Every finding on record at Pine Creek Care Center

Based on observation, interview and record review, the facility failed to ensure food safety was maintained, when:1. An opened package of mozzarella cheese had blue and fuzzy spots; and2. One dietary staff had facial hair and did not fully cover with facial hair restraint. These failures had the potential to cause food-borne illness which could cause illness in 93 out of 93 medically vulnerable residents who consumed food from the facility kitchen. The census was 93.Findings:1. A concurrent observation in the walk-in refrigerator and interview with the Registered Dietitian (RD) and the Dietary Supervisor (DS) was conducted on 6/16/26 at 8:07 a.m. It was noted that an opened package of shredded cheese had blue and fuzzy spots. The package of shredded cheese had a label written opened date of 6/5/26. On the package the manufacturer's best used by date on 6/23/26. Dietary Supervisor stated it was mozzarella cheese and changed her answer to blue and mozzarella cheese when she noted the blue fuzzy spots. Confirmed the finding with the RD and she stated it was mozzarella cheese and the blue fuzzy spots were molds. The RD further stated it should be discarded.On 6/17/26 at 9:50 a.m., a review of facility policy and procedure (P&P) titled, Procedure for Refrigerated Storage, on the Refrigerated Storage Guide stated for .soft cheese. was to follow expiration date or 7 days after the package was opened, whichever comes first. Noted the mozzarella cheese package was opened on 6/5/26, if following 7 days after opening, the discard date would be 6/12/26.During an interview with the RD on 6/18/26 at 9:46 a.m., the RD stated the dietary staff usually performed daily check. The RD stated the mozzarella cheese did not pass the manufacturer's use by date. During a review the Refrigerated Storage Guide for cheese, it indicated if the cheese package opened would follow manufacturer's used by date or 7 days after opening, which comes first. The RD acknowledged and stated the dietary staff needed in-service for the storage guide. The RD further stated the dietary staff would need to check carefully the conditions of the food products despite the expiration dates.2. During an initial and follow-up kitchen inspection on 6/16/26 at 8:31 a.m. and 6/17/26 at 10:34 a.m., observed [NAME] (CK) was preparing food in the cooking area on both occasions. It was noted that CK had full beard and mustache, and the facial hair restraint was not completely covered and the mustache was exposed. During an interview with the RD on 6/18/26 at 9:46 a.m., the RD acknowledged and stated the facial hair should be fully covered.A review of the facility P&P titled, Dress Code, dated 2023, indicated .beards and mustaches (any facial hair) must wear beard restraint.A review of the 2022 FDA Food Code, section 2-402.11 Hair Restraints - Effectiveness, indicated .food employees are required to wear hair restraints such as hair nets, beard nets, and other effective hair coverings to prevent hair from contacting exposed food, clean equipment, utensils, linens, and unwrapped single-service and single-use articles.

Based on observation, interview and record review, the facility failed to ensure the menu or spreadsheet (a menu excel sheet that indicated what items and portions to be served for each prescribed diet) was followed for the therapeutic diet during lunch on 6/16/26 and 6/17/26, when:A. During a dining observation on 6/16/26, Resident 105 did not receive a wheat roll with her lunch meal; andB. During a meal service distribution on 6/17/26:Three residents (Resident 32, 59 and 73) with renal and renal combination diets received extra portion of meat (protein) on the tacos;Four residents (Resident 9, 54, 77 and 107) with modified texture diets did not receive appropriate modified texture black beans; andTwo residents (Resident 54 and 77) with large portion diet received 1.5 servings [6 ounces (oz.)] of zucchini instead of one serving (4 oz.).These deficient practices had the potential to result in compromising the medical and nutritional status of eight residents for a census of 93 who consumed meals from the facility kitchen.Findings: A. During dining observation on 6/16/26 at 12:45 p.m.in the dining room, it was noted Resident 105 who was on a fortified (added extra calorie and/or protein), regular diet with soft and bite-sized level 6 (SB6, a modified texture designed for individuals who experience biting limitations but can chew food items for swallowing. All food prepared for the food item must be soft and chopped into pieces no larger than 1.5 centimeters (cm) x 1.5 cm). A concurrent review of Resident 105's meal ticket (a customized production document used by dietary staff to ensure a resident receives the correct food. The key components include resident details, diet orders, adaptive equipment, allergies, preferences and menu selections) stated Bread OK. A concurrent review of spreadsheet titled, Summer Menus, Week 3 Tuesday, indicated SB6 diet should receive MM (minced and moist level 5 (MM5), a modified texture designed for individuals who have biting, chewing, or swallowing limitations. The food items prepared must be soft, moist and mince to size no larger than 4 millimeters (mm) x 15 mm).A concurrent interview with Resident 105 and Certified Nurse Assistant 1 (CNA 1) was conducted. CNA 1 confirmed and stated Resident 105 did not receive bread with her meal. Resident 105 stated she loved bread and she would eat it if she received it.B. During the lunch meal distribution on 6/17/26 beginning at 12:10 p.m., the following were noted:A review of the spreadsheet titled, Summer Menus, Week 3 Wednesday, indicated Renal diet (diet to manage chronic kidney disease and usually restricted protein intake) and Renal CCHO (constant carbohydrate) diet (Renal CCHO diet usually to manage individuals who are diabetic and kidney disease together) should receive two soft tacos and ground beef as protein. Each taco should have 1.5 oz. of ground beef to make 3 oz. of protein in total for two tacos.Resident 59 with Renal diet with easy to chew level 7 (EC7, a food texture designed for individuals who can bite into soft and tender foods. All food items prepared should be soft and tender, and do not include foods that are hard, tough, chewy, fibrous, crunchy, sticky, have seeds, husks, bones, or gristle) texture. It was noted [NAME] (CK) used a gray colored scoop (scoop size #8, 4 oz.) to scoop the ground beef on each taco for Resident 59 (two of 4 oz. scoops, 8 oz. in total for two tacos).During an observation on 6/17/26 at 12:25 p.m., it was noted the gray scoop (4 oz.) for the ground beef changed to be black ladle (2 oz.) as serving utensil.Resident 32 with Renal CCHO diet and Resident 73 with Renal, EC7 diet, noted each of resident received a scoop of black ladle (2 oz.) of ground beef for each taco and received total 4 oz. of ground beef for two tacos.A review of the spreadsheet titled, Summer Menus, Week 3 Wednesday, it indicated modified texture diet (EC7, SB6, and MM5) should have modified black bean instead of Fiesta Salad for regular texture diet. EC7 and SB6 should have soft black beans, and MM5 should have MM (minced and moist) black beans.It was noted Resident 9 with MM5 diet did not receive MM black bean. Resident 54 and Resident 77 with EC7 diets did not receive soft black beans. Resident 107 with SB6 diet received regular Fiesta Salad instead of soft black bean. A review of the spreadsheet titled, Summer Menus, Week 3 Wednesday, it indicated large portion diets should receive one serving (1/2 cup = 4 oz.) of zucchini.It was noted CK used gray scoop (1/2 cup, 1 serving) and distributed 1.5 servings (6 oz.) of zucchini to Resident 54 and 77 with large portion diets.During an interview on 6/18/26 at 9:46 a.m. with Registered Dietitian (RD), RD acknowledged the findings during dining observation on 6/16/26 and meal distribution observation on 6/17/26. RD stated the staff needed to follow the spreadsheet and menu. RD further stated the supervisors would continue to train, support and supervise the staff during the meal distribution.A review of facility document titled, Job Description: Cook, dated 2/2024, indicated, Essential Duties.ability to follow prepared menu and portion control guides.to prepare special diets accurately.

Based on observation, interview and record review, the facility failed to ensure controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the medication administration record (MAR) and the Controlled Drug Record (CDR, an accountability record) for two of four randomly selected residents (Residents 44 and Resident 51). This failure resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of controlled medications.Findings: A review of Resident 44's medical record indicated a physician's order for tramadol (a narcotic medication to treat pain) 50 milligrams (mg, a unit of measurement), give 50 mg by mouth every 6 hours as needed for moderate to severe pain (4-10) (pain scale of 0 to 10, with 10 being the highest level of pain) doc (document) level of pain intensity before and after med (medication) admin (administration) using 0-10 pain scale, dated 5/20/26. A review of Resident 44's CDR for tramadol indicated one tablet was removed from the medication cart on 5/25/26 at 7:12 a.m., 6/11/26 at 9:07 a.m., 6/14/26 at 2:30 p.m., and 6/15/26 at 8:33 a.m. but their respective administrations were not documented on the MAR. The MAR indicated tramadol one tablet was administered to Resident 44 on 6/15/26 at 2:04 p.m. but its removal was not documented on the CDR. During a concurrent interview and record review on 6/17/26 at 12:08 p.m. with Licensed Nurse 11 (LN 11), Resident 44's CDR and MAR dated June 2026 were reviewed. LN 11 stated whenever a controlled medication was prepared to be administered to a resident, nursing staff were expected to verify the physical count on the medication and ensure it matched with the CDR. He stated the removal of the medication was documented on the CDR and the administration was documented on the MAR. He stated it was important to document the administration in the MAR otherwise it would not appear in the resident's medical record. LN 11 stated documentation of the removal of the medication on the CDR was important for accountability of controlled medications and to maintain an accurate count. LN 11 reviewed Resident 44's CDR and MAR and confirmed he had documented the removal of tramadol 50 mg on 6/11/26 at 9:07 a.m. and reviewed the MAR and stated, It's not in here right now. LN 11 confirmed he had documented tramadol 50 mg removed on 6/15/26 at 8:33 a.m., reviewed the MAR and stated the dose should have been documented as removed on 6/16/26 instead. LN 11 stated, Should I fix it? A review of Resident 51's medical record indicated a physician's order for oxycodone (a narcotic medication to treat severe pain) 5 mg, give 2.5 mg by mouth every 6 hours as needed for moderate pain (4-6). Document level of pain intensity before and after medication administration using 0-10 pain scale. Hold for excessive sedation and give 5 mg by mouth every 6 hours as needed for severe pain (7-10). Document level of pain intensity before and after medication administration using 0-10 pain scale. Hold for excessive sedation, dated 6/10/26. A review of Resident 51's CDR for oxycodone indicated one tablet was removed from the medication cart on 6/15/26 at 6:30 p.m. but its respective administration was not documented on the MAR. During an interview on 6/17/26 at 12:28 p.m. with the Director of Nursing (DON), the DON stated nursing staff were expected to document controlled medication administration on the CDR and the E-MAR (electronic medication administration record). The DON stated it was important to document on the CDR to maintain an accurate count of controlled medications and on the E-MAR because there was a risk of administering a medication too soon because the E-MAR alerted when the next dose was due. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 8/2025, the P&P indicated, Policy Interpretation and Implementation .12. As required or indicated for medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection site (if applicable); e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug. During a review of the facility's P&P titled, Controlled Medications, dated 10/2025, the P&P indicated, Policy: Medications included in the Drug Enforcement Administration (DEA) [the top federal law enforcement agency in the U.S. dedicated to fighting the illegal drug trade] classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility. Procedures. D. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1. Date and time of administration. 2. Amount administered. 3. Signature of the nurse administering the dose, completed after the medication is administered.

Based on observation, interview, and record review, the facility failed to ensure one of 25 sampled residents (Resident 96) was free of a significant medication error, when Taltz (a medication that stops swelling and inflammation caused by arthropathic arthritis (a type of arthritis that develops in people who have psoriasis [a skin condition causing itchy, scaly patches] when the immune system attacks healthy joints, causing them to become painful, swollen, and stiff) was not available for routine administration. This failure resulted in Resident 96 experiencing severe itching and discomfort, inability to sleep and psychosocial (the combined influence of psychological factors and the surrounding social environment on physical, emotional, and/or mental wellness) harm when his arthropathic psoriasis was left untreated. Findings:A review of Resident 96's admission Record indicated Resident 96 was admitted to the facility in December 2020 with diagnoses which included rheumatoid arthritis (a chronic autoimmune disease in which the immune system mistakenly attacks the joints causing painful swelling, stiffness, and potentially long-term joint damage) and arthropathic psoriasis.A review of Resident 96's Minimum Data Set (MDS, federally mandated resident assessment tool), dated 3/23/25, indicated Resident 96 was cognitively intact (normal mental function). A review of Resident 96's Physician's Orders (PO), dated 7/28/25, indicated, Taltz subcutaneous (under the skin) injection 80 milligrams/milliliter (mg/ml, a unit of measurement), inject one time a day, every 14 days for psoriatic arthritis. Give 1 pen 80 mg every two weeks. Rotate site. Remove from fridge 30 minutes prior to administration.A review of Resident 96's Progress Notes (PN), dated 5/27/26, indicated, [Resident 96] presents with chronic pain and insomnia reporting persistent discomfort and difficulty initiating and maintaining sleep. Symptoms are contributing to fatigue and reduced daily functioning.A review of Resident 96's Medication Administration Report (MAR), dated May 2025 through May 2026, indicated Resident 96 missed multiple administrations of his Taltz injections on 8/12/25 and 4/7/26.A review of Resident 96's PN, dated 6/3/26, indicated, [Resident 96] presents with chronic pain and insomnia reporting persistent discomfort and difficulty initiating and maintaining sleep. Symptoms are contributing to fatigue and reduced daily functioning.A review of Resident 96's MAR, dated June 2026, indicated Resident 96 was scheduled to receive a Taltz injection on 6/4/26. The MAR on 6/4/26 indicated, 9 (Other/See Nurses Notes).A review of Resident 96's PN, dated 6/4/26, indicated, Resident's scheduled Taltz dose due this date was not available for administration.Facility will continue to follow up with pharmacy. No other progress notes were documented in Resident 96's medical record to indicate the facility had followed up with the pharmacy.A review of Resident 96's CP, dated 6/11/26, indicated, At risk for symptoms of exacerbation with specialty medication (taltz).of Dx [diagnosis] of Psoriasis arthritis.Maintain ongoing communication with patient regarding medication status and expected timelines.Monitor for signs/symptoms of arthropathic psoriasis, including pain, joint swelling, redness, warmth, stiffness.A review of Resident 96's PN, dated 6/15/26, indicated, [Resident 96] presents with chronic pain and insomnia reporting persistent discomfort and difficulty initiating and maintaining sleep. Symptoms are contributing to fatigue and reduced daily functioning.During a concurrent observation and interview on 6/16/26 at 9:38 a.m. in Resident 96's room, Resident 96 was awake and alert in bed and stated he was having difficulties obtaining his Taltz injection. Resident 96 stated he was supposed to get the Taltz injection every 14 days and had not received a dose since 5/21/26. Resident 96 stated he had asked all the facility staff about where his Taltz injection was. Resident 96 stated he had lived at the facility for multiple years, and staff were aware that he needed the Taltz injection as prescribed otherwise he started to itch. During a telephone interview on 6/16/26 at 2:05 p.m. with the Pharmacy Technician (PT), the PT stated Resident 96's Taltz injection was delivered to the facility on 6/8/26, eight days prior.During a concurrent interview, and record review on 6/16/26 at 2:18 p.m. with Licensed Nurse 6 (LN 6), Resident 96's PO for Taltz was reviewed. LN 6 stated Resident 96 would get anxious about making sure his Taltz injection was available for his scheduled doses because there had been difficulty in the past obtaining it. LN 6 stated she gave Resident 96 a little paper calendar so he could circle the days his doses were due to help him keep track and alleviate his anxiety. LN 6 stated Resident 96's next dose was due on 6/18/26 and stated she was informed the medication was possibly already in the medication storage room. LN 6 stated, Normally, if the medication was not available for administration, the first step was to look around the facility to see if it was not misplaced and if it was still not found, the next step was to call the pharmacy to see if it was delivered. LN 6 indicated that the nurse who accepted and signed the medication delivery from the pharmacy was responsible for reporting to the resident's nurse that a medication was received for them. LN 6 stated the nurse who received the Taltz injection for Resident 96 could have placed it in the medication storage room without alerting his nurse.During a concurrent observation and interview on 6/16/26 at 2:37 p.m. with LN 6 at the Medication Storage Room Refrigerator, LN 6 opened the refrigerator and located two boxes of Resident 96's Taltz injection. LN 6 stated she would talk to Resident 96 to see if he wanted his injection right away or if he wanted to wait until his next scheduled dose on 6/18/26.During a concurrent observation and interview on 6/16/26 at 2:43 p.m. with LN 6, LN 6 entered Resident 96's room and spoke with him regarding his Taltz injection. LN 6 then exited the room and stated, He wants it now.During an interview on 6/16/26 at 2:56 p.m. with Resident 96, Resident 96 indicated he was miserable and was itching from head to toe and stated he had tried other medications in the past to treat his psoriasis but the Taltz injection was the only medication that worked and controlled his symptoms. Resident 96 stated that when he did not get his medication on time, he started to itch and had been itching all night due to the delay in getting his scheduled dose. Resident 96 stated the itching kept him up at night, Like you wouldn't believe. He stated that on a scale of one to 10, with 10 being the worst, his itching was at a 12. Resident 96 stated he was the type of person that would tolerate an uncomfortable situation for a long time before he spoke up or complained.During a concurrent interview and record review on 6/17/26 at 12:30 p.m. with the Director of Nursing (DON), Resident 96's medical record was reviewed. The DON stated when the facility was waiting for delivery of a resident's medication that required special ordering, they would follow up and contact the pharmacy to see where the medication was at. The DON stated when the medication was delivered, the nurse receiving the medication signed for it, and the nurse who received the medication was expected to contact the nurse practitioner or doctor to get an order to administer the medication right away or to wait. The DON stated the communication between the nurse and provider was expected to be documented in the resident's medical record. The DON reviewed Resident 96's medical record and stated the only note to administer the Taltz that was delivered on 6/8/26 was on 6/16/26 (after it was brought to the facility's attention that the medication was in the refrigerator). The DON stated she expected the provider would have been notified when Resident 96's Taltz injection was delivered on 6/8/26, the notification would have been documented, and then a decision made about whether to administer right then or to hold the dose.During a concurrent interview and record review on 6/17/26 at 2:41 p.m. with LN 10, the Consolidated Delivery Sheet (a delivery manifest from the supplier pharmacy) dated 6/8/26 was reviewed. LN 10 stated when a delivery was received from the pharmacy, each medication was physically compared with the delivery manifest to make sure everything matched. LN 10 stated it was the responsibility of nursing staff to communicate with one another if they were waiting for medication to be delivered for a particular resident. LN 10 reviewed the delivery manifest (which included Resident 96's Taltz injection) and confirmed she had signed for it. LN 10 stated she did not, however, recall specifically receiving and signing for Resident 96's Taltz injection.During an interview on 6/18/26 at 2:58 p.m. with Resident 96, Resident 96 stated his itching was improving and was starting to have relief ever since he received his Taltz injection on 6/16/26. Resident 96 stated, Without my shot, I was getting no sleep. Resident 96 indicate his whole body was itching, and stated, It drives you nuts. Resident 96 stated he had asked multiple staff where his shot was at, but no one located it prior to 6/16/26. Resident stated normally when a person had an itch they can scratch it, and stated, But how can you itch your whole body? Resident 96 stated it was maddening and as the days went on past his scheduled dose that was missed on 6/4/26, his psoriasis had caused his skin to further dry and when he stood up, the pressure on the arches of his feet would cause the skin to crack. Resident 96 stated it was extremely painful and would cause his hair to stand on end.During a concurrent observation and interview on 6/19/26 at 10:13 a.m. with LN 7, LN 7 examined Resident 96's right and left legs and feet. LN 7 stated he had cared for Resident 96 for approximately three years and stated over the course of his time caring for him, his itching had improved with the Taltz injections he received. Resident 96's right and left legs were observed with some redness and peeling between each toe. LN 7 confirmed and stated Resident 96's legs had some redness and some peeling.During an interview on 6/19/26 at 10:44 a.m. with Resident 96, Resident 96 stated he did not report his itching to staff because he felt they knew him well enough to know what happened to him when he did not receive his scheduled Taltz injections. Resident 96 stated, I didn't really say anything, I just put up with it.During a review of the facility's policy and procedure (P&P) titled, Pharmacy Services, dated 10/2025, the P&P indicated, Regular and reliable pharmaceutical service is available to provide residents with prescription and non-prescription medications, services, and related equipment and supplies.During a review of the facility's P&P titled, Physician Orders, dated 10/2025, the P&P indicated, Prescribed medication and treatment orders will be carried out in accordance with the physician/nurse practitioner's order.

Based on observation, interview, and record review, the facility failed to ensure respiratory care consistent with professional standards of practice was provided for one of 25 sampled residents (Resident 2), when the continuous positive airway pressure (CPAP, a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure) daily equipment cleaning was done as ordered. This failure had the potential to result in the buildup of bacteria, mold and allergens which could lead to respiratory-related complications and infection. Findings: During a review of Resident 2's admission Record (AR), the AR indicated, Resident 2 was admitted on 5/2026 with diagnoses which included obstructive sleep apnea (OSA, sleep related breathing disorder) pneumonia (lung infection), atelectasis (partial or complete collapse of the lung), and asthma (narrowing of the lung airways making breathing difficult). During a review of Resident 2's Physician's Order (PO), dated 5/1/26, the PO indicated, CPAP order: Wash mask in warm soapy water, rinse and air dry every day shift. Wash tubing and head gear in warm soapy water, rinse and air dry every day shift. Cleanse the reservoir with solutions and rinse. Wipe and let air dry every day shift every Sunday. Empty the reservoir and refill at night with distilled water at bedtime. The PO also indicated Resident 2 had the capacity to make health care decisions. During a review of Resident 2's Care Plan (CP) titled, Resident 2 require CPAP use related to Sleep Apnea, revised 5/6/26, the CP indicated, Goal: Will maintain patent airway. Interventions included: Mask and tubing will be cleaned after use and air dried; weekly cleaning for machine filter. During a review of Resident 2's Respiratory Administration Record (RAR), dated 5/1/26 through 5/31/26, and 6/1/26 through 6/18/26, the RAR did not show documented evidence of respiratory equipment care done daily as ordered. The RAR indicated: For the month of June 2026: June 2, 3, 4, 8, 13, 14, 15, 18.For the month of May 2026: May 4, 8, 11, 12, 14, 16, 19, 20, 22, 23, 24, 28. During a review of Resident 2's Licensed Nurses Notes (LNN) from May 1, 2026 through June 18, 2026, the LNN did not show documented evidence why respiratory care was not provided on a daily basis as ordered. During a concurrent observation and interview on 6/17/26 at 4:40 p.m., inside Resident 2's room, Resident 2 was alert and in bed, had coughing episodes, his CPAP machine was at bedside table, mask and tubing in placed. When asked how often and what time the Licensed Nurses (LNs) usually cleaned the CPAP mask and tubing, including cleaning and emptying the reservoir, Resident 2 stated nursing staff did not clean and rinse the mask and tubing and or clean the reservoir. During a concurrent interview and record review, on 6/17/26 at 4:57 p.m., with LN 8, Resident 2's RAR was reviewed. LN 8 confirmed Resident 2's CPAP should be cleaned every day as ordered. During a concurrent interview and record review on 6/17/26 at 5:06 p.m., with the Assistant Director of Nursing (ADON), Resident 2's clinical record was reviewed. The ADON confirmed the PO was to provide daily CPAP care. The ADON confirmed the RAR showed there were dates for the months of May and June 2026 when CPAP care was not done. The ADON stated CPAP machine including mask and tubing should be cleaned daily to prevent buildup of bacteria, molds and allergens which could compromised Resident 2's respiratory functioning and could lead to respiratory infection. The ADON stated if the care was not documented, it was not done. During a concurrent interview and record review, on 6/18/26 at 11:44 a.m., with the DON, Resident 2's clinical record was reviewed. The DON confirmed there were days in the RAR when CPAP care was not documented/provided. The DON stated when the care was not documented, it was not done. The DON stated when CPAP equipment including the mask, tubing and reservoir were not cleaned, it could lead to respiratory problems and infection. The DON stated she expected the LNs to follow orders for patient safety and quality of care. The DON also stated the warm, moist environment inside the mask and hose was an ideal breeding ground for bacteria, viruses, and molds, breathing in these contaminants for hours could lead to respiratory infections. During a review of the facility's Policy and Procedure (P&P), titled, CPAP/BIPAP (Bilevel PAP), revised 10/25, the P&P indicated, General guidelines for cleaning: Specific cleaning instructions are obtained from the manufacturers/supplies of the PAP machines. Machine cleaning: Wipe machine as needed. Masks, nasal pillows and tubing: Clean daily by placing in warm soapy water, rinse with warm water and allow it to dry between uses. Headgear (strap): wash with warm soapy water as needed. Allow to air dry.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for three out of eight sampled residents (Resident 5, Resident 6, and Resident 7) when:1. Resident 5 and Resident 6's call light buttons were not within their reach; and,2. Resident 7's call light system was broken and was not provided with an alternative call system.This failure placed Resident 5, Resident 6, and Resident 7's safety at risk and had the potential for the residents' needs not to be met.Findings:1a. A review of Resident 5's clinical record indicated Resident 5 was admitted February of 2026 and had diagnoses that included fracture (a break in the continuity of a bone) of the neck bone and dementia (memory loss that interferes with daily functions).A review of Resident 5's physician's order, dated 2/9/26, indicated Resident 5 had no capacity to make decisions.A review of Resident 5's care plan, dated 2/9/26, indicated, [Resident 5] is at risk for falls with or without injury related to .fracture .altered mental status .Keep call light within reach.During a concurrent observation and interview on 2/9/26 at 12:50 p.m. with Resident 5, in Resident 5's room, Resident 5 was observed lying on his bed, awake, wearing a neck brace, and his call light button was on the floor, under the bottom of his bed. Resident 5 stated he did not know where his call light button was at.During a concurrent observation and interview on 2/9/26 at 1:25 p.m. with Certified Nurse Assistant (CNA) 1, in Resident 5's room, CNA 1 confirmed that Resident 5's call light button was on the floor, under the bottom of his bed. CNA 1 stated the call light button should be placed near Resident 5 where he could reach it so Resident 5 could call for help in case of emergency or if he needs any assistance.1b. A review of Resident 6's clinical record indicated Resident 6 was admitted August of 2023 and had diagnoses that included diabetes (elevated sugar in the blood) with polyneuropathy (a condition characterized by damage to multiple peripheral nerves causing numbness, burning pain, and muscle weakness) and retinopathy (a serious, progressive eye disease causing blurred vision and potential blindness, abnormalities of gait and mobility, and muscle weakness.A review of Resident 6's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 11/19/25, indicated Resident 6 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 6 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 6's MDS Functional Abilities, dated 11/19/25, indicated Resident 6 needed partial/moderate assistance with toileting hygiene, shower/bathing self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. A further review of Resident 6's MDS Functional Abilities indicated Resident 6 needed setup or clean-up assistance with lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and toilet transfer, and needed substantial/maximal assistance with tub/shower transfer and walking.A review of Resident 6's care plan, revised 11/22/23, indicated, Falls: [Resident 6] is at risk for falls with or without injury elated [sic] to .repeated falls .A review of Resident 6's care plan intervention, dated 8/19/23, indicated, Keep call light within reach. A review of Resident 6's care plan intervention, dated 1/6/26, indicated, Educate/remind resident to call for assistance with all transfers.During a concurrent observation and interview on 2/9/26 at 1:30 p.m. with Resident 6, in Resident 6's room, Resident 6 was observed lying on her bed, awake, and her call light button was on the floor, under the bottom of her bed. Resident 6 stated she could not reach her call light button at the moment.During a concurrent observation and interview on 2/9/26 at 1:46 p.m. with CNA 2, in Resident 6's room, CNA 2 confirmed that Resident 6's call light button was on the floor, under the bottom of her bed and the call light chord was stuck on the bed frame. CNA 2 stated Resident 6 was able to use call light button. CNA 2 also stated Resident 6's call light button should always be within her reach so she could call if she needed help with anything. CNA 2 further stated there would safety issues like risk for falls if Resident 6 would not be able to call for help when she needs assistance.2. A review of Resident 7's clinical record indicated Resident 7 was admitted in August of 2025 and had diagnoses that included fracture of left upper arm, diabetes, muscle weakness, and congestive heart failure (a condition in which the heart cannot pump oxygen-rich blood efficiently to the rest of the body).A review of Resident 7's MDS Cognitive Patterns, dated 12/4/25, indicated Resident 7 had a BIMS score of 13 out of 15 which indicated Resident 7 had an intact cognition. A review of Resident 7's MDS Functional Abilities, dated 12/4/25, indicated Resident 7 needed substantial/maximal assistance with toileting hygiene, shower/bathing self, upper and lower body dressing, and putting on/taking off footwear, and needed partial/moderate assistance with personal hygiene. A further review of Resident 7's MDS Functional Abilities indicated Resident 7 needed supervision or touching assistance with rolling left and right, sit to lying, and lying to sitting on side of bed, and needed partial/moderate assistance with sit to stand, chair/bed-to-chair transfer, and toilet transfer.A review of Resident 7's care plan, revised 8/28/25, indicated, Falls: [Resident 7] is at risk for falls with or without injury related to .Fx [fracture], Fall hx [history] .heart failure .Educate/remind resident to call for assistance with all transfers .Keep call light within reach.During an interview on 2/9/26 at 1:46 p.m. with CNA 2, CNA 2 stated Resident 7's call light usually gets broken and would not work. CNA 2 further stated staff would try to fix Resident 7's call light but then it would get broken again.During an interview on 2/9/26 at 2:05 p.m. with Resident 7, at the therapy room, Resident 7 stated he just recently got transferred to his room, but he feels annoyed and he does not feel comfortable staying in his room because his call light has been broken since last Thursday [2/5/26]. Resident 7 further stated facility staff were aware that his call light button was broken but had not fixed it.During a concurrent observation, interview, and record review on 2/9/26 at 2:14 p.m. with CNA 3, in Resident 7's room, CNA 3 checked and confirmed that Resident 7's call light system was broken, and Resident 7 was not provided with an alternative call system. CNA 3 stated she was not aware that Resident 7's call light was broken. CNA 3 also stated Resident 7 should be provided with a functioning call system because Resident 7 should always be able to call for assistance and in cases of emergency, Resident 7 should be able to call for help. CNA 3 further stated they would write in the maintenance logbook or directly call the maintenance staff if a facility equipment was broken. The Maintenance Logbook was then reviewed and CNA 3 confirmed that there was no report that Resident 7's call light has been broken. During a concurrent observation and interview on 2/9/26 at 2:23 p.m. with the Maintenance Supervisor (MS), in Resident 7's room, the MS checked and confirmed that Resident 7's call light system was broken and stated he needs to replace it. The MS stated a staff told him this morning that Resident 7's call light was broken but he has not fixed it.During an interview on 2/9/26 at 4:50 p.m. with the Director of Nursing (DON), the DON stated she would expect that residents would be provided with a working call light system and it should be placed within the reach of the residents. The DON further stated there would be safety concerns if residents' call lights were not working or not within their reach.A review of the facility's policies and procedures titled, Answering the Call Light, dated 10/2010, indicated, 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .7. Report all defective call lights to the nurse supervisor promptly.

Based on interview and record review, the facility failed to follow the discharge process for one of three sampled residents (Resident 1), when Resident 1 was transferred to an acute hospital and Resident 1's Responsibility Party (RP) was not informed of intent to discharge the resident or provided with notice of bed-hold.This failure resulted in Resident 1 being denied return to the facility causing disruption of care. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in June 2025 with multiple diagnoses including metabolic encephalopathy (a change in brain function due to a systemic illness affecting the body's metabolism), dementia with behavioral disturbance (loss of memory and brain function with symptoms including agitation, aggression, psychotic symptoms, and mood changes), and enterocolitis due to clostridium difficile (bacterial infection of the bowel that can cause inflammation and diarrhea). A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 7/4/25, indicated Resident 1 had Brief Interview for Mental Status (BIMS- tool to assess cognition) of 4 out of 15, that indicated Resident 1 had severe cognitive impairment. A review of Resident 1's MDS, Behavior, dated, 7/4/25, indicated Resident had delusions (belief that is persistently held but is untrue) and had behavioral symptoms including hitting, scratching, rummaging, smearing bodily wastes that put Resident 1 at risk for physical injury, interfered with care, and put others at risk for injury. A review of Resident 1's Order Summary Report indicated order dated 7/18/25 .Send Resident to acute on 7/18/25 due to increased behaviors resulting in concerns for safety . A review of Resident1's Order Summary Report indicated order dated 7/12/25 .Please call [Resident 1's RP] if patient refuses labs or medication, or becomes agitated or combative . A review of Resident 1's Order Summary Report indicated order dated 6/27/25 .Seroquel [antipsychotic medication used to improve mood, thoughts and behaviors] .Give 6.25 mg [milligrams] by mouth at bedtime for hospital delirium [change in mental abilities resulting in lack of awareness of surroundings] MB [manifested by] agitation/inability to sleep causing distress to self . A review of Resident 1's Change in Condition Evaluation, dated 7/18/25 indicated .patient has been combative, not following directions, not cooperative with care; patient wondered [sic] into other patients' rooms, eating their food or took their drink; patient wonders [sic] into nurses station and starts to open peoples' hand bags and takings thingsout [sic] .Recommendations of Primary Clinician(s) . [name of physician] and management are informed with order to send patient to acute care. Management stated that [RP] has been informed about the transfer .A review of Resident 1's Notice of Proposed Transfer/Discharge, dated 7/18/25, indicated .Transfer/Discharge Reasons .The transfer or discharge is necessary for the resident . A review of Resident 1's Progress Notes, Type: Physician Progress Note, dated 7/18/25, indicated .The patient was very agitated and screaming and shouting at the nursing staff, and case was discussed with the [RP] also that we increase the dose of Seroquel, but the patient was non-compliant and the daughter was also refusing any interventions. So it was suggested that the patient is not safe here and need to go to acute care facility because of safety concerns. So the patient was sent to acute care facility as the patient was non-compliant and the [RP] was also non-compliant with the treatment plan .With underlying cognitive impairment with dementia .Patient and family both refusing to increase the dose of Seroquel. Patient need to go to acute care facility for further evaluation . A review of Resident 1's Progress Note, Type: Nurse's Note, dated 7/18/25 at 12:55 p.m., indicated .Received orders from [name of physician] to increase patients Seroquel from 6.25mg to 12.5mg due to increased behavioral issues. Patient has been combative, hitting care staff, throwing things at other patients, eating other patients food and hard to reorient and redirect. Patient's [RP] notified by charge nurse of increasing agitation this morning .called patient's [RP] to relay doctors order . writer notified her of .order to increase Seroquel from 6.25mg to Seroquel 12.5mg . or send patient to acute for increasing agitation and combativeness for patients/care staff safety if family not agreeable to medication changes. [RP] refused medication changes and was notified patient would be sent to acute for safety purposes . A review of Resident 1's Progress Note, Type: Nurse's Note dated 7/18/25 at 10:27 a.m., indicated .Called [RP] back at 10:42am .and explained to her .resident is still agitated and hitting staff members and going into other Resident's rooms . a safety risk -for our residents and our staff . [RP] was agreeable at this time and said she will be in the facility shortly to help with agitation and well as speak with [name of physician] of the POC [plan of care] going forward .Called [name of physician] .informed him of the above behaviors-he stated we could either 1-Increase Seroquel to 12.5 mg per dose. 2- Send resident out to acute for further evaluation due to increased agitation . [RP] was not agreeable to all options. Send out to acute was initiated due to safety concerns .' A review of Resident 1's Care Plan, The resident has a behavior problem r/t [related to] increased agitation, initiated 7/12/25, indicated . Goal .The resident will have fewer episodes of behavior by review date Target Date 9/25/25 . Interventions .Anticipate and meet The resident's needs .Caregivers to provide opportunity for positive interaction, attention .Praise any indication of The resident's progress/improvement in behavior . A review of Resident 1's Care Plan, [Resident 1] was noted with increased combativeness/ agitation 7/12/25 .revised 7/14/25, indicated .Interventions .Approach in a calm, reassuring manner .Encourage family visits and interactions .Monitor for signs and symptoms of decreased psychosocial well-being, adjustment issues, emotional distress, ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual wellbeing and report abnormal findings to physician .Reorient and redirect as necessary .A review of Resident 1's Care Plan, Psychosocial Behavior: Exhibits or is at risk for behavioral symptoms (i.e. striking out, grabbing others, combative, verbally, or physically abusive, inappropriate disrobing, smears/throws food/feces/objects due to delirium .initiated 7/2/25 . Goal Will be compliant with nursing care .Will not harm self-and/or others secondary to socially inappropriate and/or disruptive combative behavior . Target Date 9/25/25, .Interventions .Administer medication as ordered .Document and record behavioral episodes .Maintain a calm, slow, understandable approach . During a telephone interview on 7/22/25 at 11:45 a.m. with Resident 1's RP, Resident 1's RP stated she was notified in the morning of 7/18/25 that Resident 1 did not take her medications and was having behavior issues. The RP stated the facility wanted to double her Seroquel medication. The RP stated she was told that if you do not agree to Seroquel dosage increase, then the facility will send her to the acute hospital. Resident 1's RP stated she asked the facility not to send Resident 1 out until she arrived at the facility and she was on her way. Resident 1's RP stated she wanted to review with the physician the increase in medication before agreeing to increase. She stated she was called and notified that Resident 1 had been sent to the acute hospital. When asked if Resident 1's RP had been offered a bed- hold, the RP stated a bed-hold was never mentioned. During a joint interview on 7/23/25 at 9:50 a.m. with the Administrator (ADM) and the Director of Nursing (DON), the DON reviewed the process for resident transfer to acute hospital. The DON stated process is to receive physician's order for transfer, notify resident or RP, call ambulance for transport, and provide report to hospital. The DON stated Notice of Proposed Transfer/ Discharge is provided to resident or RP and sent to the ombudsman. The DON stated a bed hold option is offered to resident or RP, but it may be a private pay bed hold. The ADM and DON stated Resident 1 was sent to acute hospital on 7/18/25 due to increased behaviors, combativeness, direct threat to residents, wandering into patients' rooms, throwing things at residents, and was non-redirectable. The DON stated the provider wanted to increase the Seroquel but Resident 1's RP refused, and Resident 1's RP was informed Resident 1 would be sent to the acute hospital. The ADM stated if the Resident 1's RP had agreed to the medication change, would have tried that out to see if effective and Resident 1 would not have been sent out that day. During an interview on 7/23/25 at 2:25 p.m. with Licensed Nurse (LN) 1, LN 1 stated Resident 1 started having increased behaviors including hitting and punching staff, threatening residents and families, and became non-redirectable. LN 1 stated when transferring a resident to the hospital the Notice of Proposed Transfer/Discharge is completed to notify family of hospital transfer. During a subsequent joint interview on 7/23/25 at 4:10 p.m. with the ADM and DON, ADM stated that Resident 1's RP was not offered bed- hold because the determination had already been made that Resident 1 was not appropriate for the facility. The ADM stated it was an unplanned discharge due to severity of behavior. During a telephone interview on 7/23/25 with the Medical Doctor [MD], the MD stated Resident 1 was sent to the acute hospital on 7/18/25 due to behaviors. The MD stated Resident 1 had become more agitated, more combative, was going into residents' rooms, and had risky behavior. The MD stated Resident 1's RP was given option to increase dose of Seroquel, but did not agree to the increase, so was sent to the acute hospital.During a concurrent telephone interview and record review on 7/30/25 at 9:53 a.m. with the ADM, the ADM stated Resident 1 was discharged , not transferred, from the facility on 7/18/25. Reviewed Resident 1's Progress Notes from 7/18/25 and that there was no documentation that Resident 1's RP was notified it was a facility discharge and not an acute transfer. The ADM stated it was communicated to Resident 1's RP it was a discharge, and the Notice of Proposed Transfer/Discharge was given as a notice of discharge. The ADM stated a bed hold was not offered because the facility knew they were not accepting Resident 1 back. When asked how the facility determined that upon the transfer to acute hospital on 7/18/25, that Resident 1 would not return to the facility if behaviors were able to be managed, the ADM stated Resident 1 had escalating behaviors and the MD made the decision she was not safe in the facility. Reviewed with the ADM, facility policy Bed-Holds and Returns that indicated residents are provided written bed-hold information at the time of transfer and that residents be permitted to return to the facility following hospitalization. The ADM stated Resident 1's RP had not been agreeable to interventions prior to acute transfer so MD made decision she would not be safe in facility after hospitalization. A review of the facility's Policy and Procedure (P&P) titled Bed-Holds and Returns, revised 10/22, indicated .Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies .All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice .notice 2: at the time of transfer (or, if transfer was an emergency, within 24 hours) .The written bed-hold notices provided to the residents/ representatives explain in detail .the facility return policy .The requirement that residents be permitted to return to the facility, following hospitalization or therapeutic leave applies to all residents regardless of payer source .A review of the facility's P&P titled Transfer or Return, revised 3/25, indicated .Once admitted to the facility, residents have the right to remain in the facility. Transfers and discharges must meet specific criteria and require resident/ representative notification, orientation, and documentation in the medical record .Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility .When the facility transfers or discharges a resident, the following information is documented in the medical record .That an appropriate notice was provided to the resident and/or legal representative .

Based on interview and record review, the facility failed to ensure controlled medications (medications that the use and possession of are controlled by the federal government) for three residents (Resident 30, Resident 38, and Resident 51) of a census of 95 were accurately accounted for on the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications given to a resident) and Controlled Drug Record (CDR - a log for tracking dispensing of controlled substances to ensure compliance with relevant regulations). This failure decreased the facility's potential to ensure accurate accountability for residents' controlled medications and prevent their misuse. Findings: A review of Resident 30's admission record indicated he was readmitted on [DATE] with a diagnosis of orthopedic (medical care pertaining to bone injuries or deformities) aftercare following surgical amputation (surgical removal of a body part, usually a limb) and osteoarthritis (degeneration of joint cartilage and underlying bone). A review of Resident 30's Order Summary Report, dated 4/15/25, indicated an order for hydrocodone-acetaminophen (an opioid medication used to treat pain) 5/325 milligrams (mg; a unit of measurement), one tablet every six hours as needed for pain management. A review of Resident 30's CDR and MAR, dated 3/2025, indicated hydrocodone-acetaminophen was given on 3/2/25 at 2:30 p.m. in the CDR and not noted as given in the MAR. A review of Resident 38's admission record indicated he was admitted to the facility on [DATE] with a diagnosis of femur (thigh bone) fracture and subsequent surgical repair. A review of Resident 38's Order Summary Report, dated 4/15/25, indicated an order for hydrocodone-acetaminophen 5/325 milligrams, one tablet every four hours as needed for moderate to severe pain. A review of Resident 38's CDRs and MARs, dated 3/2025 and 4/2025, indicated hydrocodone-acetaminophen was given on 3/29/25 at 5 p.m. in the CDR, but not listed as administered in the MAR. The CDR also indicated the medication was given on 3/30/25 at 5:12 p.m. and 4/6/25 at 8 p.m. and were not listed as given in the MAR. A review of Resident 51's admission record indicated she was admitted to the facility on [DATE] with a diagnosis of thoracic vertebrae (the interlocking bones in the middle section of the spine) fracture. A review of Resident 51's Order Summary Report, dated 4/15/25, indicated there was an order for hydrocodone-acetaminophen 5/325 mg, one tablet every eight hours as needed for moderate to severe pain. A review of Resident 51's CDR and MAR, dated 3/2025, indicated a hydrocodone-acetaminophen dose was given on 3/29/25 - the CDR denoted the dose was given at 5:30 p.m., and the MAR displayed an administration time of 3:04 p.m. During interviews on 4/11/25 at 12:29 p.m. and 3:10 p.m. with the Director of Nursing (DON), the inaccuracies of Resident 30's, 38's, and 51's CDRs and MARs were discussed. DON stated correct documentation was important for controlled drug accountability. Incorrect records of doses could be associated with medication misuse and drug diversion. A review of the facility's policy and procedures titled, Controlled Medications, revised 9/2024, indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record . Date and time of administration . Amount administered . Signature of the nurse administering the dose, completed after the medication is actually administered.

Based on observation, interview, and record review, the facility failed to provide two (2) of 27 sampled residents (Resident 30 and Resident 38) proper hygiene when: 1. Resident 30 and Residents 38's fingernails were untrimmed, jagged and had black substances underneath the nailbeds; 2. Resident 30's skin on right foot was dry and scaly; 3. Resident 38's skin on right and left feet were dry and scaly; and, 4. Resident 30 and Resident 38's traced of colored-liquid, old and dry food residue stacked in between their beards. This failure decreased the facility's ability to maintain Resident 30 and Resident 38's overall health, comfort, and a sense of dignity. Findings: A review of Resident 30's admission Record (AR) indicated he was admitted in June 2024 with diagnoses which included osteoarthritis (a degenerative joint disease where cartilage breaks down, causing pain, stiffness, and reduced movement) generalized muscle weakness and left below the knee amputation (LBKA). A review of Resident 30's revised Care Plan (CP) dated 2/7/25, titled ADL(activities of daily living- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves)/MOBILITY: indicated, Resident 30 is at risk for ADL/mobility decline and requires assistance . During an observation on 4/8/25 at 8:56 a.m. and on 4/9/25 at 11:07 a.m., Resident 30's fingernails were untrimmed, jagged with a black substance underneath the nailbeds, his right foot skin was dry and scaly, and there were traces of colored-liquid and old, dry food residue stacked in between his beard. A review of Resident 38's AR indicated he was admitted in January 2025 with diagnoses which included Parkinsons disease (PD, progressive neurological disorder primarily affecting movement) and dementia (a progressive state of decline in mental abilities). A review of Resident 38's CP initiated on 2/27/25, indicated, Resident 38's ADL/MOBILITY: Resident 38 is at risk for ADL/mobility decline and requires assistance . During an observation on 4/8/25 at 9:12 a.m. and on 4/9/25 at 12:11 p.m., Resident 38's fingernails were untrimmed, jagged, and had black substance underneath the nailbeds. Skin on his left and right feet were dry and scaly and there were traces of colored-liquid and old, dry food residue stacked in between his beard. During concurrent observations and interviews on 4/10/25 at 9:05 a.m., with the Treatment Nurse (TN), the TN confirmed the findings: Resident 30 and Resident 38's fingernails were untrimmed, jagged and had black substances underneath their nailbeds; their skin were dry and scaly; and traces of colored-liquid, and, old and dry food residue stacked in between their beards. The TN stated he would not like Resident 30 and Resident 38 to look dirty and unkempt for dignity and infection control issues. The TN stated accumulated food residue in facial beard can lead to unpleasant odors and even skin irritation. The TN stated Resident 30 and Resident 38 should have been cleaned and properly groomed but they were not. During an interview on 4/10/25 at 2:43 p.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 30 and Resident 38 should be groomed and clean at all times. The ADON stated a lack of hygiene could facilitate the spread of infections and could lead to more health problems such as skin complaints and could cause residents' discomfort, low self-esteem, and embarrassment. During an interview and record review on 4/11/25 at 8:24 a.m., with the Director of Nursing (DON), Resident 30 and Resident 38's medical records were reviewed. The DON confirmed Resident 30 and Resident 38's functional capability for ADL's required staff assistance. The DON stated her expectations required Resident 30 and Resident 38 and all residents to be cleaned and groomed. The DON confirmed unkempt residents' fingernails could potentially cause skin irritation, discomfort and affect the residents' dignity. The DON also stated residents' skin should be lotioned and moistiorized, due to when residents get older, skin gets thinner and drier, so, it is prone to damage. A review of the facility's policy and procedure (P/P) titled, :ACTIVITIES OF DAILY LIVING, SUPPORTING, revised 10/24, indicated, Residents will be provided with care. treatment, and services as appropriate to enable to carry out activities of daily living .appropriate care and services will be provided for residents who are unable to carry out ADLs independently .

2. A review of Resident 25's AR indicated Resident 25 was admitted to the facility in December 2024 with diagnoses which included congestive heart failure (fluid buildup in the body, especially the lower extremities) and muscle weakness. A review of Resident 25's Order Summary Report (OSR, physician orders) indicated an order for compression stockings (TED hose) during the morning shift every day, for edema, and off at nighttime, with a start date of 3/31/25. During a concurrent observation and interview with Resident 25 on 4/8/25 at 9:56 a.m. in the resident's room, Resident 25 was in bed, wearing a facility gown. Resident 25 confirmed she was not wearing compression stockings and she had not been since being admitted to the facility. During a concurrent observation, interview and record review on 4/10/25 at 10:34 a.m. with LN 6, in Resident 25's room, Resident 25's April 2025 Medication Administration Record (MAR) was reviewed. LN 6 confirmed Resident 25 was not wearing compression stockings. LN 6 acknowledged her initials on the April 2025 MAR and she had documented that Resident 25's TED hose had been applied on 4/4/25 and 4/6/25 when she had not applied the TED hose. LN 6 acknowledged she documented a treatment she did not administer, and she should not document something she did not do. A review of Resident 67's AR indicated Resident 67 was admitted to the facility in March 2025 with diagnoses which included muscle weakness and multiple sclerosis (autoimmune disorder where the immune system mistakenly attacks the body's own tissues). A review of Resident 67's OSR/(PO-physician orders) indicated Resident 67 had an order for TED hose: apply in the morning and remove at bedtime, with a start date of 3/29/25. During a concurrent observation and interview on 4/9/25 at 10 a.m. with Resident 67 and the Physical Therapy Assistant (PTA), in Resident 67's room, Resident 67 was observed laying in bed, in her own gown, without TED hose on. Resident 67 stated she has never been fitted for TED hose while at the facility. The PTA acknowledged the license nurses supply the TED hose for the resident. The PTA checked through Resident 67's belongings and closet and confirmed there were no TED hose available. During a concurrent observation, interview and record review on 4/10/25 at 1:57 p.m. with LN 6 and Resident 67, in Resident 67's room, Resident 67's OSR and April 2025 MAR were reviewed. LN 6 acknowledged Resident 67 had an order for TED hose and confirmed her initials were on the April 2025 MAR that indicated she had applied the TED hose on 4/4/25, 4/6/25 and 4/10/25. LN 6 observed Resident 67 was not wearing the TED hose. Resident 67 acknowledged she was not wearing TED hose and retrieved them from her bedside table. LN 6 admitted she documented something she did not do. 3. A review of Resident 249's AR indicated Resident 249 was admitted to the facility in April 2025 with diagnoses including pseudomonas aeruginosa (a bacterial infection) and cystitis (an infection in the bladder). A review of Resident 249's OSR indicated an order for 2 grams of ceftriaxone sodium (antibiotic) intravenously one time a day for sepsis. A review of Resident 249's April 2025 MAR indicated LN 7 had administered Resident 249's IV antibiotics on 4/6/25 and 4/8/25. During a concurrent interview and record review on 4/9/25 at 4:20 p.m. with LN 7, Resident 249's April 2025 MAR was reviewed for the administration of IV antibiotics. LN 7 stated a Registered Nurse needs to administer IV antibiotics and the staff member who administers the medication or treatment documents the action in the medical record. LN 7 confirmed her initials were on the MAR for the administration of IV antibiotics on 4/6/25 and 4/8/25. LN 7 agreed those entries in Resident 249's MAR were inaccurate and she should not document something she did not do. During a concurrent interview and record review on 4/10/25 at 11:15 a.m. with the DON, Resident 25's, Resident 67's and Resident 249's records were reviewed. The DON acknowledged LN 6 and LN 7 had documented entries in the Residents' MAR that were inaccurate, and staff should not sign off on something they did not do. A review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised 2024, indicated, Services provided to the resident shall be documented in the resident's medical record .documented information in the in a resident medical record can include: .medications administered .treatments or services performed .Entries may only be recorded in the resident's clinical record by licensed personnel .in accordance with state law and facility policy .Documentation of procedures and treatments may include .The name and title of the individual(s) who provided the care. 4. During a concurrent observation and interview of the kitchen dishwashing on 04/11/25 09:39 a.m. with the kitchen Dishwasher (DW) employee, the DW was observed scraping the leftover breakfast food from the trays into the garbage container. The contents of the garbage was observed to contain scraped food items, and further observation of the garbage container it was observed there were other resident's meal tickets at the bottom of the garbage container. There were two meal tickets observed on the top portion of the garbage which were within reach. There were two meal tickets obtained from the garbage which were identified for Random Resident 1 and Random Resident 32. Further observation, the two meal tickets were printed with the resident's name, room number, allergies to food, food likes and dislikes. During the interview with the DW, she confirmed in preparation for washing the dishes she must first scrape off the food and the meal tickets are disposed in the garbage. During an interview with the Dietary Manager (DM) on 4/11/25 at 9:41 a.m., the DM was shown the meal tickets obtained from the garbage can. The DM confirmed they were the residents meal tickets from the breakfast meal. The DM stated the current practice were for the food scraps and meal tickets to be disposed of together into the regular garbage. Further interview with the DM confirmed the printed meal tickets had the resident's name, room number, diet, likes and dislikes and allergies. The DM confirmed the printed meal tickets contained resident's confidential information, and should be disposed of in the confidential shredding bin and not into the regular garbage. Record review of the facility Policy and Procedure Confidentiality of Information and Personal Privacy revised 10/24 indicated: .Our facility will protect and safeguard resident confidentiality and personal privacy .1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records .4. Access to resident personal and medical records will be limited to authorized staff and business associates . Record review of facility Policy Retention of Medical Records and Destruction dated 2001 indicated: .Facility is contracted with [Name of Medical Record Destruction Company] for the destruction of records . 5. During a record review of Resident 48's AR indicated he was admitted to the facility with diagnoses of dementia (the loss of cognitive functioning, thinking, remembering, and reasoning), anxiety disorder (persistent and excessive anxiety and worry about activities or events, even ordinary or routine), and depression. Review of Resident 48's OSR/PO indicated on 4/7/25 the physician ordered the medication . Brexpiprazole (an antipsychotic medication used to treat major depressive disorder (MDD) and agitation associated with dementia) 0.5 mg (milligram, a unit of measure) tablet by mouth one time a day for dementia with behaviors and psychosis (where an individual experiences a significant loss of touch with reality) agitation for 7 days manifested by auditory hallucinations. Further review of Resident 48's OSR indicated the medication Brexpiprazole was to be administered beginning 4/8 through 4/15/25. Before administering of the medication could begin, an informed consent (IC) must be obtained from the resident or the Responsible Party (RP). Record review of Resident 48's IC with an effective date of 4/7/25 at 1:33 p.m. the IC verification section of the document indicated the licensed nurse obtained a verbal/phone consent on 4/7/27 at 5:40 p.m. as evidenced by two (2) Licensed Nurses (LN) signatures. Further review of the IC document's line 1b indicated: .Name of person giving verbal or phone consent was left blank it did not indicate the name from whom the LNs obtained the consent from. During an interview with the Assistant Director of Nursing (ADON) on 4/11/25 at 12:25 p.m., the IC for the use of Brexipiprazole 0.5 mg was reviewed with the Assistant Director of Nursing (ADON) and he confirmed that the informed consent for Brexpiprazole was signed and witnessed by two (2) LNs and was complete. The ADON stated he also signed and confirmed the IC obtained was complete before administering Brexpiprazole. The ADON was asked to review the consent. The ADON after reviewing the document stated the IC was inaccurate as it did not document the name of the RP giving the consent. He stated the RP name must be confirmed and verified. Review of the facility Policy and Procedure Psychotropic Medication Use dated 10/23 indicated: .4. The licensed nursing staff will verify that an informed consent was obtained by the prescribing licensed healthcare practitioner from the resident or resident's authorized representative prior to administration of psychotropic medications and every six (6) months. Based on observation, interview, and record review, the facility failed to accurately document and secure the care and treatment provided for five of 27 sampled residents (Resident 82, Resident 25, Resident 67, Resident 249, and Resident 48) when: 1. Licensed Nurse 4 (LN4) documented she had applied Resident 82's Thrombo-Embolic Deterrent, (TED stockings, also known as anti-embolism stockings, designed to prevent blood clots and swelling in the legs, particularly after surgery) and lymphatic compression device (helps the trapped lymph fluid to move and flow through the lymph vessels) when she had not; 2. Resident 25 and Resident 67's administration records indicated TED hose had been applied daily by the LNs, when LN's had not; 3. Resident 249's intravenous antibiotics (IV, a type of antibiotic administered directly into a vein to treat infections) was documented as administered by a Licensed Vocational Nurse (LVN), which was not within the scope of practice; 4. Residents' meal tickets were disposed of in the regular garbage bin; and 5. Resident 48's Informed Consent (IC, voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for the use of psychoactive medications (affecting the mind or behavior) was inaccurate. These failures decreased the facility's ability to provide a clear and consistent picture of the patient's conditions, treatment responses, outcomes, and risk factors to improve patients' health and safety and the potential to expose multiple residents health information by persons not involved in the residents' care for a census of 95 residents. Findings: 1. A review of Resident 82's admission Record (AR) indicated he was admitted in February 2025 with diagnoses which included endocarditis (serious infection and inflammation of the inner lining of the heart chambers and heart valves) and generalized muscle weakness. A review of Resident 82's Physician's Order (PO) dated 2/13/25, the PO indicated, TED Hose: apply TED hose [every] [morning] and remove [every] [afternoon] and offer Lymphatic Compression Device for bilateral lower extremities (BLE) after meals every shift. A review of Resident 82's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 2/14/25 indicated he had mental capacity to make healthcare decisions. During a concurrent observation and interview on 4/10/25 at 2:03 p.m., Resident 82 stated he was wearing regular socks and not TED stockings and had not been using the compression device. Resident 82 confirmed he did not like what the compression device had effect to his body, that he did not like to wear it and no one had offered it to him. During a concurrent observation, interview, record review, on 4/10/25 at 2:03 p.m., with Licensed Nurse 4 (LN 4), LN 4 confirmed Resident 82 had on order to use TED stocking in the morning and remove in the evening and to offer to wear the compression device after meal time. Inside the room, LN 4 confirmed Resident 82 was wearing black-colored regular socks and the compression device was out of sight inside Resident 82's room cabinet. LN 4 confirmed she had not applied those devices as ordered. LN 4 stated she should not document in the treatment administration record (TAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) that she had applied those devices when she had not. During a concurrent interview and record review on 4/11/25 at 10 a.m., with the Director of Nursing (DON), Resident 82's medical record was reviewed and confirmed Resident 82 had an order for TED hose and compression device due to swelling. The DON stated her expectation was for the nurses to follow physician's order and document Resident 82's response to treatment. The DON stated nurses should document accurately when care and treatment were provided and/or not provided. A review of the facility's Policy and Procedure (P/P), titled, Physician's Order, revised 10/24, the P/P indicated, Prescribed medications and treatment orders will be carried out in accordance with the physicians/nurse practitioner's order.

Based on observation, interview and record review, the facility failed to provide sufficient hydration for four residents (Resident 13, Resident 298, Resident 299, Resident 300) of a census of 95, when staff did not deliver bedside water pitchers for two days. This failure had the potential to cause dehydration (a harmful reduction in the amount of water in the body) to the residents. Findings: A review of all four residents' care plans (Resident 13, Resident 298, Resident 299, Resident 300) indicated they were at risk for dehydration due to their medical conditions. A review of Resident 13's face sheet indicated she was admitted to the facility on [DATE] with diagnoses including urinary tract infection (an illness in the urinary system-kidneys, bladder, or urethra-typically caused by bacteria), type 2 diabetes mellitus (a disease in which the body's inability to produce or respond to the hormone insulin is impaired - symptoms include thirst and frequent urination) and high blood pressure. A review of Resident 13's Order Summary Report indicated her primary physician did not put her on fluid intake restrictions (medically prescribed regime limiting the amount of daily fluid consumption to assist in preventing fluid build-up in the body) when her diet was ordered on 3/10/25. Resident 13 also had a medication order for furosemide 20 milligram (mg-unit of measure), which is a diuretic (a medication that helps reduce fluid buildup in the body, prescribed for high blood pressure or heart problems. Side effects include dry mouth, increased thirst and frequent urination.) A review of Resident 13's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 3/17/25, indicated her BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 11 out of 15, indicating she had moderate cognitive impairment. During a concurrent observation and interview on 4/8/25 at 11:37 a.m., Resident 13 had no water pitcher on her bedside table or nightstand. There was a partially filled cup of water on her bedside table. Resident 13 stated she was unsure why the Certified Nursing Assistants (CNAs) were not giving her a daily water pitcher, but she would have liked one as she gets thirsty during the day. During an observation on 4/9/25 at 3:48 p.m. in Resident 13's room, no water pitcher was on the bedside table. Resident 13 told Licensed Nurse (LN) 2 she was very thirsty and asked for water. Resident 13's Fluid Intake sheet indicated that on 4/8/25, her fluid intake was 680 milliliters (ml-unit of volume measure), and on 4/9/25, her fluid intake was 330 ml. The average fluid intake for the rest of the month was 1070 ml per day. A review of Resident 298's face sheet indicated he was admitted to the facility on [DATE], with a diagnosis of type 2 diabetes mellitus. A review of Resident 298's Order Summary Report indicated that the facility physician did not order fluid restrictions on 3/31/25 when the physician prescribed the resident's diet. A review of Resident 298's Minimum Data Set, dated [DATE], showed that his BIMS score was 8 out of 15, indicating he had moderate cognitive impairment. During a concurrent observation and interview with Resident 298 on 4/8/25 at 11:22 a.m. in his room, no water pitcher was found at his bedside. Resident 298 stated the CNAs will bring a cup of water to him at mealtimes. During an observation 4/9/25 at 4:03 p.m., it was noted there was no pitcher of water on resident's bedside table. A review of Resident 299's face sheet indicated he was admitted to the facility on [DATE]. A review of Resident 299's Order Summary Report indicated his diet was prescribed on 4/3/25, without fluid intake restrictions. According to the Medical Records Administrator on 4/9/25, Resident 299's BIMS score was yet to be entered in his records since he had been recently admitted . The MDS and BIMS score was not available at the time of survey exit. During a concurrent observation and interview with Resident 299 on 4/8/25 at 11:28 a.m. in his room, his bedside table had no water pitcher. He denied being on fluid restrictions. During a subsequent observation on 4/9/25 at 4 p.m. in Resident 299's room, no pitcher of water was found on resident's bedside table. A review of Resident 300's face sheet indicated she was admitted to the facility on [DATE]. A review of Resident 300's Order Summary Report stated her physician ordered her diet on 4/2/25, with no fluid restrictions. A review of Resident 300's BIMS score on 4/5/25 (care plan) denoted she scored 9 out of 15, indicating she was moderately cognitively impaired. Her MDS report was not available at time of survey exit. During an observation of Resident 300 on 4/8/25 at 11:48 a.m. in her room, it was observed that the resident did not have a water pitcher at her bedside table. During an observation on 4/9/25 at 3:57 p.m. with Resident 300, no water pitcher was found on resident's bedside table. During an interview with Licensed Nurse (LN) 2 on 4/9/25 at 3:50 p.m., LN 2 stated that Resident 13 vomited earlier that day and needed to drink fluids. LN 2 confirmed that Resident 13's water pitcher was missing and would bring one to her. She stated all patients are supposed to have water pitchers on their bedside table. She added that even if a resident is on fluid restrictions, they are still given a pitcher with the restricted amount of water, so every resident should have a water pitcher at their bedside. During an interview with Certified Nursing Assistant (CNA) 1 on 4/9/25 at 3:55 p.m., CNA 1 stated the night shift is supposed to provide fresh water pitchers for the residents on their bedside tables. The CNA stated that if the day shift CNAs do not see pitchers on the bedside tables, they put a new pitcher on the bedside table. She had not noticed any missing pitchers that day. During an interview on 4/10/25 at 8:25 a.m. with LN 2, LN 2 stated that the outcome of patients not having a water pitcher by the bedside could have an adverse consequence like dehydration in a resident who is already medically compromised. During an interview with the Director of Nursing (DON) on 4/10/25 at 9:32 a.m., DON stated that limiting residents' fluid intake by not giving them water pitchers could result in not getting enough fluids, putting them at risk for dehydration. A review of facility document titled, Hydration, dated September 2024, indicated, The staff will monitor the individual's current hydration status .The staff will provide supportive measures such as supplemental fluids and adjusting environmental temperature, where indicated. A review of facility job description titled, Certified Nursing Assistant, undated, indicated, Keep residents' water pitchers clean and filled with fresh water (on each shift), and within easy reach of the resident .Record the resident's food/fluid intake.

3. During a concurrent observation and interview on [DATE] at 12:39 p.m. with Licensed Nurse (LN 5) in the hallway by medications cart #3, the medications cart was inspected, and one round, white unlabeled tablet was found at the bottom of one of the drawers that stored blister packs of medications. LN 5 disposed the medication in the medication disposal container and stated that medication carts should be free of loose or unlabeled medications. During a review of the facility's P&P titled, Storage of Medications, revised [DATE], the P&P indicated, Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. 2. During an observation on [DATE] at 12:05 p.m. at Nursing Station 1, one medication cart was observed unlocked and unattended by staff. During a concurrent observation and interview on [DATE] at 12:09 p.m. with LN 3, LN 3 observed and acknowledged the medication cart was unlocked and unattended at Nursing Station 1. LN 3 stated, .it's [the medication cart] supposed to be locked .it's a safety concern. During an interview on [DATE] at 11:15 a.m. with the DON, the DON acknowledged the medication carts should be locked when unattended. The DON stated, Yes, I expect the medication carts to be locked when unattended, that's a safety concern. During a review of the facility's Policy and Procedure (P&P) titled, Storage of Medications, revised [DATE], the P&P indicated, The facility stores all drugs and biologicals in a safe, secure and orderly manner .compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use .unlocked medication carts are not left unattended. Based on observation, interview, and record review, the facility failed to ensure that: 1. Discontinued medications were not available for resident use; 2. Medications were stored locked in medication cart; and, 3. Medications were stored in original packaging with pharmacy approved labels. These deficient practices had the potential for unsafe medication storage and administration for a census of 95. Findings: A review of Resident 29's Face Sheet indicated she was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia (not enough oxygen in the blood), and chronic obstructive pulmonary disease (a condition of lung damage which makes it hard to breathe). A review of Resident 29's Order Summary Report indicated she was prescribed Arformoterol Tartrate Inhalation Nebulization Solution 15 micrograms/2 milliliter (mcg/ml - units of measure) (a medication used for maintenance of air flow blockage in the lungs) on [DATE]. A review of Resident 29's Discharge summary, dated [DATE], indicated Resident's discharge date and time was [DATE] at 11 a.m. During a concurrent observation and interview on [DATE] at 12:28 p.m. with Licensed Nurse (LN) 1 in Medication room [ROOM NUMBER], the prescription drug Arformoterol Tartrate Inhalation Nebulization Solution 15 mcg/2 ml, was found in the medication refrigerator next to active medications. LN 1 stated Resident 29 was discharged from the facility days earlier, and the inhaler should have been removed from the medication refrigerator immediately upon the resident's discharge. He took the discontinued medication out of the refrigerator, placed it in a locked cabinet in the medication room for disposal. He stated discontinued medications should be locked there until they can be properly disposed of. During an interview on [DATE] at 9:32 a.m. with the Director of Nursing (DON), DON stated discontinued medications should not be located next to active, current medications. DON stressed that it is the responsibility of the nurse performing resident discharge to set aside remaining discontinued medications for disposal. She stated an inexperienced nurse could possibly give the discontinued medication to another patient if the nurse doesn't read the label accurately or misinterprets the resident's name. During an interview on [DATE] on 12:29 p.m. with DON, she stated that discharged residents' discontinued medications should be discarded the day of the patients' release. If not done the same day, it should be done immediately after - the next day. DON stated this medication should not have remained in the medication refrigerator six days after the resident went home. She and the Assistant Director of Nursing (ADON) stop by the units weekly to pick up expired or discontinued medicines for disposal. A review of facility policy titled, Storage of Medications, revised [DATE], indicated, Discontinued, outdated, or deteriorated drugs or biologicals are placed in designated appropriate bins for destruction.

Based on observation, interview, and record review, the facility failed to provide care and services for three (3) of 27 sampled residents (Resident 82, Resident 25 and Resident 67) according to accepted standards of clinical practice when: 1. Resident 82's order for Thrombo-Embolic Deterrent, (TED stockings, also known as anti-embolism stockings, to prevent blood clots and swelling in the legs, particularly after surgery) and lymphatic compression device (devices that work by inflating sleeves around the legs to mimic muscle contractions, helping blood flow back to the heart) were not applied as ordered; and, 2. Resident 25 and Resident 67's TED hose were not applied as ordered. This failure decreased the facility's ability to provide a clear and consistent picture of the residents's conditions, treatment responses, outcomes, and risk factors to improve residents' health and safety. Findings: 1. A review of Resident 82's admission Record (AR) indicated he was admitted in February 2025 with diagnoses which included endocarditis (serious infection and inflammation of the inner lining of the heart chambers and heart valves) and generalized muscle weakness. A review of Resident 82's Physician's Order (PO) dated 2/13/25, indicated, TED Hose: apply TED hose [every] [morning] and remove [every] [afternoon] every day and evening shift; and PO dated 2/28/25, indicated Offer Lymphatic Compression Device (used to help prevent blood clots in the deep veins of the legs) for [BLE, bilateral lower extremities] after meals every shift. A review of Resident 82's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 2/14/25 indicated he had mental capacity to make healthcare decisions. During a concurrent observation and interview on 4/10/25 at 2:03 p.m., inside Resident 82's room, he stated he was wearing regular socks not TED stockings and had not been using the compression device. Resident 82 confirmed he did not like what the compression device effect to his body, that he did not like to wear it and no one had offered it to him. During a concurrent observation, interview, record review, on 4/10/25 at 2:03 p.m., with Licensed Nurse 4 (LN 4), LN 4 confirmed Resident 82 had on order to use TED stocking in the morning and remove in the evening and to offer to wear the compression device after meal time. LN 4 confirmed Resident 82 was wearing black-colored regular socks and the compression device was out of sight and inside Resident 82's room cabinet. LN 4 confirmed she had not applied those devices as ordered. During a concurrent interview and record review on 4/11/25 at 10 a.m., with the Director of Nursing (DON), Resident 82's medical record was reviewed. The DON confirmed Resident 82 had an order for TED hose and compression device due to swelling. The DON stated her expectation was for the nurses to follow physician's order and document Resident 82's response to treatment. 2. A review of Resident 25's AR indicated Resident 25 was admitted to the facility in December 2024 with diagnoses which included congestive heart failure (fluid buildup in the body, especially the lower extremities) and muscle weakness. A review of Resident 25's Order Summary Report (OSR, physician orders) indicated an order for: a. Compression stocking during AM shift every day shift, for edema off at nighttime, with a start date of 3/31/25; and, b. Daily weights, with a start date of 12/11/24. During a concurrent observation and interview with Resident 25 on 4/8/25 at 9:56 a.m. in the resident's room, Resident 25 was laying in bed, wearing a facility gown. Resident 25 confirmed she was not wearing compression stockings. During a concurrent observation and interview on 4/10/25 at 10:34 a.m. with LN 6, in Resident 25's room, LN 6 confirmed Resident 25 was not wearing compression stockings. A review of Resident 25's weight summary from 12/6/24 to 4/11/25 indicated Resident 25 was not weighed daily as ordered. During a concurrent interview and record review on 4/11/25 at 9:59 a.m. with the Director of Staff Development (DSD), Resident 25's OSR and weight log was reviewed. The DSD acknowledged Resident 25 had an order for daily weights and confirmed daily weights for Resident 25 were not completed. A review of Resident 67's AR indicated Resident 67 was admitted to the facility in March 2025 with diagnoses which included muscle weakness and multiple sclerosis (autoimmune disorder where the immune system mistakenly attacks the body's own tissues). A review of Resident 67's OSR/Physician's Order (PO) indicated Resident 67 had an order for TED hose: apply in the morning and remove at bedtime, with a start date of 3/29/25. During a concurrent observation and interview on 4/9/25 at 10 a.m. with Resident 67 and the Physical Therapy Assistant (PTA), in Resident 67's room, Resident 67 was observed laying in bed, in her own gown, without TED hose on. Resident 67 stated she has never been fitted for TED hose while at the facility. The PTA acknowledged the license nurses supply the TED hose for the resident. The PTA checked through Resident 67's belongings and closet and confirmed there were no TED hose available. During an interview on 4/10/25 at 9:56 a.m. with the Nurse Practitioner (NP), the NP stated she expected nursing staff to follow resident orders as written. The NP stated, Orders are written for the safety of the resident, or for a specific diagnosis and treatment. During a concurrent observation, interview and record review on 4/10/25 at 1:57 p.m. with LN 6, in Resident 67's room, Resident 67's OSR was reviewed. LN 6 acknowledged Resident 67 had an order for TED hose and confirmed they were not applied. During a concurrent interview and record review on 4/11/25 at 10:18 a.m. with the DON, Resident 25 and Resident 67's OSR was reviewed. The DON stated she expected staff to follow physician orders as written for the residents at the facility. A review of the facility's P&P titled, Physician Orders, reviewed October 2024, the P&P indicated, Prescribed medication and treatment orders will be carried out in accordance with the physician/nurse practitioner order .the licensed staff shall carry out physician/nurse practitioners' orders as prescribed.

Based on observation, interview and record review the facility failed to provide one resident out of 27 sampled residents (Resident 79) with appropriate supervision and assistance during meals. This failure had the potential for Resident 79 to experience malnutrition and an increased risk of choking during meals. Findings: A review of Resident 79's admission Record indicated Resident 79 was admitted to the facility in December 2024 with diagnoses which included dysphagia (difficulty swallowing) and partial paralysis to the left side. A review of Resident 79's Order Summary Report (physician orders) indicated an order with a start date of 3/1/25 for 1:1 supervision for meals, cue resident to slow rate, pre-cut food into bite sized pieces with meals. During a concurrent observation and interview on 4/8/25 at 12:37 p.m. with Resident 79, in her room, Resident 79 was sitting up in bed, leaned over to the right side, unattended. Resident 79 acknowledged staff bring the meal trays, sit her up to eat and then leave. During a follow-up observation on 4/09/25 at 7:33 a.m. in Resident 79's room, Resident 79 was sitting up in bed with her eyes closed and her breakfast tray in front of her uncovered and unattended. A review of Resident 79's point of care electronic record indicated Resident 79 was to be provided with 1:1 supervision for meals. There was no data recorded for the last 30 days. A policy and procedure (P&P) which included the definitions of various levels of meal assistance was requested on 4/9/25 at 10:50 a.m. from the Administrator. A P&P was not provided. During an interview on 4/10/25 at 9:56 a.m. with the Nurse Practitioner (NP), the NP stated she expected nursing staff to follow resident orders as written. The NP stated, Orders are written for the safety of the resident, or for a specific diagnosis and treatment. A review of the facility's P&P titled, Assistance with Meals, revised October 2023, the P&P indicated, Residents will receive assistance with meals in a manner that meets the individual needs of each resident. A review of the facility's P&P titled, Physician Orders, reviewed October 2024, the P&P indicated, Prescribed medication and treatment orders will be carried out in accordance with the physician/nurse practitioner order .the licensed staff shall carry out physician/nurse practitioners' orders as prescribed.

Based on observation, interview, and record review the facility failed to develop and implement a Care Plan (CP, a detailed document outlining a person's healthcare needs, goals, and the specific care and support they will receive) for one out of 27 sampled residents (Resident 79). This failure had the potential for Resident 79 to not receive the highest practible level of care for her health and wellness. Findings: A review of Resident 79's admission Record indicated Resident 79 was admitted to the facility in December 2024 with diagnoses which included dysphagia (difficulty swallowing) and partial paralysis to the left side. During a concurrent observation and interview on 4/8/25 at 10:11 a.m. with Resident 79, in the resident's room, Resident 79 stated, It'd be great if I could get this G-tube [a surgically placed feeding tube inserted through the abdomen directly into the stomach] out. Resident 79 lifted her shirt to where the G-tube was observed. A review of Resident 79's Order Summary Report (OSR, physician orders) did not indicate Resident 79 had an order for a G-tube. A review of Resident 79's CP which included current and resolved items did not indicate Resident 79 had a care plan implemented or resolved for a G-tube. During a concurrent interview and record review on 4/9/25 at 1:10 p.m. with Licensed Nurse (LN) 3, Resident 79's OSR and CP was reviewed. LN 3 acknowledged Resident 79 had a G-tube in place, but did not have a current physician's order or a CP for one. During an interview on 4/10/25 at 9:56 a.m. with the Nurse Practitioner (NP), the NP acknowledged there should still be a current order for Resident 79's G-tube and a CP for the care and treatment of the device. During a concurrent interview and record review on 4/11/25 at 10:18 a.m. with the Director of Nursing (DON), Resident 79's OSR and CP was reviewed. The DON acknowledged there were no current orders for the placement, care and treatment of the G-tube and a CP had not been developed, revised or resolved for Resident 79's G-tube. The DON acknowledged the CP should include the resident's diagnoses, medications and medical devices. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive, reviewed October 2024, indicated, A comprehensive care plan that includes measurable objectives .to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive care plan will: describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to meet food storage and service practices that met professional standards for food service safety when: 1. There were opened food packages found with no opened date label; 2. There were foods found removed from their original packaging without labels; 3. There was food stored in unsealed packaging; and, 4. The sanitizer solution was below the effective range. These failures decreased the facility's potential to prevent food borne illness for 89 residents who ate facility prepared foods. Findings: 1. During a concurrent observation and interview on 4/16/24 at 8:20 a.m. with the Food and Nutrition Assistant (FNA) during the initial kitchen tour, in the walk in refrigerator a bottle of barbecue sauce found opened with no label indicating what date it had been opened. The FNA acknowledged the barbecue sauce did not have an opened date labeled. The FNA stated she expected opened packages of food items should be labeled with the date they were opened to determine when they should be thrown away based on storage guidelines. The FNA pointed to documents posted in kitchen titled Dry Goods Storage Guidelines. During a concurrent observation and interview on 4/16/24 at 8:56 a.m. with the Food and Nutrition Director (FND) during the initial kitchen tour, containers of: dried basil, Italian seasoning, and Hungarian paprika found opened without labels indicating the date each seasoning was opened. The FND acknowledged the seasonings were not labeled and he expected the seasonings to have a label to indicate the opened date. During a review of the facility's policy and procedure titled, Labeling and Dating Foods, revised 5/30/23, indicated, .all food items in the storeroom, refrigerator, and freezer need to be labeled and dated .Dry storage guidelines are to be used to determine the .opened on shelf and opened and refrigerated use by date . During a review of a facility document titled, Dry Goods Storage Guidelines, dated 2023, indicated, .BBQ [barbecue] sauce .opened, refrigerated .4 months .Spices, ground .opened on shelf .2 years .spices, whole .opened on shelf .3 years . 2. During a concurrent observation and interview on 4/16/24 at 8:20 a.m. with the FNA during the initial kitchen tour, three packs of frozen waffles, one bin of bulk white granular substance, and two bins of brown grain substance had been removed from their original packaging and were missing labels which indicated what the items were. The FNA acknowledged three packs of waffles had no labels, a bin of white granular substance was sugar and was missing a legible identification label, and two bins of brown grain substance were brown rice which were also missing identifying labels. The FNA stated foods removed from their original packaging should be labeled to indicate what the product was. A review of the facility's policy and procedure titled, Labeling and Dating Foods, revised 5/30/23, indicated, .all food items in the storeroom, refrigerator, and freezer need to be labeled and dated . A review of the U.S. Food and Drug administration's Food Code, dated 2022, indicated, .Preventing food and ingredient contamination .Food Storage Containers, Identified with Common Name of Food .working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT .shall be identified with the common name of the FOOD . 3. During a concurrent observation and interview on 4/16/24 at 8:20 a.m. with the FNA during the initial kitchen tour, opened boxes which had opened and unsecured packages of meatless meatballs, meatless breaded wings, and oatmeal cookie dough were found inside the freezer. The FNA acknowledged the boxes were opened and the plastic bags inside the box were not sealed. The FNA stated she expected the bags to be sealed to prevent cross contamination. In an interview on 4/16/24 at 8:56 a.m., the FND stated bags of food stored in boxes in the freezer need to be securely closed. The FND added if the bags were not securely closed, the food could become freezer burned and the food could be, ruined. A review of the facility's policy and procedure titled, Food Receiving and Storage, undated, indicated, .all foods stored in the refrigerator or freezer will be covered, labeled, and dated .Wrappers of frozen foods must stay intact until thawing . A review of U.S. Food and Drug administration's Food Code, dated 2022, indicated, .Preventing food and ingredient contamination .Packaged and Unpackaged Food - Separation, Packaging, and Segregation .FOOD shall be protected from cross contamination by .storing the food in packages, covered containers, or wrappings . 4. During a concurrent observation and interview on 4/16/24 at 8:56 a.m. with the FND during the initial kitchen tour, the FND stated the kitchen uses quaternary ammonium (chemical used to kill bacteria, viruses, and mold) sanitizer soaked towels for sanitizing surfaces throughout the kitchen. The FND pointed out the red buckets found at food preparation areas in the kitchen with towels fully submerged in the sanitizer solution. The FND stated kitchen staff is expected to change the sanitizer solution in the red buckets every two hours or as needed when the sanitizer solution becomes cloudy or is below the 200 to 400 parts per million (ppm, a unit of measure for concentration of solution) of sanitizer solution. At the three compartment sink, the FND retrieved a sanitizer solution test strip from a dispenser mounted to the wall, the FND dipped the test strip into the red bucket of sanitizer solution and compared the color of the test strip to the test strip packaging. The FND stated the test strip color indicated the sanitizer solution was at 100 ppm and added, we need to change it. The FND added when the solution is too low it is not effective at sanitizing. In an interview on 4/17/24 at 10:51 a.m., the FND stated kitchen staff including the cooks and dietary aides are responsible for changing the sanitizer solution every 2 hours or as needed. The FND denied there is a schedule or a timer to trigger when the sanitizer solution should be checked and changed. During a concurrent observation and interview on 4/17/24 at 10:56 a.m., the Dietary Aide 1(DA 1) tested the sanitizer solution in the red bucket at the three compartment sink. The DA 1 removed a test strip from the dispenser mounted on the wall, dipped the test strip in the red bucket of sanitizer solution and compared the color of the test strip to the test strip packaging. The DA 1 stated the test strip color indicate the sanitizer solution was between 100 and 200 ppm. The DA 1 looked at the sanitizer solution log on the wall and stated the sanitizer solution needed to be changed every two hours or as needed and the sanitizer solution should be at 400 ppm. An interview on 4/17/24 at 10:57 a.m., the FND confirmed the sanitizer solution should have been between 200 and 400 ppm and the solution needed to be changed. The FND added the DA was too nervous to recite the expected range of the sanitizer solution. During a concurrent observation and interview on 4/19/24 at 9:13 a.m. at the dishwashing area, the FNA retrieved a sanitizer solution test strip, dipped it in the red bucket sanitizer solution, removed the test strip and compared it to the test strip packaging, and stated the sanitizer solution reading was at 150 ppm. FNA stated the sanitizer solution needed to be changed as it should be between 200 and 400 ppm. During a review of the facility's policy and procedure titled, Quaternary Ammonium Log Policy, undated, indicated, The concentration of the ammonium in the quaternary sanitizer will be tested to ensure the effectiveness of the solution .the solution will be replaced when the reading is below 200 ppm [parts per million] .

Based on observation, interview and record review, the facility failed to follow infection control standards of practice when: 1. A shower chair with brown substance on its surface was observed stored in the hallway, and staff did not follow recommended minimum disinfectant contact time for sanitation of the chair; 2. Staff did not sanitize the exterior surface of the washing machine including the door handle after loading dirty laundry; 3. Staff did not perform hand hygiene prior to donning and after doffing personal protective equipment (PPE, example: gowns, gloves, mask) during medication administration; 4. Staff did not disinfect the vital signs (VS, example: blood pressure, pulse, etc.) machine in between resident use and after use; 5. Oxygen tubing (used for oxygen delivery) was not labeled with a date for Residents 6, 36, and 95; 6. Nebulizer (a device that changes medication from liquid to a mist for inhalation) equipment not labeled with a date or stored in anti-microbial bag for Resident 6; and, 7. Urinal (a container used to collect urine) was not labeled with resident identifiers for Resident 6 and 7. These failures decreased the facility's potential to prevent the spread of infection. Findings: 1. During an observation on 4/17/24 at 8:50 a.m. in facility's hallway near room [ROOM NUMBER], a shower chair with a few brown chunky splatters was observed stored against the wall directly next to an ice chest. There were no staff observed in or around the hallway and there were no residents in the shower room. During a concurrent observation and interview on 4/17/24 at 9:52 a.m. with Certified Nursing Assistant 4 (CNA 4) in the hallway near room [ROOM NUMBER], CNA 4 confirmed the presence of brown splattered substance on the shower chair and stated all equipment should be cleaned after use and prior to storage in the hallway. The CNA 4 took the shower chair back to the shower room and used water and a wash rag to remove the splattered brown substance from the surface of the chair. After the stains were removed, she wiped down the chair using a bleach-containing product and rinsed the rag with water for approximately 30 seconds. After rinsing the rag, she immediately used the rag to wipe the bleach-containing product off of the surface of the chair. The CNA 4 then pushed the shower chair back into the hallway for storage. The CNA 4 was asked how long the bleach-containing product was supposed to be on the surface in order for it to properly disinfect. The CNA 4 confirmed the bleach-containing product was supposed to be left on the surface for at least 3 minutes. The CNA 4 admitted she wiped it off with water before the required 3 minutes. In an interview on 4/19/24 at 12:21 p.m. the Director of Nursing (DON) stated equipment stored in the hallway should be clean, and staff should follow manufacturer's recommended treatment time for sanitation depending on the product used. Storing dirty equipment in the hallway and not following recommended treatment time increases the risk of cross-contamination. A review of facility's policy titled Cleaning and Disinfection of Resident-Care Items, Surfaces and Equipment, revised October 2021, indicated, Reusable items, including environmental surfaces will be cleaned and/or disinfected between residents and when surfaces are visibly soiled .Reusable resident care equipment will be cleaned and disinfected between residents according to manufacturer's instructions. 2. During a concurrent observation and interview on 4/17/24 commencing at 10:24 a.m. in the facility's laundry room with the laundry attendant (LA), the LA put on a gown and gloves to handle dirty laundry and loaded it into the washing machine. After completing the loading process, she closed the washer door, removed the gloves and gown, and washed her hands at the sink located in the room. The LA then placed her back against the door of the washer to speak with the surveyor and she touched the washer door handle with her elbow. The LA then moved to the clean side of the room to fold clean linens. The LA was not observed to sanitize the exterior surface of the washing machine including washer door handle. The LA stated she usually cleans the laundry room and the equipment at the end of her shift. In an interview on 4/17/24 at 10:48 a.m. the LA acknowledged she should have disinfected the outside surface of the washing machine after handling dirty laundry but she forgot to do it. The LA confirmed the exterior surface of the washing machine needed to be cleaned in-between loads. In an interview on 4/19/24 at 12:21 p.m. the DON stated her expectation was for staff to clean the outside surface of the washing machine after the dirty laundry has been loaded; not cleaning it would increase the risk of cross contamination. A review of the facility's policy titled Departmental (Environmental Services)- Laundry and Linen, revised January 2024, indicated, Separate soiled and clean linen at all times .Wash hands after handling soiled linen and before handling clean linen . Handle linen using standard precaution. 40214 3. During a medication administration observation on 4/17/24 at 8:52 a.m., near room [ROOM NUMBER], a posted sign on the wall indicated, .Enhanced Standard Precautions .EVERYONE MUST: Perform hand hygiene before entering the room . The Licensed Nurse (LN) 1 was observed to prepare Resident 5's antibiotic medication to be administered via a peripherally inserted central catheter (PICC, a long, thin invasive tube inserted through a vein in the arm and passed through to the larger veins in the heart), entered room [ROOM NUMBER], and donned PPE without performing hand hygiene. The LN 1 grabbed two paper towels from the wall dispenser, set them on a side table and set the intravenous (IV) medication and equipment on top of the paper towels, without disinfecting the side table. Without changing gloves and performing hand hygiene, LN 1 then proceeded to access Resident 5's PICC line and administer the antibiotic medication. During an observation on 4/17/24 at 9:06 a.m., the LN 1 was obtained Resident 16's Vital Signs (VS), doffed her gloves, and without performing hand hygiene donned a new pair of gloves and proceeded to administer Resident 16's medications. During an interview on 4/17/24 at 9:35 a.m., the LN 1 acknowledged she did not perform proper infection control practices during medication administration. 4. During an observation on 4/18/24 at 7:20 a.m., in the nursing station 1 hallway, the CNA 1 entered room [ROOM NUMBER] and obtained the residents' VS. Without performing hand hygiene and disinfecting the VS machine, the CNA 1 immediately entered room [ROOM NUMBER] and obtained Resident 30's VS. The CNA 1 exited room [ROOM NUMBER] and stored the VS machine in the hallway without performing hand hygiene and disinfecting the VS machine. During an interview on 4/18/24 at 7:23 a.m., Resident 30 stated, The CNA did not wipe down the [VS] machine before and after using it on me. During an interview on 4/18/24 at 7:23 a.m., the CNA 1 said she obtained VS from rooms [ROOM NUMBER] A. The CNA 1 confirmed she had not performed hand washing/hand hygiene and had not disinfect the VS machine in-between and after resident use. The CNA 1 stated she was supposed to wash her hands and wipe down the machine in-between resident use to minimize cross contamination. During an interview on 4/18/24 at 7:34 a.m., the LN 3 said staff were expected to disinfect the VS machine before using it, after using it, and in between resident use. The LN 3 further said staff were expected to practice hand hygiene before and after resident care. During an interview on 4/18/24 at 7:42 a.m., with the Infection Preventionist (IP), the IP said the expectation for staff who provide care for residents with a PICC line and enhanced standard precautions (such as residents with indwelling catheter, wound, or IV) need to perform hand hygiene prior to donning PPE and after doffing PPE. The IP further said staff should perform hand hygiene and sanitize the VS equipment before using it, in-between resident use, and after using it. The IP considered it an infection control issue. During an interview on 4/19/24 at 2:36 p.m., with the DON stated staff were expected to perform hand hygiene prior to entering the resident room and right before leaving the room. The DON also expected staff to perform hand hygiene prior to donning and after doffing PPE. During a review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, revised October 2023, indicated, Hand hygiene is performed to prevent the spread of .infections .Personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors .Hand hygiene is indicated .prior to care .before .handling an invasive medical device .after care .after touching the resident's environment .Use an alcohol-based hand rub .was hands with soap and water . During a review of an undated facility's policy and procedure titled, CONTINUOUS ADMINISTRATION OF SOLUTION VIA CENTRAL VENOUS CATHETER, indicated, .To provide guidelines for the safe administration of prescribed solution intravenously through a central line catheter .Wash hands . During a review of the facility's policy and procedure titled, Cleaning and Disinfecting of Resident-Care Items, Surfaces and Equipment, revised October 2021, indicated, Resident-care equipment, including reusable items and durable medical equipment .including environmental surfaces will be cleaned and/or disinfected between residents and .before reuse by another resident . 47563 5. In an observation on 4/16/24 at 10:10 a.m., in Resident 36's room, Resident 36 wore an oxygen (O2) nasal cannula (NC, a device to deliver oxygen through the nose) with a label attached to the O2 tubing with illegible writing. During a concurrent observation and interview on 4/16/24 at 10:19, in Resident 36's room, the LN 9 inspected Resident 36's O2 tubing and label and confirmed the label was illegible. The LN 9 added resident equipment should be labeled with a date to know how long it has been used. In an observation on 4/16/24 at 10:32 a.m. in Resident 6's room, Resident 6 was wearing an O2 NC without a label attached to indicate the date it was placed. During a concurrent observation and interview on 4/16/24 at 10:35 a.m., in Resident 6's room, the LN 9 inspected Resident 6's O2 tubing and confirmed it was not labeled with the date it was placed. The LN 9 stated the tubing should be labeled with a date. In an observation and interview on 4/16/24 at 10:44 a.m., in Resident 95's room, Resident 95 was wearing an O2 NC without a label to indicate the date it was placed. During a concurrent observation and interview on 4/16/24 at 10:50 a.m., in Resident 95's room, the LN 9 inspected Resident 95's O2 tubing and confirmed it was not labeled with the date it was placed. The LN 9 stated the tubing should be labeled with a date. In an interview on 4/19/24 at 7:48 a.m., the Director of Staff Development (DSD) stated she expected O2 tubing to be replaced weekly and to be labeled with the date the tubing had been replaced for infection control purposes. In an interview on 4/19/24 at 9:18 a.m., the LN 10 stated O2 tubing should be changed weekly and should have a sticker indicating what date the tubing had been changed for infection control purposes. In an interview on 4/19/24 at 12:21 p.m., the DON stated she expected O2 tubing should be changed weekly and labeled with the date it was changed. The DON stated undated O2 tubing could potentially cause the tubing to not be changed timely which could lead to a buildup of microorganisms (tiny living things such as bacterium, fungus, virus, and molds). A review of the facility's policy and procedure title, Oxygen administration, revised October 2023, indicated, .the oxygen tubing is changed at least weekly, labeled with the date it was changed, and stored in and Anti-microbial [kill or slow the spread of microorganisms] bag which is changed at least every 30 days . 6. In an observation on 4/16/24 at 10:32 a.m. in Resident 6's room, Resident 6's nebulizer mask was sitting on a stack of newspapers on top of the resident's nightstand and the nebulizer tubing did not have a label indicating the date it was placed. During a concurrent observation and interview on 4/16/24 at 10:35 a.m., in Resident 6's room, the LN 9 inspected Resident 6's nebulizer mask and tubing and confirmed the nebulizer tubing had no date indicated. The LN 9 stated the tubing should be labeled with a date. The LN 9 stated the nebulizer mask should also be stored in a bag to protect it. In an interview on 4/19/24 at 7:48 a.m., the DSD stated she expected the nebulizer tubing to be replaced weekly and to be labeled with a date the tubing had been replaced for infection control purposes. The DSD added the mask and tubing was expected to be placed in an anti-microbial bag when not in use for infection prevention purposes. In an interview on 4/19/24 at 9:18 a.m., the LN 10 stated nebulizer tubing should be changed weekly and should have a sticker indicating what date the tubing had been changed for infection control purposes. The LN 10 added nebulizer masks should be stored in an anti-microbial bag for infection control purposes. In an interview on 4/19/24 at 12:21 p.m., the DON stated she expected nebulizer tubing to be changed weekly and labeled with the date it was placed. The DON stated nebulizer tubing not labeled with a date could potentially cause the tubing to not be changed timely which could lead to buildup of microorganisms. The DON stated she expected nebulizer masks to be placed in a bacteriostatic (stops bacteria from growing) bag when not in use. 7. In an observation on 4/16/24 at 10:32 a.m. in room [ROOM NUMBER], there were two beds in the room. Resident 7's bed, Bed A (the bed closest to the door), had two urinals hanging off the side of the bed. Neither of the urinals was labeled to identify which resident the urinals belonged to. Resident 6's bed, Bed B (the bed closest to the window), had one urinal hanging off the side of the bed which was not labeled to identify which resident the urinal belonged to. During a concurrent observation and interview on 4/16/24 at 10:35 a.m., in Resident 6's room, the LN 9 inspected the urinals and confirmed the urinals did not have labels to indicate who they belonged to. The LN 9 added the urinals should be labeled with the room number and which bed to identify which urinal belongs to which resident. In an interview on 4/19/24 at 7:48 a.m., the DSD stated when two residents in the room use urinals, she expected staff to label the urinals with the resident's name to identify who the urinal belongs to. In an interview on 4/19/24 at 8:08 a.m., the Restorative Nurse Assistant Supervisor (RNAS) stated when there are multiple residents in a room using urinals, she expected the urinals to be labeled with the name of the resident it belongs to. The RNAS added urinals are labeled for infection control, [staff] wouldn't want A bed to use B bed's urinal .it could spread infections. In an interview on 4/19/24 at 12:21 p.m., the DON stated when residents share a room the urinals should be labeled with the resident's name on it. The DON added if the urinals are not labeled, it could cause the other resident to use the wrong urinal which would be a concern for cross-contamination. A review of the facility's policy and procedure titled, Urinal Assistance, revised April 2024, indicated, .ensure the urinal being used belongs to the resident .

Based on observation, interview and record review the facility failed to revise a care plan for one resident (Resident 310) out of 24 sampled residents when Resident 310's care plan was not updated to reflect the placement of an elopement management bracelet (a bracelet that triggers alarms on doors to prevent the resident leaving unattended). This failure decreased the facility's potential to provide consistent nursing interventions for residents. Findings: A review of Resident 310's admission record indicated admission to the facility on [DATE], with diagnoses which included left hip fracture, dysphagia (difficulty swallowing), and dementia without behavioral disturbance (memory loss and difficulty with communication, reasoning, and problem solving). During a concurrent observation and attempted interview on 4/16/24 at 11:08 a.m. in Resident 310's room, Resident 310 was observed laying in her bed wearing a facility gown, watching television. When questioned about her stay at the facility Resident 310 responded with mumbled incoherent speech. During an observation on 4/17/24 at 8:19 a.m. in Resident 310's room, Resident 310 was observed laying in bed wearing a facility gown. At 11:43 a.m. Resident 310 was observed laying in bed under the covers. During an observation on 4/18/24 at 9:37 a.m. in Resident 310's room, Resident 310 had a elopement management bracelet on the left ankle. During a concurrent observation and interview on 4/18/24 at 9:53 a.m. with Certified Nursing Assistant 5 (CNA 5) in Resident 310's room, CNA 5 stated, That's news to me, when asked what the bracelet on Resident 310's ankle was for. During a concurrent interview and record review on 4/18/24 at 11:44 a.m. with the Assistant Director of Nursing (ADON), Resident 310's care plan dated 4/4/24 - 4/18/24 was reviewed. The ADON confirmed Resident 310's care plan was not updated to reflect the use of the elopement management bracelet. The ADON stated, It [care plan] should have been updated yesterday. During a concurrent interview and record review on 4/19/24 at 9:23 a.m. with the Director of Nursing (DON), Resident 310's care plan dated 4/4/24 - 4/18/24 was reviewed. The DON confirmed Resident 310's Care Plan was not updated to reflect the use of the elopement management bracelet. The DON stated, Care plans need to be updated as soon as possible, if there's a change or update to the treatment plan. During a review of the facility's policy and procedure titled, Care Plan Revision, revised April 2023, indicated, Care plans shall be reviewed/revised to incorporate goals and objectives to meet resident's individual needs.

Based on observation, interview, and record review the facility failed to develop and implement an accurate baseline care plan for three residents (Resident 297, Resident 301 and Resident 307) out of 24 sampled residents when: 1. Resident 297's and Resident 301's did not have a care plan for their urinary catheter; and, 2. Resident 307 did not have a care plan for his urinary catheter, peripherally inserted central catheter (PICC, a long, thin tube inserted through a vein in the upper arm and passed through to the larger veins near the heart, used for long term fluids or treatments), abdominal binder (a wide compression belt that encircles the abdomen) and thrombo-embolic deterrent hose (TED hose, stockings used to help prevent blood clots and swelling in the legs). These failures decreased the facility's potential to implement effective, person-centered care for residents. Findings: 1. A review of Resident 297's admission record indicated admission to the facility on [DATE], with diagnoses which included fracture of the left hip, fracture of the left ankle and muscle weakness. During a concurrent observation and interview on 4/16/24 at 9:50 a.m. in Resident 297's room, Resident 297 was sitting up in bed and a urinary catheter was observed hanging from the side of the bed. Resident 297 was aware she had the urinary catheter in place but was not sure how long she would need it. A review of Resident 297's Order Summary Report (OSR, physician orders) dated 4/14/24 indicated Resident 297 had a urinary catheter in place due to urinary retention. During a review of Resident 297's care plan, initiated on 4/14/24, there was no documented evidence the resident had a care plan for a urinary catheter. A review of Resident 301's admission record indicated she was readmitted to the facility on [DATE] with diagnoses which included muscle weakness, fracture of the left lower arm and chronic respiratory failure. A review of Resident 301's OSR, dated 1/25/24, indicated Resident 301 had a urinary catheter. During a review of Resident 301's care plan initiated on 1/25/24 there was no documented evidence the resident had a care plan for a urinary catheter. 2. A review of Resident 307's admission record indicated admission to the facility on [DATE], with diagnoses which included lymphoma (cancer that begins in cells of the lymph system), benign prostatic hyperplasia (enlarged prostate gland) and muscle weakness. During a concurrent observation and interview on 4/16/24 at 12:30 p.m. in Resident 307's room, Resident 307 was sitting in the wheelchair next to his bed after having physical and occupational therapy sessions. A urinary catheter bag was observed hanging off the side of the bed and a PICC line was observed in Resident 307's upper right arm. When asked if he had an abdominal binder and TED hose for use when he was out of bed, Resident 307 stated the abdominal binder was on the shelf in his closet; however, he did not know what or why he would wear the TED hose. Resident 307 confirmed he was not wearing an abdominal binder or TED hose nor had staff offered them to him. A review of Resident 307's OSR indicated the following orders: - an indwelling urinary catheter with a start date of 4/8/24; - for staff to change the PICC dressing on the right arm with a start date of 4/9/24; and, - for the use of TED hose and an abdominal binder when out of bed during every shift for orthostatic hypotension (low blood pressure which occurs when changing position from sitting or lying down to standing up) with a start date of 4/11/24. A review of Resident 307's Care Plan, initiated 4/8/24, indicated there was no documented evidence the resident had a care plan for a urinary catheter, PICC, abdominal binder or TED hose. During a concurrent interview and record review on 4/19/24 at 9:23 a.m. with Director of Nursing (DON), Resident 297's, Resident 301's, and Resident 307's care plans were reviewed. The DON confirmed the missing care plans for Resident 297, Resident 301 and Resident 307. The DON stated, The baseline care plan needs to include the resident's primary diagnoses and seven basic topics; including the resident's bowel and bladder status and skin conditions or concerns. These care plans need to be completed within the first 24-48 hours of a resident's admission. A request for the facility's policy and procedure (P&P) regarding Baseline Care Plans was requested on 4/18/24 and 4/19/24. The facility was unable to provide a P&P for Baseline Care Plans.

Based on observation, interview, and record review, the facility failed to ensure accurate assessments for two residents (Resident 15 and Resident 301) of 24 sampled residents when: 1. Resident 15's Minimum Data Sheet (MDS, an assessment tool) indicated one side lower extremity impairment; and, 2. Resident 301's MDS indicated intermittent catheterization (a catheter used drain urine from the bladder on a temporary basis). These failures resulted in inaccurate assessments that did not reflect the residents' status and care needs. Findings: 1. A review of an admission record indicated Resident 15 was admitted to the facility in late 2022 with multiple diagnoses including hemiplegia and hemiparesis (body paralysis and weakness) after stroke and general muscle weakness. During an observation during the initial tour and concurrent interview on 4/16/24 at 9:50 a.m., in Resident 15's room, Resident 15 was in bed lying facing the right side of the room with both knees contracted. Resident 15's left knee was bent and positioned over his bent right knee. Resident 15 reported a pain intensity level of 8 out of 10 and confirmed both his legs were contracted. During a concurrent observation and interview on 4/16/24 at 9:55 a.m., in Resident 15's room, the Certified Nursing Assistant 3 (CNA 3) was repositioning Resident 15 to face the left side of the room. Resident 15's face grimaced and he verbalized pain during the repositioning. The CNA 3 confirmed both Resident 15's knees were contracted. During an interview on 4/16/24 at 10:08 a.m., with Licensed Nurse 4 (LN 4), the LN 4 confirmed both Resident 15's knees were contracted. During a concurrent interview and record review on 4/18/24 at 11:42 a.m., with the MDS Coordinator (MDSC), Resident 15's MDS dated [DATE] was reviewed. The MDS indicated, .Lower extremity (hip, knee, ankle, foot) - impairment on one side . The MDSC confirmed the MDS assessment was inaccurate and should have indicated impairment on both sides. The MDSC further stated an inaccurate assessment could affect the resident's plan of care. 48140 2. A review of Resident 301's admission record indicated Resident 301 was admitted to the facility in January 2024, with diagnoses which included muscle weakness, fracture of the left lower arm and chronic respiratory failure. During a review of Resident 301's MDS dated [DATE] and 2/3/24, the bladder and bowel section indicated Resident 301 was receiving intermittent catheterization. A review of Resident 301's Order Summary Report (OSR, physician orders) indicated there was no order for intermittent catheterization. During a concurrent interview and record review on 4/18/24 at 1 p.m. with the MDSC and LN 5, Resident 301's MDS and OSR were reviewed. The MDSC and LN 5 confirmed the MDS was inaccurate and there were no orders for intermittent catheterization for Resident 301. The LN 5 stated, There needs to be an accurate assessment to be able to provide the proper care for the resident. The MDSC additionally stated, That's incorrect coding on the MDS. During an interview on 4/19/24 at 2:36 p.m. with the Director of Nursing (DON), the DON stated the expectation was resident assessments should be accurate. During a review of the facility's policy and procedure titled, Resident Assessments, revised October 2023, indicated, A comprehensive assessment of each resident is completed .the resident assessment coordinator is responsible for ensuring .appropriate resident assessments .attesting to the accuracy of such information .

Based on interview, clinical record review, and facility policy review, the facility failed to notify or consult the Director of Nurses (DON) or a primary care provider for 1 of 4 sampled residents (Resident 1) of a change of condition when a resident's left foot was noted to have a purple discoloration. This failure led to a full day delay in the provision of physician services, a delay in treatment, and to the subsequent amputation of Resident 1's left lower leg. Findings: Review of Resident 1's clinical record revealed the following: A Resident Face Sheet, indicated Resident 1 was a [AGE] year old female admitted to the facility in July of 2022 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Resident Progress Notes: [Resident 1], dated 7/4/22 at 10:56 p.m., indicated the Resident's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS - an assessment tool), dated 7/7/22, indicated the resident had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Resident Progress Notes: [Resident 1], dated 7/15/22 at 11:17 a.m., indicated Resident 1's condition was evaluated and found to be stable. The note further indicated, Nursing staff to monitor patient's physical, cognitive, and functional status and notify NP/MD [Nurse Practitioner/Doctor of Medicine] of any changes or concerns. A Resident Progress Notes: [Resident 1], dated 7/19/22 at 9:08 a.m., indicated Resident 1 was noted with mild purple discoloration to left foot. Patient wearing brace to left foot, writer checked fit of brace to make sure it was not cutting off any circulation. Pulse felt and foot blanching [a test done to check circulation], pt [patient] does not c/o [complain of] pain to foot. Pt refused to straighten leg out, she kept her legs crossed and pulled into body .Will continue to monitor. A Resident Progress Notes: [Resident 1], dated 7/20/22 at 9:17 a.m., indicated Upon inspection Pts [Patient's] left foot found to be dark purple in color and Pt [Patient] reported it feeling cold. Wound nurse notified. A Resident Progress Notes: [Resident 1], dated 7/20/22 at 10:00 a.m., indicated Upon wound care this AM patient is noted with sever [sic] color change to left foot. Foot is noted with no palp pulse, cold to touch and non-blanching .NP [Nurse Practitioner] notified of change in condition of left foot and per NP okay to send to acute [hospital] for further evaluation. A concurrent interview and record review was conducted with Licensed Nurse (LN) 1 on 8/3/22 at 3:45 p.m. Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] ***Treatment Nurse*** Multiple diabetic ulcers to left foot - Paint with [MEDICATION(S)], leave open to air, on date 7/18/22, meant the treatment was not done. LN 1 confirmed all of the wound care ordered for 7/18/22 was not completed as indicated by the parentheses present in the record. LN 1 further stated nurses were expected to complete wound care even if the treatment nurse was not there that day. An interview was conducted with LN 2 on 8/3/22 at 3:58 p.m. LN 2 stated he noticed Resident 1's foot was purple one morning because her feet were uncovered when he went into the room to check on her. An interview was conducted with Treatment Nurse (TN) 1 on 8/5/22 at 2:25 p.m. TN 1 acknowledged Resident 1 was admitted after surgery to place stents in the legs and indicated she would check for CSM [circulation, sensation, motion - a nursing assessment used to determine blood flow to the extremities], when providing wound care in all residents with vascular issues. In the same interview on 8/5/22 at 2:25 pm, TN 1 confirmed wound care had not been completed on 7/18/22, and during wound care the morning of 7/19/22, she noticed Resident 1's left foot had changed in color. TN 1 further indicated Resident 1 did not allow her to complete her assessment by pulling her legs away, and the resident ' s nurse was notified and instructed to keep the legs elevated. TN 1 indicated the plan was to come back the next day and re-evaluate the foot. In the same interview on 8/5/22 at 2:25 p.m., TN 1 indicated upon arrival to the facility the next day, on 7/20/22, Resident 1's nurse immediately informed her how bad the resident's foot appeared. TN 1 indicated the left foot appeared dark and cold. An interview was conducted with LN 3 on 8/19/22 at 2:49 p.m. LN 3 confirmed she took care of Resident 1 on the evening shift of 7/19/22 and stated she did check Resident 1's leg circulation because she read the resident's history and physical but nothing stood out. LN 3 stated she had only had the resident for one or two days, so could not be sure if the resident ' s foot looked different from before. LN 3 indicated she did not document the circulation assessment, and no one had communicated to her the resident required increased monitoring because there had been a color change in the resident's foot earlier that day. An interview was conducted with LN 4 on 8/24/22 at 9:34 a.m. LN 4 indicated she took care of Resident 1 three to four times, during the resident ' s facility stay. LN 4 stated the resident was at the facility for diabetic wound care to the feet, and could not recall if the resident had surgery prior to facility admission. Further, LN 4 indicated she had not received any reports or information from other nurses regarding a color change to Resident 1's foot on the morning of 7/19/22 or if the resident required additional monitoring. An interview was conducted with Nurse Practitioner (NP) 1 on 8/24/22 at 12:15 p.m. NP 1 stated she recalled seeing Resident 1 on 7/15/22 and the resident had been admitted to the facility for, multiple vascular issues and diabetic foot wounds. NP 1 indicated continuous assessment of the resident's vascular system would be important, but care of the resident was difficult due to resident noncompliance. NP 1 further indicated vascular conditions can change pretty rapidly, and would expect staff to monitor a resident if a color change to the foot was noticed. NP 1 stated she was not aware of or notified of Resident 1's change in color to the left foot on 7/19/22, the day prior to transfer to the general acute care hospital. During an interview the Director of Nurses (DON) on 8/25/2022 at 12:28 p.m., the DON confirmed Resident 1 was admitted to the facility following a procedure to the vascular system. The DON indicated if an initial change was assessed, the expectation would be for nurses to increase monitoring for additional changes and notify the provider and other nurses taking over resident care. A voicemail left by the Administrator on 8/25/22 at 5:03 p.m., indicated the outcome sustained to Resident 1 is something no one would want, and there was evidence from the acute chart prior to facility admission amputation was anticipated due to the progression of the resident's PVD. An interview with the Facility Administrator, the DON, and TN 1 was conducted on 8/26/22 at 3:50 p.m. TN 1 stated the morning of 7/19/22, the resident was in the fetal position and the left foot was noted to be darker in color. TN 1 indicated the color change to the left foot went away temporarily when the resident's legs were extended, and then the discoloration came back because the resident was noncompliant with positioning - she repeatedly flexed her legs. TN 1 further stated, prior to 7/19/22, Resident 1 had no previous discoloration to the feet noted with position changes, and therefore, the change in color was not resolved that day. Review of Resident 1's general acute care hospital records revealed an Hospitalist H&P [history & physical], dated 7/20/22. The note indicated Resident 1 was brought to the hospital for concerns of having difficulty moving her toes and foot being discolored. The note further indicated Resident 1 was evaluated by a vascular surgeon emergently in the emergency department .for evaluation of left lower extremity ischemia [an inadequate blood supply to an organ or part of the body]. The note further indicated, Recommend plans for amputation after area demarcates [a term used to describe the line where skin color changes]. Review of Resident 1's general acute care hospital records revealed a Vascular Surgery Consult, dated 7/20/22. The note revealed a physical exam of the Left Leg: Diffuse [spread out] purple and gray mottling [patchy or blotchy skin indicating decreased blood flow] through foot, ankle, lower leg. No sensation below proximal [closer to the center of the body] thigh, no flexion or extension of knee, ankle, toes. The note indicated, Revascularization is futile at this point, would provide no benefit ., and Patient should be prepared instead for amputation after demarcation. The note further indicated, Her limb appears grossly ischemic which appears to have been present for days, not hour [sic]. The facility policy titled Change in a Resident's Condition or Status, revised April 2011, indicated, 1. The Nurse Supervisor/Charge Nurse will notify the resident ' s Attending Physician or On-Call Physician when there has been: .d. A significant change in the resident's physical/emotional/mental condition; .i. Instructions to notify the physician of changes in the resident's condition. The policy further indicated, 2. A 'significant change' of condition is a decline or improvement in the resident ' s status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not ' self-limiting ' ). A review of the document titled Facility Assessment Tool, dated 3/5/22, indicated; Part 1: Our Resident Profile .Diseases/conditions, physical and cognitive disabilities .Category .Heart/Circulatory system .Common diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment tool further indicated, Part 2: Service and Care We Offer Based on our Resident ' s Needs .General Care .Management of medical conditions .Assessment, early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions .

Based on interview, clinical record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 4 sampled residents (Resident 1) based on admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure led to a delay in the provision of physician services, a one full day delay in treatment, and subsequent amputation of Resident 1's left lower leg. Findings: Review of Resident 1's clinical record revealed the following: A Resident Face Sheet, indicated Resident 1 was a [AGE] year old female admitted to the facility in July of 2022 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Resident Progress Notes: [Resident 1], dated 7/4/22 at 10:56 p.m., indicated the Resident's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated 7/7/22, indicated the resident had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Resident Progress Notes: [Resident 1], dated 7/19/22 at 9:08 a.m., indicated Resident 1 was noted with mild purple discoloration to left foot. Patient wearing brace to left foot, writer checked fit of brace to make sure it was not cutting off any circulation. Pulse felt and foot blanching [a test done to check circulation], pt [patient] does not c/o [complain of] pain to foot. Pt refused to straighten leg out, she kept her legs crossed and pulled into body .Will continue to monitor. A Resident Progress Notes: [Resident 1], dated 7/20/22 at 9:17 a.m., indicated Upon inspection Pts [Patient's] left foot found to be dark purple in color and Pt [Patient] reported it feeling cold. Wound nurse notified. A Resident Progress Notes: [Resident 1], dated 7/20/22 at 10:00 a.m., indicated Upon wound care this AM patient is noted with sever [sic] color change to left foot. Foot is noted with no palp pulse, cold to touch and non-blanching .NP [Nurse Practitioner] notified of change in condition of left foot and per NP okay to send to acute [hospital] for further evaluation. An interview was conducted with Licensed Nurse (LN) 2 on 8/3/22 at 3:58 p.m. LN 2 stated he noticed Resident 1's foot was purple one morning because her feet were uncovered when he went into the room to check on her. An interview was conducted with Treatment Nurse (TN) 1 on 8/5/22 at 2:25 p.m. TN 1 indicated she would check for CSM [circulation, sensation, motion - a nursing assessment used to determine blood flow to the extremities], when providing wound care in all residents with vascular issues, but there were no orders or care plan interventions in Resident 1's record to address the need to check circulation. In the same interview on 8/5/22, TN 1 stated on the morning of 7/19/22, she noticed Resident 1's left foot had changed in color. TN 1 further indicated she attempted to change the position of the resident's legs and the color seemed to improve, but Resident 1 did not allow her to complete her assessment. TN 1 stated the resident's nurse was notified of the color change and instructed to keep the legs elevated. TN 1 acknowledged the resident's frequent noncompliance with elevating the legs, and indicated the plan was to come back the next day and re-evaluate the resident's left foot. In the same interview on 8/5/22 at 2:25 p.m., TN 1 indicated upon arrival to the facility the next day, on 7/20/22, Resident 1's nurse immediately informed her how bad the resident's foot appeared. TN 1 indicated the left foot appeared dark and cold. An interview was conducted with LN 3 on 8/19/22 at 2:49 p.m. LN 3 confirmed she took care of Resident 1 on the evening shift of 7/19/22 and stated she did check Resident 1's leg circulation because she read the resident's history and physical but nothing stood out. LN 3 stated she had only had the resident for one or two days, so could not be sure if the resident's foot looked different from before. LN 3 indicated she did not document the circulation assessment, and no one had communicated to her the resident required increased monitoring because there had been a color change in the resident's foot earlier that day. An interview was conducted with LN 4 on 8/24/22 at 9:34 a.m. LN 4 indicated she took care of Resident 1 three to four times, during the resident's facility stay. LN 4 stated the resident was at the facility for diabetic wound care to the feet, and could not recall if the resident had surgery prior to facility admission. Further, LN 4 indicated she had not received any reports or information from other nurses regarding a color change to Resident 1's foot on the morning of 7/19/22 or if the resident required additional monitoring. An interview was conducted with Nurse Practitioner (NP) 1 on 8/24/22 at 12:15 p.m. NP 1 stated she recalled seeing Resident 1 on 7/15/22 and the resident had been admitted to the facility for, multiple vascular issues and diabetic foot wounds. NP 1 indicated continuous assessment of the resident's vascular system would be important, that vascular conditions can change pretty rapidly, and would expect staff to monitor a resident if a color change to the foot was noticed. A voicemail left by the Administrator on 8/25/22 at 5:03 p.m., indicated the outcome sustained to Resident 1 is something no one would want, and there was evidence from the acute chart, prior to facility admission, that an amputation was anticipated due to the progression of the resident's PVD. An interview with the Facility Administrator, the Director of Nurses (DON), and TN 1 was conducted on 8/26/22 at 3:50 p.m. The Administrator and DON indicated the resident's record was reviewed and did not contain a care plan specific to the resident's impaired circulation or the need for continued assessments of circulation. Review of Resident 1's general acute care hospital records revealed an Hospitalist H&P [history & physical], dated 7/20/22. The note indicated Resident 1 was brought to the hospital for concerns of having difficulty moving her toes and foot being discolored. The note further indicated Resident 1 was evaluated by a vascular surgeon emergently in the emergency department .for evaluation of left lower extremity ischemia [an inadequate blood supply to an organ or part of the body]. The note further indicated, Recommend plans for amputation after area demarcates [a term used to describe the line where skin color changes]. Review of Resident 1's general acute care hospital records revealed a Vascular Surgery Consult, dated 7/20/22. The note revealed a physical exam of the Left Leg: Diffuse [spread out] purple and gray mottling [patchy or blotchy skin indicating decreased blood flow] through foot, ankle, lower leg. No sensation below proximal [closer to the center of the body] thigh, no flexion or extension of knee, ankle, toes. The note indicated, Revascularization (restoring blood flow in blocked blood vessels) is futile at this point, would provide no benefit ., and Patient should be prepared instead for amputation after demarcation. The note further indicated, Her limb appears grossly ischemic which appears to have been present for days, not hour [sic]. A review of the facility policy titled, Care Plans - Comprehensive, Revised October 2010, indicated The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. The policy further indicated, Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; i. Reflect currently recognized standards of practice for problem areas and conditions. A review of the document titled Facility Assessment Tool, dated 3/5/22, indicated; Part 1: Our Resident Profile .Diseases/conditions, physical and cognitive disabilities .Category .Heart/Circulatory system .Common diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment tool further indicated, Part 2: Service and Care We Offer Based on our Resident's Needs .General Care .Management of medical conditions .Assessment, early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions .

Based on observations, interviews, and record review the facility failed to protect one of seven sampled Residents (Resident 1) from abuse when: 1. Resident 1 developed a bruise to the right side of chin after an incident described as a squeeze to the face by Certified Nurse Assistant (CNA) 1. 2. Resident 1 verbalized concerns related to fear and safety. This failure caused Resident 1 to experience emotional and physical harm. Findings: Review of a facility's document titled Resident Face Sheet: (Resident name) indicated Resident 1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. and [MEDICAL CONDITION] disease (a disease that alters the blood supply to the brain). Resident 1's Brief Interview for Mental Status (BIMS, resident cognitive impairment) was scored as 4 (indicate severe cognitive impairment). According to the facility report titled 5 Day Follow- Up dated 4/18/19, on the night of 4/17/19, at approximately 3 a.m., Resident 1 informed staff she was afraid and asked staff to not allow CNA 1 to continue as her care provider. During an observation and interview with Resident 1 on 4/18/19 at 9:59 a.m., Resident 1 expressed someone touched her face, he's long gone .Resident 1 verbalized , .don't' want him anymore . A deep purple bruise approximately a quarter size in diameter was present to Resident 1's right chin. Skin was intact. At the time of the interview, Resident 1 denied pain. During a observation and interview with Resident 1 and CNA 2 on 4/18/19 at 11:35 a.m., CNA 2 described Resident 1 as Sometimes she will yell out, sometimes a little combative. Not overly aggressive, few and far between agitated days, if you try to push it (care assistance) . I would remove yourself, If she feels safe then return. Usually if you explain why, she is more compliant, reapproach works. (sic) At the time of the observation and interview, bilateral bruises in various stages of healing were present to Resident 1's inner forearms and wrists. During an interview with CNA 1 on 4/19/18 at 10:14 a.m., CNA 1 described the incident as I was trying to help a lady. She told me that her brief (adult incontinent brief) wasn't wet. I told her it was and that I couldn't leave her that way. I took it upon myself to remove the wet brief. I tore one side of it (brief) and then removed it from the other side .I put the new brief on and pulled it up on her legs. She started screaming, she didn't' want me to help her. She scratched me. I have pictures .So when she started yelling and scratching me, I didn't feel threatened, I went to the the door to get another CNA to help me .She (Resident 1) told them (CN and RNA) she did not want me taking care of her anymore . Review of a facility document titled 5 Day Follow- Up (FU, an investigation report required 5 days after an allegation of abuse) dated 4/18/19 indicated the following: 1. On the night of 4/17/19 Resident 1 yelled out. Per the FU, the charge nurse (CN) and rehabilitation nurse assistant (RNA) went to Resident 1's room to assess Resident 1's needs. Upon arrival to the room the alleged perpetrator (CNA 1) was exiting the room. Resident 1 was located in the bathroom upon their arrival to the room. The FU indicated the staff was informed by CNA 1, he was scratched by Resident 1 while attempting to provide care. 2. Resident 1 was crying and told the CN and RNA that she did not want him to take care of her. Per the FU, It was the CN and RNA's understanding that Resident 1 was talking about CNA 1. 3. At around 5 a.m. Resident 1 was reassessed by the CN. At the time of reassessment, A bruise was found on the right chin of Resident 1. 4. At 9 a.m., Resident 1 was interviewed by the facility' administrator (ADM) with the presence of the assistant director of nursing (ADON). During the interview, Resident 1 shared he had grabbed her chin, she did not want him (CNA 1) to take care of her and that she would like us to protect her. 5. The administrator interviewed CNA 1 after he heard Resident 1's allegation of abuse. Per the FU, CNA 1 denied the allegation. 6. At 3:35p.m., local law enforcement officer (PD) arrived to investigate the allegation of abuse. During an interview with Resident 1, Resident 1 informed PD He had grabbed her chin. PD showed Resident 1 pictures of three males, one picture was of the alleged perpetrator CNA 1. The FU indicated, Resident 1 identified CNA 1 as the one that grabbed her chin. 7. The FU confirmed At this time, we believe that CNA 1 is not a appropriate CNA for (facility name). CNA 1 has failed his 90 day probationary period and will be termed (terminated) . Review of a facility document titled Resident Progress Notes: (Resident Name) dated 4/17/19, at 11 a.m., confirmed Resident 1 (Resident name) was interviewed and asked what had happened to her chin and how she had attained the discoloration. (Resident Name) replied, reaching for her chin area and stated he squeezed and proceeded to demonstrate how she was touched. (Resident name) was also asked who had done this act and she had replied him and stated she does not want said staff to handle her care. When (Resident name) was shown a picture of alleged abuser and had said yes, that's him, staff ensured (Resident name) that said staff member will no longer be helping her in the future. CN notified all proper authorities: and filled appropriate .documents dt (due to)suspected case of abuse leading to physical harm .(sic) Review of a facility's document titled Hospice Progress Note dated 4/17/19, no time provided, indicated the following: A/O (alert and oriented): Reports pain to jaw from someone squeezed her. Bruise 4 cm x 4 cm to rt. (right) jaw line. Small abrasion inside mouth from tooth .Pain 0-2 unless area touched. Normal jaw movement. ADON is investigating possible abuse. (sic) .visit to check on pt (patient) after abuse allegations. Pt tearful for a moment .Pt able to clearly state what happened. She expressed fear re (referenced) the accused returning to work. MSW (social worker) provided assurance she is safe and will be protected. She (Resident 1) said I didn't know this actually happens . Review of a facility's document titled physician's orders [REDACTED]. X-ray results dated 4/17/19 failed to determine cause of rt.chin bruise. Review of facility's document titled Skin Observation, weekly summary included the following notation: 4/17/19 Discoloration to right chin, Discoloration to inner right forearm., 4/18/19 Discoloration to right chin 2.0 x 4.0 x 0 cm (centimeter, a unit of measure), Right upper arm (RUE) scattered discoloration and Left upper arm (LUE) scattered discoloration, dark skin pigmentation to coccyx, intact skin. (sic) Review of a facility document titled Abuse Investigation and Reporting, revised (MONTH) (YEAR), indicated .8. If the investigation reveals that the allegation(s) of abuse are founded, the employee(s) will be terminated .