin checks between November and December of 2024, that they had missed Resident #16's weekly skin checks since, and have none since to provide.

Based on medical record review and staff interview, it was determined that the facility failed to ensure that all residents were offered pneumococcal vaccination when indicated and received the pneumococcal vaccination or did not receive the pneumococcal vaccination due to medical contraindication or refusal. This was evident for 3(#1, #3, #4) of 5 residents reviewed for pneumococcal vaccinations. The findings include: Pneumococcal Vaccination requires two types of vaccines for immunity. The Centers for Disease Control provide guidance to providers for administration of these vaccinations to achieve immunity in vulnerable adults. This guideline indicates how to proceed when a person has a known vaccination history or when it is unknown. 1. On 2/4/20 at 1:00 PM, a review of Resident #1's medical record revealed the resident was admitted to the facility in September 2020. Review of Resident #1's Immunization Report in the electronic medical record (EMR) revealed documentation that Resident #1 received a [MEDICATION NAME] (pneumococcal) vaccine (dose one), 10/11/16. Continued review of Resident #1's medical record failed to reveal evidence that the resident received a second pneumococcal immunization or did not receive a second pneumococcal immunization due to medical contraindication or refusal. 2. On 2/4/21 at 2:00 PM, a review of Resident #3's medical record revealed the resident was admitted to the facility in September 2020. Review of Resident #1's Immunization Report in the EMR revealed documentation that Resident #3 received a [MEDICATION NAME] (pneumococcal) vaccine (dose one), 12/8/15. Continued review of Resident #3's medical record failed to reveal evidence that the resident received a second pneumococcal immunization or did not receive a second pneumococcal immunization due to medical contraindication or refusal. 2. On 2/4/21 at 3:00 PM, review of Resident #4 medical record revealed the resident was admitted to the facility in December 2019. Review of Resident #4's Immunization Report in the EMR failed to reveal documentation that the resident had received a pneumococcal immunization. Continued review of Resident #4's medical record failed to reveal evidence that Resident #4 either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. On 2/5/21 at 2:30 PM, an interview was conducted with the Director of Nurses (DON), who is also the Infection Preventionist. At that time, the DON was made aware of the above concerns and indicated he/she would look into the concerns. On 2/5/21 at 3:44 PM, the DON confirmed the above findings.

Based on medical record review and staff interview, the facility staff failed to provide supervision to prevent an accident (Resident #2) This was evident for 1 of 4 residents reviewed during a complaint survey. The findings include: Review of Resident #2's medical record revealed the Resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Further review of Resident #2's medical record revealed the Resident was assessed by two physicians to lack adequate decision making capacity. Facility Reported Incident MD 173 was reviewed on 10/28/20 and 10/29/20. According to the facility investigation on 11/24/19 at 8:30 PM Resident #2 was able to take the elevator down to the lobby, push open the locked fire door and exit the facility. At approximately 8:35 PM staff realized the Resident was not in his/her room and began a search. The Resident was found unharmed and returned to the facility. During interview with the Administrator on 10/28/20 at 11:10 AM, the Administrator stated the Resident had been wandering the unit prior to the elopement but had never attempted to leave the facility and the facility had placed the Resident on hourly checks. The Administrator also stated at that time the facility had ordered a wanderguard protection system on 10/21/19 but it had not been installed until 12/18/19. Further review of Resident #2's medical record revealed the Resident was placed on 1 to 1 immediately following the elopement until discharge from the facility. Medical record review revealed a wanderguard was placed on the Resident on 12/18/19 and the Resident had no further elopement from the facility. Interview with the Director of Plant Operations on 10/29/20 at 10:57 AM revealed the wanderguard system is checked daily for functionality. The surveyor then accompanied the Director of Plant Operations to the elevators and exits in the facility for long term care and no issues were detected with the wanderguard functionality. The Director of Nursing and the Administrator on 10/29/20 at 2:00 PM were made aware of the concerns regarding the Resident being allowed to exit the facility. They both stated the wanderguard system was installed on 12/18/19, all staff were educated on the system and there have been no further elopements.

Based on medical record review and interview, it was determined the facility staff failed to thoroughly clarify a medication order with the physician for Resident (#228). This was evident for 1 of 29 residents selected for review during the annual survey process. The findings include: Medical record review on 2/28/20 at 11:00 AM revealed on 9/27/19 the physician ordered: [MEDICATION NAME] 50 milligrams by mouth 3 times a day as needed for blood pressure of systolic (top number) of above 160 or diastolic (bottom number) greater than 100. [MEDICATION NAME] is used with or without other medications to treat high blood pressure. On 10/28/19 the physician ordered: [MEDICATION NAME] 25 milligrams by mouth 3 times a day (not as needed but routine), hold for systolic blood pressure less than 110; however, the facility staff failed to clarify the [MEDICATION NAME] order with the physician to determine if both medication orders were still valid. Interview with the medical director on 2/28/20 at 2:00 PM revealed the facility staff would not administer both ordered Hydrazine medications (as needed and routine). The medical director stated the facility nursing staff should have clarified the [MEDICATION NAME] order and if needed discontinue the as needed order. Interview with the Director of Nursing on 2/28/20 at 2:00 PM confirmed the facility staff failed to thoroughly clarify a medication order with the physician for Resident #228.

Based on record review, observation and staff interview, it was determined the facility staff failed to ensure the resident's environment was free from potential accidents (#12 and #14). This was evident for 2 of 2 residents selected for review of accidents and 2 of 29 residents selected for review during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. MDS assessments contain standardized questions about several elements of functional and cognitive status and mobility, Behavioral symptoms - a number of items about behavioral symptoms common in dementia, Psychosocial functioning - resident participation in activities and resident preferences, Symptoms and geriatri[DIAGNOSES REDACTED]s - for example pain, continence, falls, nutritional status, activities of daily living and many others and [DIAGNOSES REDACTED].g. antipsychotics, sedative-hypnotics) to name a few. 1. The facility staff failed to transfer Resident #12 with 2 staff members. Medical record review on 2/27/20 at 10:00 AM for Resident #12 revealed on 12/5/19 the facility staff assessed the resident and documented on the MDS: Section G- Activities of Daily Living, subs-section B: Transfer, how the resident moved between surfaces- to and from bed to chair, wheelchair. The facility staff documented the resident was an extensive assist and 2 persons assist for transfer. Further record review revealed the following Nurses' Note: 12/25/2019 9:35 PM: Note Text: patient fell while the aide was transferring resident from recliner chair to the wheelchair due to left leg weakness. Interview with the Director of Nursing on 2/28/20 at 2:00 PM confirmed the facility staff failed to provide an environment for Resident #12 free from accidents by transferring the resident with 1 staff member while being assessed to be a 2-person transfer. 2. The facility staff failed to maintain an environment free from potential accidents for Resident #14. Surveyor observation of Resident #14 on 2/26/20 at 11:00 AM and 2/27/20 at 9:00 AM revealed a bottle of Prevagen on the over bed table in the resident's room. Prevagen is a dietary supplement that has been clinically shown to help with mild memory loss associated with aging. Prevagen is formulated with apoaequorin, which is safe and uniquely supports brain function. When questioned, the resident stated the medication was for memory, but was not sure how well it worked. Review of the physician's orders [REDACTED]. Interview with the Director of Nursing on 2/28/20 at 2:00 PM confirmed the facility staff failed to maintain an environment for Resident #14 free from potential accidents.

Based on a facility self-report received by the Office of Health Care Quality (OHCQ), medical record review and staff interview it was determined that the facility staff failed to follow a physician's orders [REDACTED]. The failure of the facility staff to follow the physician's orders [REDACTED].#1's right Ankle. The findings include: Review of the facility self report # MD 351on 01/24/18 received by the OHCQ on 09/19/17 revealed that Geriatric Nursing Assistant (GNA) staff #1 was assigned to care for Resident #1 on the 3-11 PM shift on 09/17/17. The facility's investigation revealed that staff #1 transferred Resident #1 and did not use proper equipment for the transfer. Staff #1 transferred Resident #1 by herself manually and while doing so twisted Resident #1's ankle. Resident #1 was sent to the hospital for further evaluation and the x-ray revealed a [MEDICAL CONDITION] fibula. Following completion of the investigation the facility Administrator determined that the allegation of abuse was founded. Review of the Medical Record revealed that Resident #1 was admitted to the facility on [DATE] from an acute care hospital with [DIAGNOSES REDACTED]. Upon admission on 06/05/17 a physician's orders [REDACTED].#1 to be transferred with a Hoyer Lift at all times. In addition, according to the Minimum Data Set (MDS) (which is part of the U.S. federally mandated process for clinical assessment of all Long Term Care residents providing a comprehensive assessment of each resident's cognitive and functional capabilities and helps nursing home staff identify care needs) assessment dated [DATE] Resident #1 was determined to require total assistance with transfers and required 2 staff to assist with transfers. As a result of the MDS assessment Resident #1 was also care planned for Activities of Daily Living (ADL) self-care performance deficit and limitations related to limited mobility and recent [MEDICAL CONDITION]. The 3-11 PM shift assignment given to staff #1 for 09/17/17 included Resident #1 and stated Hoyer lift for transfers. Additionally the facility's Policy and Procedure for use of a Hoyer Lift requires Two persons must participate in every Hoyer transfer. Medical record review on 01/24/18 further revealed that on the morning of 09/18/17 Resident #1 reported to the 11 PM-7 AM GNA Staff #2 that Staff #1 transferred him/her from a chair to his/her bed and did not use the machine (the Hoyer Lift: a lift that allows a person to be lifted and transferred with a minimum of physical effort). Resident #1 reported that during the transfer s/he twisted his/her right ankle and it hurt very bad. She further stated that when she told staff #1 that she hurt his/her ankle Staff #1 said there is nothing wrong with your ankle and left the room. Staff #2 reported Resident #1's complaint to the charge nurse staff #3. Staff # 3 reported that on 09/18/17 at approximately 6:12 AM she spoke with Resident #1 and confirmed his/her allegations of the injury by Staff #1 during the transfer to bed. Staff #3 examined Resident #1's right ankle and followed up by sending an e-medical (e-mail to the physician) requesting an x-ray of the right ankle. Staff #3 stated that she told the 7am-3pm charge nurse Staff #4 about the need for the x-ray and asked her to order the x-ray. I an interview on 01/24/18 with Staff #4 she confirmed that she learned about Resident #1's injury during the change of shift report and she ordered a mobil x-ray to be done on 01/18/17. Further review of the medical record revealed that the right ankle x-ray was completed on 01/18/17 at 5:59 PM and the report was received at the facility at 7:48 PM with findings of a [MEDICAL CONDITION] and medial malleoli. A nursing progress note dated 09/18/17 at 11:35 PM by RN staff #5 stated that the results of the x-ray were sent via e-medical to the nurse practitioner on call who gave an order to send Resident #1 to the emergency room (ER) for further evaluation. A private ambulance was called and transported Resident #1 to the ER at 1:30 AM, it was documented that Resident #1's daughter was notified and met Resident #1 in the ER. Review of the Hospital ER record revealed that Resident #1 was examined on 09/19/17 at 2:54 AM and the findings included a distal fibular [MEDICAL CONDITION] ankle. A soft splint was applied, Resident#1 was instructed to follow up with an Orthopedist in 1 week, received a prescription for pain medication and instructions not to bear weight on the right foot. Resident #1 returned to the facility on [DATE] at 5:45 AM. In an interview with the Director of Nursing (DON) and the Administrator on 01/24/18 at 9:45:AM they confirmed that the DON was made aware of the above mentioned concerns on 09/18/17 at 7:30 AM. An investigation began immediately including interviews with several staff members and staff #1 was immediately placed on suspension until the conclusion of the investigation. An initial report was faxed to the OHCQ on 09/19/17 followed by a final report on 09/21/17 at 6:28 PM. The police were called on 09/19/17 at 8:35 AM. In addition the Administrator and the DON stated that they were very concerned about the incident and immediately developed and began implementing a plan of correction. The administrator provided documentation to show that Staff #1 had successfully completed all of the required training for orientation and had only been employed by this facility for approximately 1 month at the time of this incident. Staff #1's employment was terminated effective 9/21/17 and subsequently a report was sent to the Board of Nursing on 09/24/17. Plan of Correction: A Quality Assurance (QA) meeting was held on 09/25/17 to discuss the concerns and to develop a plan of correction. Deficient Practice: Not following a physician's orders [REDACTED]. Delay in care following an injury. Not using a Hoyer Lift and not having a second person. Not notifying the nurse of the incident and that resident had expressed being hurt. Not notifying the DON and/or the Administrator right away about the incident. Not sending the order for x-ray right away either STAT or 911. Not notifying the family right away. Not completing an incident report. Residents to be affected: All Residents requiring a mechanical lift could be affected by this deficient practice. Corrective Actions: A Quality Assurance (QA) meeting was held on 09/25/17 to discuss the concerns and to develop a plan of correction. Several In-services were completed by the DON and/or the Administrator to include all of the facility staff through (MONTH) (YEAR) addressing: Abuse reporting; Resident Rights and Crime Reporting; Review of Self-Report and ways we must fix the communications; Policy & Procedure Compliance; Transfer Techniques and Compliance Reviewed. Policies for: Abuse/Description; Investigation and Reporting; Resident Rights to Privacy & Confidentiality; Crime Reporting were distributed. Monitoring tool created to ensure proper use of mechanical lifts for residents who have orders. Staff in serviced on communication of any resident expressing pain. Staff in-serviced to communicate with their supervisor and also to inform DON and Administrator. Staff in-serviced on the urgency of obtaining diagnostics for timely treatment. They should either call in a STAT order or send them out to the ER. The Monitoring Tool for Mechanical Lift Resident Transfers was implemented in (MONTH) (YEAR). It is completed daily on each shift and will be audited by the DON and brought to the monthly QA meetings for 6 months with a threshold of 100% compliance.