Every finding on record at Pine View Nursing and Rehab Center

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation, the facility failed to protect one of seven residents' (R11) right to be free from physical abuse from a resident (R10). Actual harm was identified to have occurred on 05/12/2026 when R10 struck R11, causing maxillary sinus and orbit fractures and lacerations to R11's face and scalp. Findings include:Review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation, revised 11/28/2017, revealed the section titled, Policy included, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The section titled Prevention revealed, The center is committed to the prevention of abuse, neglect, misappropriation of resident property, and exploitation. The following systems have been implemented:.Department Heads and supervisors that monitor staff to identify inappropriate behavior. Monitoring of residents who may be at risk is the responsibility of all facility staff. This includes monitoring residents who are at risk or vulnerable for abuse, for indications of changes in behavior, changes in condition, or other non-verbal indications of abuse.Review of a Facility Incident Report dated 05/12/2026 revealed the facility reported an incident of resident-to-resident abuse. Details of the incident were as follows: R10 struck his roommate R11 with a metal object during an argument over the television (TV) being too loud. R11 received a laceration to the side of the face and head. R11 sent out to ER [emergency room]. Administrator, DON [Director of Nursing], MD [Medical Director], and responsible parties all notified of the incident. Police also notified of the incident. R10 is currently being closely monitored.Review of the Police Department Persons Crime Report dated 05/12/2026 at 11:50 PM revealed that an officer was dispatched to the facility in reference to an altercation that had taken place between two residents. The report documented that a nurse informed the officer that R10 had struck R10 with a metal pipe, and R11 was transported to the hospital for treatment. 1. Record review revealed R10 was admitted to the facility with diagnoses that included, but were not limited to, unspecified intellectual disabilities, schizophrenia, and major depressive disorder.Review of R10's Annual Minimum Data Set (MDS), dated [DATE], revealed Section C (Cognitive Patterns) documented R10 had a Brief Interview of Mental Status (BIMS) of 14 (indicating little to no cognitive impairment). Section E (Behaviors) documented that the resident exhibited physical and verbal behavioral symptoms towards others during the assessment period. Review of the care plan for R10 revealed the resident had impaired psychosocial well-being, mood, and behavior with episodes of anger, physical aggression, and pyromania. He threatened to burn the building down and was verbally aggressive with staff on 12/12/2025 and struck his roommate with an object on 05/12/2026. Interventions included approaching R10 in non-judgmental manner, encourage R10 to use appropriate behavior, encourage R10 to participate in activities with peers, R10 placed on one to one supervision due to incident on 05/12/2026 with roommate, provide close observation when behavior is escalated, notify MD (Medical Director) of changes in behavior and refer for admission to behavioral health for in-patient services as ordered by MD if threats or aggressive behavior occurs.Review of the progress notes for R10 revealed an entry dated 5/13/2026 stating that, at approximately 11:20 PM (on 05/12/2026), a Registered Nurse (RN) found R10 and R11 in a physical altercation with each other. R10 had a metal bar in his hand. The residents were separated, and R10 was assisted from the room. A call was attempted to the Resident Representative (RP), the Director of Nursing (DON) and Administrator were notified. 2. Record review revealed R11 was admitted to the facility with diagnoses that included, but were not limited to, cerebrovascular disease, unspecified, other symptoms and signs involving cognitive functions and awareness, major depressive disorder, mild cognitive impairment, bipolar II disorder, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, irritability and anger, vascular dementia, unspecified severity, with agitation.Review of R11's Quarterly MDS, dated [DATE], revealed that Section C (Cognitive Patterns) documented R11 had a BIMS of five (indicating severe cognitive impairment). Section E (Behaviors) documented that the resident exhibited hallucinations and delusions during the assessment period. Review of the progress notes for R10 revealed an entry dated 5/13/2026 that at approximately 11:20 PM (on 05/12/2026), a Registered Nurse (RN) found R10 and R11 in a physical altercation with each other. R10 had a metal bar in his hand. R11 had blood coming from a wound on his head. The residents were separated, R10 was assisted from the room, towels were applied to R11's head, Emergency Medical Services (EMS) was called, the on-call provider was paged, the RP, DON, and Administrator were notified. Review of the Emergency Department Discharge Instructions for R11, dated 05/13/2026, revealed the discharge diagnosis was maxillary sinus fracture, orbit fracture, and scalp laceration. The disposition was discharge to the nursing home. The follow-up information was to return to the emergency department within one to two weeks and have the staples removed in 10 days. In an interview on 07/21/2022 at 3:30 PM, the Administrator confirmed a physical altercation occurred between R10 and R11. The Administrator stated the residents were separated, R10 was placed on 15-minute checks, and R11 was transported to the ER for injuries to his head. The Administrator stated that behavioral health services, the physician, responsible parties, and law enforcement were notified of the incident for both residents.The facility implemented the following:1. On 05/12/2026, the facility submitted an incident report to the State Survey Agency (SSA).2. On 05/12/2026, a police report was completed at 11:50 PM. Case number: 202605121.3. On 05/12/2026, R11 was transported to the ER for treatment.4. On 05/12/2026, R10 was placed on 15-minute monitoring checks, one-to-one supervision on 05/20/2026, every thirty minute monitoring on 06/18/2026, and every sixty-minute monitoring on 06/21/2026. 5. Beginning 05/12/2026, R10 was placed in a private room.6. On 05/13/2026, a room audit was conducted of R10 and R11's room. Three screwdrivers were removed from R11's nightstand. 7. On 05/13/2025, R11 had a room change to a separate hall from R10. 8. On 05/13/2026, care plan interventions were updated for R10 and R11.9. On 05/13/2026 and 05/14/2026 Social Services provided services to R11.10. On 05/13/2026 and 05/14/2026 Social Services provided services to R10.11. On 5/13/2026, a psychological referral was submitted to the behavioral health services for R10 and R11. 12. On 05/13/2026, 05/14/2026, 05/15/2026, 05/22/2026, and 05/25/2026, the Social Service Director submitted referrals for R10 to behavior units. 13. On 05/13/2026 and 05/14/2026, education titled Abuse and De-Escalation was conducted with staff. Review of the sign-in sheets revealed 43 unique names/signatures.14. The facility is currently waiting for bed placement at a behavioral health unit for R10. R10 remains in a private room.

Based on observations, staff and resident interviews, and record review, the facility failed to ensure care plan interventions were implemented for one of 16 sampled residents (R) (R16). This deficient practice had the potential to place R16 at risk of falls and unmet care needs. Findings include: A review of the electronic medical record (EMR) revealed that R16 had diagnoses of, but not limited to, extrapyramidal and movement disorder, type 2 diabetes mellitus without complications, history of falling, unspecified dementia, osteoarthritis of hip, unspecified and displaced fracture of lateral end of left clavicle.Review of the most recent Significant Change Minimum Data Set (MDS) assessment for R16, dated 07/01/2026, revealed that Section GG (Physical Abilities and Goals) documented that R16 required substantial/maximal assistance with bed mobility and was dependent with transfers. Section J (Health Conditions) documented the resident had a fall in the last six months.Review of the care plan for R16 revealed a 'Focus,' last revised 05/21/2026, that the resident was at risk for injury from falls, had a history of falls, and had poor safety awareness. 'Interventions' included an intervention dated 01/09/2026 for having a fall mat at bedside while in bed. During an observation on 07/20/2026 at 12:04 PM, R16 was observed lying in bed asleep. A fall mat was folded and positioned at the bottom of her bed. During observation on 07/20/2026 at 3:42 PM, R16 was observed lying in bed asleep. A fall mat was present and folded on the floor at the bottom of the bed.During observation and interview on 07/21/2026 at 9:05 AM, Hospice Registered Nurse (RN) AA confirmed that the fall mat was observed on the floor at the foot of the bed rather than beside the bed to provide protection in the event of a fall.During an interview and tour of R16's room on 07/21/2026 at 12:47 PM, the Assistant Director of Nursing (ADON) confirmed that the fall mat was not positioned at the resident's bedside as ordered. Instead, it was propped against the foot of the roommate's bed. The ADON confirmed that the resident's care plan included an intervention to place the fall mat beside the resident's bed whenever the resident was in bed.

Based on record review, and staff interviews, the facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program which systematically identified, reviewed, developed, and implemented plans to correct quality deficiencies. Specifically, the facility failed to Maintain and/or produce documentation that demonstrates evidence of its ongoing QAPI program. The deficient practice had the potential to affect resident care outcomes and quality of life for 109 residents.Findings include:A request to review the facility QAPI program documentation, including but not limited to meeting attendance revealed the facility could not produce any documentation for review.A request to review the QAPI policy revealed QAPI policy was not produced for review.Interview on 02/19/2026 at 5:30 PM with the Administrator revealed the facility does not maintain QAPI documentation. The Administrator stated documentation is not available because the facility has not been documented as required. She further stated the QAPI program is not effective. The Administrator confirmed there is currently no tracking and trending of data for trends. She stated most issues are addressed during the morning clinical meeting.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Nutrition Policy, the facility failed to properly prepare pureed food and ensure nutritive value for eight of eight residents receiving a pureed diet. This failure had the potential to serve food at a lesser nutritive value that could cause weight loss.Findings include:Review of the facility's policy titled, Nutrition Policy effective 09/01/2024 revealed under Pureed- Dysphagia Level 1: The pureed consistency is planned according to the regular consistency, but the texture is modified to a smooth, pudding- like texture for all food items. This consistency follows the guidelines as set forth by the National Dysphagia (difficulty with swallowing) Task Force. Pureed recipes are needed for each item that requires addition of fluid and mechanical manipulation to achieve a pudding- like, smooth, lump free, puree consistency. Only nutritive fluids such as broth, gravy, juice and milk are designed for use in pureed recipes.Observation of the puree process on 02/17/2026 at 10:45 AM revealed Dietary Aide (DA) II loading a food processor with food product without measuring. No liquids were used to dilute/ liquify/ mechanically manipulate the substance to achieve the smooth, pudding- like texture, nor was a recipe followed. The processor was tilted back and forth then the substance transferred into a serving tray. DA II failed to assess the consistency before transferring the mixture.Interview on 02/17/2026 at 11:00 AM with DA II, she denied following a recipe and stated that she was not aware that she had to use any. DA II confirmed she was not trained on the proper technique of completing the puree process and stated that she had been doing it since she started working in the facility.During a second observation of the puree process on 02/19/2026 at 10:45 AM revealed DA JJ performing the puree process. She removed seven scoops of sweet potatoes from a baking tray that was removed from the oven and placed them into the food processor. She then added three scoops of the broth and blended the mixture. DA JJ tilted it back and forth before pouring the mixture into the serving tray. Interview on 02/17/2026 at 11:00 AM with DA JJ revealed she did not follow a recipe to prepare the meal nor used proper measurement documented in the recipe for the eight residents that were on a pureed diet. DA JJ revealed using the liquid from the baked potatoes instead of milk and not following the recipe though she had read it prior to starting. She stated that she completed the process based on how she was instructed by the Dietary Manager (DM). She stated that she had been working in the facility less than 30 days and had not been formally trained on puree meal preparation but stated, I know how to make puree because I used to do it for a family member. DA JJ revealed she was not aware of how many residents she was preparing for nor how many scoops of potatoes she had pureed.Review of the puree recipe book on 02/19/2026 at 11:00 AM revealed no recipe recommendations for hamburger helper preparation. The recipe provided revealed lasagna with no substation for hamburger helper. The recipe also called for eight ounces with 1 and1/4 cups of beef broth for ten servings. Further observation of the recipe book revealed that the sweet potato's recipe called for ten ounces of two percent milk and five cups of sweet potatoes for ten servings.Interview on 02/17/2026 at 11:10 AM with the DM, she stated that most of her staff were fairly new to the facility. She admitted to not training the staff on the puree process stating, they have watched other staff complete the puree process. The DM confirmed that the staff were not using the puree recipe book while preparing meals and revealed she verbally instructed them on what ingredients to use.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Food Safety and Sanitation, the facility failed to ensure that food was stored in a manner that prevented foodborne illness to the residents, failed to ensure the food was stored at the appropriate temperatures and failed to ensure that dishes and utensils were cleaned under proper sanitary conditions. The deficient practices had the potential to place all residents at risk of acquiring foodborne illnesses. There were 104 residents who received an oral diet from the kitchen.Findings include:Review of the undated facility's policy titled, Food Safety and Sanitation revealed in the initial paragraph, Having an established policies and procedures related to food safety and sanitation, along with ongoing training and monitoring is critical in preventing foodborne illness. From receiving until service, there are certain control points that must be closely monitored. Control point- a step in the flow of food where a potential hazard can be controlled. Critical control point- the last step to prevent a potential hazard prior to service. Receiving. Label foods with delivery date and discard by date.Freezer Storage: Freezer temperatures should be 0 (degrees) F (Fahrenheit) or below to ensure frozen foods remain frozen. Foods should be stored away from fans, vents, and pipes. Foods should be stored at least 6 inches off the ground. Sanitation: Maintain logs that include dishwasher temperatures and monitor chemical sanitizers on a regular basis. Keep maintenance records along with manufacturers specifications for proper use. Follow a regular written cleaning schedule and document cleaning.Dish Machine Temperatures. Low temperature dish machine (chemical sanitation): wash 120 F- final rinse 50 PPM (parts per million) chlorine. Manual washing (3 compartment sink): wash in hot water, at least 110 F and detergent. Rinse with water at least 110 F. Sanitize: hot water at least 171 F or chemical sanitizer in accordance with manufacturer specifications. No towel drying.Observations during the initial tour of the kitchen on 02/17/2026 at 8:50 AM with the Dietary Manager (DM) revealed a thick buildup of ice on the floor of the freezer with icicles hanging from boxes stored on the shelves. Several bags of frozen foods: French fries, hamburger patties, mixed vegetables and meats were observed in a box on a shelf with no expiration date nor opened/ used by date documented. An opened loaf of bread, a few slices of molded cheese, an opened box of pancakes and a staff member's personal medications were observed in the refrigerator. The three-compartment sink was observed with pots and pans with staff hand washing them using a bottle of bleach as sanitizer.Observation of the dishwasher on 02/17/2026 at 9:12 AM revealed the dishwasher was running, one staff member prewashing dishes, cups and utensils and another using a dish towel to hand dry them.Interview on 02/17/2026 at 9:17 AM with Dietary Aide (DA) II and the [NAME] revealed that the dishwasher was not working correctly. She also stated that the chemicals for the 3-compartment sink had been hooked up incorrectly. The [NAME] stated that the company was contacted about the issue and would be returning to correct it.Observation of the dishwasher temperatures and chemicals solution on 02/18/2026 at 9:30 AM revealed that the temperature gauge was not registering, and chemical testing strips did not give a reaction.Interview on 02/18/2026 at 9:43 AM with the DM confirmed that the staff had been hand washing the dishes prior to placing them into the dish washed and adding bleach to the machine to assist with sanitizing. She confirmed that the testing strips were not reading unless bleach was added and therefore no correct reading was obtained. She stated that the freezer was leaking the day before and caused the water to be leaking inside causing the icicles.Interview on 02/18/2026 at 4:36 PM with the Corporate Manager (CM) revealed that she was made aware of the issue only a few minutes prior and had instructed the staff to continue to use the bleach and do another cycle until the repairman comes in the morning. She denied having an alternate plan but stated she would contact her boss and communicate with the DM on formulating a different plan. CM revealed that the facility will purchase disposable plates, cups and utensils for use until the dish washer can be fixed.Interview on 02/19/2026 at 2:00 PM with the Administrator revealed her expectation was that all department heads would communicate issues and solutions to problems faced on a daily basis so they could be addressed in a timely manner.

Based on observations, record review, staff interviews, and review of the facility policy titled, Administering Medications, the facility failed to ensure that medication was administered according to physician's orders for one of three residents (R) (R79) observed during medication administration. Specifically, R79 received medications by mouth when she should have received the medication through her G-tube (gastrostomy tube). This deficiency had the potential to cause R79 to aspirate which could have led to physical harm or hospitalization.Findings include: Review of the facility policy titled Administering Medications revised 06/06/2024 revealed under Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation revealed: .3. Medications must be administered in accordance with the orders, including any required time frame.7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.Review of the electronic medical record (EMR) revealed R79 was readmitted to the facility on [DATE] with a G-tube and diagnoses including but not limited to chronic obstructive pulmonary disease with acute exacerbation, hyperlipidemia, dysphagia (difficulty swallowing), major depressive disorder, and altered mental status, Review of R79's significant change Minimum Data Set (MDS) assessment, with an assessment reference date of 2/10/2026, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated R2 was cognitively intact. Section K revealed the resident had a feeding tube and received 51 percent or more of total calories and 501 cubic centimeters or more of fluid intake per day through the feeding tube.Review of R79's care plan indicated a problem: R79 alteration in nutrition related to tube feed with the potential for significant weight loss/gain/aspiration precaution, 5% (percent) WT (weight) loss for the month of FEB (February) 2026-12 lb (pound). Goal is R79 will be free from complications related to G-tube: aspiration, dehydration, abdominal distress/ SIG (significant) WT loss/gain. Interventions include R79 NPO (nothing by mouth) with Jevity 1.5 at 55ml/hr (milliliters per hour) with flush per MD (medical doctor) order, monitor abdomen for distention with aspiration precautions and HOB (head of bed) elevated with input/output Q (every) shift, monitor for placement and patency per policy.Review of the physician orders for R79 revealed an order dated 2/17/2026:Enteral Feed Order every 4 hours for Dysphagia, G-tube dependent Give 240 cc Jevity bolus with 60 cc water flush.Review of the physician orders for R79 included but not limited to:Clopidogrel Bisulfate Oral Tablet 75 MG (clopidogrel bisulfate) Give 1 tablet via G-Tube one time a day for blood clot preventionDivalproex Sodium Oral Tablet Delayed Release 250 MG (divalproex sodium) Give 1 tablet via G-Tube one time a day for headacheGabapentin Capsule 300 MG Give 1 capsule via G-Tube two times a day for painLactobacillus Capsule Give 1 capsule via G-Tube one time a day for anti-diarrheaMirabegron ER (extended release) Oral Tablet Extended Release 24 Hour 50 MG (Mirabegron) Give 1 tablet via G-Tube one time a day for bladder spasmsParoxetine HCl Oral Tablet 40 MG (paroxetine HCl) Give 1 tablet via G-Tube one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATESeroquel Oral Tablet 200 MG (quetiapine fumarate) Give 2 tablet via G-Tube two times a day for anxiety.Observation on 02/17/2026 at 12:30 PM of R79 revealed her sitting on her roommate's bed. She was receiving Jevity 1.5 at 55ml/hr with water flush at 40ml/hr through a G-tube.Observation on 02/18/2026 at 09:00 AM with R79 revealed her walking around in her room. She no longer had the continuous G-tube feedings. The order was changed to bolus (feeding given via syringe through the G-tube) feeding.Observation of medication administration on 02/18/2026 at 08:28 AM on the C with the Licensed Practical Nurse (LPN) KK revealed LPN KK administered all medications to R79 by mouth. Interview with LPN KK confirmed that the medication cards and physician orders were for G-tube administration and she had given the medications by mouth. When questioned why she had given the medications by mouth, LPN KK stated that R79 had been sneaking and eating and that the facility was trying to get R79 cleared to remove the G-tube. LPN KK stated that she should have followed the orders because the resident could have aspirated.Interview on 02/19/2026 at 10:43 AM with the Advanced Practice Registered Nurse (APRN) revealed that R79 should be receiving her medications via the G-tube as ordered.

Based on observations, record review, staff interviews, and review of the facility policy titled, Administering Medications, the facility failed to ensure that the medication error rate was less than five percent (%) for one of three residents (R) (R79) observed during medication administration. There were 26 opportunities observed for three residents with ten errors resulting in an error rate of 38.46 %.Findings include:Review of the facility policy titled, Administering Medications revised 06/06/2024 revealed in the policy statement that medications shall be administered in a safe and timely manner, and as prescribed. Under Policy Interpretation and Implementation: .3. Medications must be administered in accordance with the orders, including any required time frame.7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.Observation of medication administration on 02/18/2026 at 08:28 AM on the C Wing with Licensed Practical Nurse (LPN) KK. LPN KK administered multiple medications to R79. The following observations were made:Clopidogrel 75 mg (milligram) was administered by mouth.Divalproex sodium 250 mg Delayed Release Oral Tablet [Depakote] was administered by mouth.ACIDOPHILUS (lactobacillus) 1 capsule was administered by mouth.24 HR (hour) mirabegron 50 mg Extended-Release Oral Tablet was administered by mouth.Actos Oral Tablet 15 mg (pioglitazone HCl) was administered by mouth.Seroquel Oral Tablet 200 mg (quetiapine fumarate) was administered by mouth.Carvedilol 12.5 mg Oral Tablet was given by mouth.Gabapentin Capsule 300 mg was given by mouth.Buspirone HCl Oral Tablet 30 mg was given by mouth.Paroxetine HCl Oral Tablet 40 mg was given by mouth.Review of the February 2026 monthly Physician's orders in the electronic medical record EMR) of R79 revealed the following orders:Clopidogrel Bisulfate Oral Tablet 75 MG (clopidogrel bisulfate) Give 1 tablet via G-Tube (gastrostomy tube) one time a day for blood clot preventionDivalproex Sodium Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet via G-Tube one time a day for headacheGabapentin Capsule 300 MG Give 1 capsule via G-Tube two times a day for painLactobacillus Capsule Give 1 capsule via G-Tube one time a day for anti-diarrheaMirabegron ER (extended release) Oral Tablet Extended Release 24 Hour 50 MG (Mirabegron) Give 1 tablet via G-Tube one time a day for bladder spasmsParoxetine HCl Oral Tablet 40 MG (paroxetine HCl) Give 1 tablet via G-Tube one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATESeroquel Oral Tablet 200 MG (Quetiapine Fumarate) Give 2 tablet via G-Tube two times a day for anxietyActos Oral Tablet 15 MG (pioglitazone HCl) Give 1 tablet via G-Tube one time a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONSBuspirone HCl (hydrochloride) Oral Tablet 30 MG (Buspirone HCl) Give 1 tablet via G-Tube two times a day for anxietyCarvedilol Oral Tablet 12.5 MG (carvedilol) Give 1 tablet via G-Tube two times a day related to ESSENTIAL (PRIMARY) HYPERTENSIONReview of the Medication Administration Record (MAR) for R79 confirmed these orders were correctly transcribed from the Physician's orders to the MAR.All medications were administered by mouth. The physician order notes that the medications were to be administered via G-Tube. Medications were given using the wrong route. Seroquel 200 mg was given; the order was for 400 mg. LPN KK administered the wrong dosage of Seroquel to R79.Interview on 02/18/2026 at 08:28 AM with LPN KK confirmed that the medication cards and physician orders for R79 were for G-tube administration and she had given the medications by mouth. When questioned why she had given the medications by mouth, LPN KK stated that the resident had been sneaking and eating and that the facility was trying to get R79 cleared to remove the G-tube. LPN KK stated that she should have followed the orders because the resident could have aspirated.Interview on 02/19/2026 at 10:50 AM with the Assistant Director of Nursing (ADON) revealed that she expected nurses to follow physician's orders when administering medications.Interview on 02/19/2026 at 05:10 pm with the Administrator revealed that she expected nurses to give medications as ordered and follow the rights of administration.

Based on observations, staff interviews, record reviews, and review of the facility's policies titled, Hand Hygiene and Legionella Surveillance, the facility failed to ensure staff performed proper infection control practices while serving meals to the residents on two of five halls (D Hall and E Hall). In addition, the facility failed to ensure an effective water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building's water system. The deficient practices had the potential to spread infection by cross-contamination and placed the residents at risk of waterborne illnesses, including Legionnaires disease. The facility census was 97 residents. Findings include: 1. Review of the facility's policy titled, Hand Hygiene, reviewed 6/25/2020, revealed the Policy section stated, Staff involved in direct resident contact will perform proper hygiene procedure to prevent the spread of infection to other personnel, residents, and visitors. The Hand Hygiene Table section included Either Antimicrobial Soap and Water or Alcohol Based Hand Rub is to be used between resident contacts. Observation on 12/3/2024 at 12:50 pm, on D Hall revealed Certified Nursing Assistant (CNA) BB did not sanitize her hands after leaving a resident's room. Further observation revealed her to take a food tray into another resident's room and exited the room without sanitizing her hands upon entry or exit of the room. CNA BB was observed to place a meal tray on the meal cart, and did not sanitize her hands after handling the dirty tray. Observation on 12/3/2024 at 12:56 pm on E Hall revealed CNA HH serving meals to the residents. Observation revealed that she took the meal tray from the meal cart, went into the resident's room, exited the resident's room, returned to the meal cart for another resident's meal tray, and took it to the other resident's room. CNA HH did not sanitize her hands between serving the residents their meal trays. In an interview on 12/3/2024 at 12:54 pm, CNA BB confirmed she did not sanitize her hands after exiting the resident's room on the D Hall. She stated she should have sanitized her hands after exiting the resident's room, but she forgot. She further stated not sanitizing her hands between residents could expose residents to germs and infections. In an interview on 12/3/2024 at 1:00 pm, CNA HH confirmed she did not sanitize her hands while serving the residents' meals. She stated she should have sanitized her hands between serving meals to the residents, but she did not. She stated she was trying to get the residents' lunches to them as quickly as possible, so she did not sanitize her hands in between serving the residents. She further stated not sanitizing her hands between residents could cause germs to spread between residents and cause illness. In an interview on 12/5/2024 at 5:50 pm, the Director of Nursing (DON) stated her expectations were for all staff to sanitize their hands between contact with residents and before and after attending to a resident. She stated if staff didn't sanitize their hands between residents, infections could be spread to residents. 50803 2. Review of the facility's policy titled, Legionella Surveillance, revised 11/20/2022, revealed the Policy section stated, It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections. The Policy Explanation and Compliance Guidelines section included 1. Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems. A water management program policy was requested and not provided. In an interview on 12/5/2024 at 3:11 pm, the Maintenance Director and Environmental Services Director (ESD) revealed that both the Maintenance Director and ESD share the responsibility of overseeing the water management program for the facility. They stated the current Maintenance Director had been in his position for almost three months. They further stated the previous Maintenance Director had full responsibility for maintaining the water management program and took all the water management program documentation and information with him at the end of his employment. They stated that they were in the process of developing the water management program and confirmed there was no current water management program for the facility.

Based on observations, staff interviews, and review of the facility policy titled, Environment, the facility failed to provide a safe, functional, sanitary, and comfortable environment on three of five halls and one of two shower rooms. These deficient practices had the potential to place residents at risk of living in an unsanitary living environment and a potential for diminished quality of life. The facility census was 97 residents. Findings include: Review of the facility policy titled, Environment, dated 12/5/2018, revealed the Policy section stated, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. The Policy Explanation and Compliance Guidelines section included . 9. General considerations: a. Minimize orders by disposing of soil linens properly and reporting lingering orders at bathrooms needing cleaning to housekeeping department. Observations on 12/3/2024 at 1:00 pm revealed patched walls at the end of A Hall and stained ceiling tiles on A Hall. Observations on 12/5/2024 at 3:31 pm revealed the Shower Room on C Hall had missing floor tiles, scuffed walls, and a foul odor. Further observation revealed stained ceiling tiles on C Hall. During a concurrent interview and observations on 12/6/2024 at 1:44 pm, the Administrator and Maintenance Director confirmed the patched walls at the end of A Hall and the missing floor tiles and scuffed walls in the C Hall Shower Room. They further confirmed stained ceiling tiles on A Hall and C Hall. 50524 Observation on 12/3/2024 at 10:00 am revealed an unpleasant odor on the D Hall. Observation on 12/4/2024 at 11:00 am and 5:20 pm revealed an odor of urine on the D Hall. The odor was strongest close to room D2 and between rooms D9 and D10. In an interview on 12/4/2024 at 5:34 pm, Certified Nursing Assistant (CNA) JJ confirmed the odor of urine on the D Hall and confirmed the odor was strongest close to room D2 and between rooms D9 and D10. She stated the D Hall usually had an unpleasant odor. She further stated there were bins in the hallway between rooms D9 and D10 which contained linen and incontinence pads, and they were usually emptied by the CNAs on the units. She confirmed the bins needed to be emptied. In an interview on 12/4/2024 at 5:43 pm, the Director of Nursing (DON) confirmed the D Hall had an unpleasant odor. She stated her expectations were for the hallways to be odor-free. She stated the outcome of unpleasant odors could negatively affect the residents. In an interview on 12/5/2024 at 11:20 am, Environmental Services Lead TT stated one of the two large black garbage bins in the D Hall contained incontinence trash of urine and feces, and the other one had dirty resident laundry. She stated she did not know why the D Hall was the only hall with those bins, but they had always been there. She further stated the CNAs would change the residents and often leave the soiled undergarments in the bins. She stated she believed the bins were the reason for the D Hall smelling bad. In an interview on 12/6/2024 at 11:00 am, the Administrator stated she expected the facility to not have unpleasant odors. She confirmed the D Hall had unpleasant odors and stated she expected unpleasant odors to be addressed quickly.

Based on observations, staff interviews, and review of the facility's policy titled, Storage of Medications, the facility failed to ensure expired medications were removed from one of two medication storage rooms. The deficient practice placed residents at risk of receiving expired medications. The facility census was 97 residents. Findings include: Review of the facility's policy titled, Storage of Medications, revised 8/2020, revealed the Policy stated, Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. The Procedures section included Expiration Dating (Beyond-Use Dating) . 8. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining. Observation on 12/4/2024 at 3:07 pm of the Front Hall Medication Storage Room with Licensed Practical Nurse (LPN) DD revealed 14 blister-pack medications dated 7/2024 on the counter. Further observation revealed one bottle of vitamin D 250 microgram (mcg) with an expiration date of 10/2024 and one bottle of vitamin D 400 international units (IUs) with an expiration date of 11/2024 on the counter. LPN DD verified the expired medications and stated they should have been discarded. In an interview on 12/4/2024 at 3:15 pm, Nursing Supervisor (NS) EE confirmed there were 14 blister packs of three residents' medications dated 7/2024 on the counter in the Front Hall Medication Storage Room and stated they should not be on the counter but should be placed in a sealed bag and labeled for the pharmacy to pick up. NS EE stated her expectations were for the expired medications to be removed from the medication room and sent to the pharmacy. In an interview on 12/5/2024 at 5:50 pm, the Director of Nursing (DON) stated she expected the nurses to remove expired medications from the medication room because the residents could be adversely affected if they received expired medications.

Based on observations, staff interviews, and review of the facility's policy titled, Controlled Substance Prescriptions, the facility failed to ensure controlled medication shift counts were documented with nurse signatures on one of four medication carts (D Hall Medication Cart). This deficient practice had the potential to affect the availability of residents' controlled medications. Findings include: Review of the facility's policy titled, Controlled Substance Prescriptions, revised 8/2020, revealed the Policy section stated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances and medications classified as controlled substances by state law are subject to special ordering, receipt, and record-keeping requirements in the facility, in accordance with federal and state laws and regulations. Observation on 12/4/2024 at 10:25 am of the controlled-substance document titled Narcotic Sign Off Form on the D Hall Medication Cart revealed 28 missing signatures of 112 opportunities for controlled-substance shift counts for incoming and outgoing nurses between 9/29/2024 through 10/27/2024. The dates of missing nurses' signatures were 9/29/2024 (two missing signatures), 10/5/2024 (two missing signatures), 10/6/2024 (two missing signatures), 10/7/2024 (two missing signatures), 10/12/2024 (one missing signature), 10/13/2024 (two missing signatures), 10/14/2024 (one missing signature), 10/15/2024 (two missing signatures), 10/16/2024 (one missing signature), 10/19/2024 (two missing signatures), 10/20/2024 (two missing signatures), 10/21/2024 (two missing signatures), 10/22/2024 (two missing signatures), 10/24/2204 (two missing signatures), 10/26/2024 (one missing signature), and 10/27/2024 (two missing signatures). In an interview on 12/4/2024 at 4:14 pm, Nursing Supervisor (NS) EE stated her expectations were for the nurses to count the narcotics and document the count by signing the controlled substance sheet at the change of each shift. She stated if there was a discrepancy in the controlled medications counts, the residents may not receive their medications if the medications were missing. In an interview on 12/5/2024 at 5:50 pm, the Director of Nursing (DON) stated the controlled medications should be counted by the nurses at shift change and the controlled substance sheet shift change form should be signed by the oncoming and off-going nurse at each shift change to verify the accuracy of the controlled substance count.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Activities of Daily Living (ADLs), the facility failed to ensure activities of daily living care, specifically fingernail care and oral hygiene, were provided for two of 40 sampled residents (R) (R11 and R2). The deficient practice had the potential to place R11 and R2 at risk for unmet needs and a diminished quality of life. Findings include: Review of the facility's policy titled, Activities of Daily Living, dated 10/17/2022, revealed the Policy section stated, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate. The Policy Explanation and Compliance Guidelines section included .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal hygiene. 1. Review of R11's Admission Record revealed diagnoses including, but not limited to, cerebrovascular disease, Parkinson's disease, vascular dementia, age-related nuclear cataract, and type 2 diabetes. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 3 (indicating severe cognitive impairment), Section GG (Functional Abilities and Goals) documented R11 required substantial to maximal assistance with ADLs. Review of R11's care plan dated 1/2/2024 included a Focus of total care for dressing/grooming. Interventions included staff to provide ADL care daily to make sure all his daily needs are met. During observation and interview on 12/4/2024 at 12:45 pm with R11 in his room, observation revealed his fingernails were long and had a dark substance underneath them. R11 stated he did not like his nails long. He stated it had been a month since they were cut. Observation on 12/5/2024 at 8:35 am revealed R11 was sitting in the day room watching television. Further observation revealed his fingernails were long with a dark substance underneath. In an interview on 12/5/2024 at 8:45 am, Certified Nurse Assistant (CNA) BB stated R11 required total assistance with ADL care. She stated she did not cut fingernails often, but if they were dirty or needed clipping, she would. She confirmed R11's nails were long with a dark substance underneath them and needed cleaning and trimming. In an interview on 12/5/2024 at 4:57 pm, the Director of Nursing (DON) stated she expected staff to check residents' nails and attend to them when providing care. She stated nail care was included in ADL care. 50803 2. Review of R2's Admission Record revealed diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, adult failure to thrive, muscle weakness, and contracture of muscle in the left forearm, left hand, right forearm, right hand, and right upper arm. Review of R2's Annual MDS assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a BIMS of 15 (indicating no cognitive deficit), and Section GG (Functional Abilities and Goals) documented R2 had an impairment on both upper extremities and was dependent on a helper for assistance with all ADLs. Review of R2's care plan dated 3/28/2023 revealed a Focus of total assistance for bathing, dressing, and grooming. Interventions include R11 is total care for oral care every shift and as needed, and staff to provide ADL care daily to make sure his daily needs are met. An observation and interview on 12/4/2024 at 9:15 am in R2's room revealed that R2 had a foul odor from his mouth. In an interview, R2 stated that it had been over two weeks since he had assistance with brushing his teeth. In an interview on 12/6/2024 at 10:15 am, R2 revealed staff had not assisted him with oral care this week. He stated that the staff did not help him with brushing his teeth. He further stated staff helps with using mouthwash, but he would like help brushing his teeth. In an interview on 12/6/2024 at 1:06 pm, CNA RR revealed that R2 needed total assistance with ADL care, including oral care. She further stated that she provided R2 with mouthwash but had not offered to help with brushing his teeth. In an interview on 12/6/2024 at 12:01 pm, the DON stated she expected staff to provide ADL care for dependent residents as often and as needed, including brushing their teeth daily in the morning and anytime it is needed.

Based on staff interviews and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded to reflect the resident's status at the time of the assessment for one of 40 sampled residents (R) (R42). This deficient practice had the potential to affect the assessment of R42's care needs. Findings Include: A review of R42's electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including, but not limited to, schizophrenia, bipolar disorder, major depressive disorder, and anxiety disorder. A review of R42's Annual MDS dated [DATE] revealed Section A (Identification Information) documented the resident had not been evaluated by Level II PASRR [Preadmission Screening and Resident Review] and determined to have a serious mental illness and/or mental retardation or a related condition. Review of R42's EMR revealed a PASRR Level II dated 9/21/2023. In an interview on 12/5/2204 at 10:42 am, the MDS Coordinator verified R42 had a PASRR Level II dated 9/21/2023, and it was not coded accurately on the MDS assessment dated [DATE]. In an interview on 12/05/24 at 2:05 pm, Registered Nurse (RN) GG stated she signed the MDS assessments confirming completion by the required date. She further stated she does not check the MDS for accuracy. In an interview on 12/5/2024 at 2:21 pm, the Administrator stated RN GG's role in the MDS process was to sign off to confirm the MDS was complete. The Administrator further stated her expectation was for the MDS assessment information to be accurate. She acknowledged that a possible negative outcome of inaccurate MDS information could be that the facility could be submitting inaccurate assessments and compromise resident care. In an interview on 12/6/2024 at 11:55 am, the Administrator confirmed that the facility did not have a specific MDS policy but followed the Resident Assessment Instrument (RAI) guidelines.

Based on staff interviews, record review, and review of the facility's policy titled, Bed Hold Policy, the facility failed to provide written bed hold notices for one of three residents (R) (R201) reviewed for hospitalization . This failure had the potential to place R201 at risk of possible denial of re-admission and loss of their room following a transfer to the hospital. Findings include: Review of the facility's undated policy titled, Bed Hold Policy revealed, There will be times that the resident is out of the facility overnight, whether due to a hospital stay. Should any events occur there are clear guidelines regarding payment source to maintain, or hold the resident's bed in the facility. Review of R201's Admission Record revealed R201 was admitted to the facility on [DATE]. Review of the Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Section A (Identification Information) documented R201 was discharged to a short-term hospital with an anticipated return. Review of the Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Section A (Identification Information) documented R201 was discharged to a short-term hospital with an anticipated return. Review of the Nurse's Notes revealed an entry dated 7/24/2024 at 12:21 pm of Resident was transferred Hospital. [sic] The reason for transfer is an immediate transfer or discharge is required by the resident's urgent medical needs . At the time of transfer, the resident was Alert, disoriented, but can follow simple instructions. Review of the Nurse's Notes revealed an entry dated 8/4/2024 at 12:37 am of .Resident had abnormal breathing . SN [Skilled Nurse] called PCP [Primary Care Physician]. PCP stated sent to the ER [emergency room ]. SN called EMS [emergency medical services]. They arrived around 0020. SN gave report to ER nurse and updated resident brother. In an interview on 12/5/2024 at 3:30 pm, the Business Office Manager (BOM) and Administrator verified there was not a bed hold notice provided for R210 for 7/23/2024 and 8/4/2024. The Administrator stated the families were made aware of the bed hold policy at admission, and it is a part of their admission packet. The BOM confirmed she does not provide a bed hold policy when a resident is transferred to the hospital.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Bedside Medication Storage, the facility failed to ensure unauthorized medications were not stored at the bedside for one of 40 sampled residents (R) (R10). This deficient practice had the potential to place R10 at risk of the use of unauthorized medications in an unsafe manner. Findings Include: A review of the facility's policy titled, Bedside Medication Storage, revision date 8/2020, revealed the Policy section stated, Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team (or equivalent). The Procedures section included 1. A written order for the bedside storage of medication is present in the resident's medical record. 2. Bedside storage of medications is indicated on the resident Medication Administration Record (MAR) and in the care plan for the appropriate medications. 6. All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of this procedure and related policy when necessary. A review of R10's electronic medical record (EMR) revealed an admitted [DATE] with diagnoses including, but not limited to, hypo-osmolality and hyponatremia, cardiomegaly, essential (primary) hypertension, and muscle weakness. A review of R10's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 14 (indicating little to no cognitive impairment) and Section GG (Functional Abilities and Goals) documented R10 required assistance with activities of daily living (ADLs). A review of R10's care plan revealed no care plan area for self-administration of medication. A review of R10's Physician Orders revealed no order for self-administration of medications. Further review revealed there was no physician's order for Gold Multi + Vita -Lea with Vitamin K. An observation and interview on 12/3/2024 at 11:05 am with R10 revealed a bottle labeled Gold Multi + Vita -Lea with Vitamin K 120 capsules on her bedside table. R10 revealed she had been taking the vitamins before she was admitted to the facility and had continued to take them at the facility. R10 stated the staff knew she had the vitamins. An observation on 12/4/2024 at 10:01 am revealed one bottle of Gold Multi + Vita -Lea with Vitamin K 120 capsules was seen on her bedside table. In an interview on 12/4/2024 at 12:02 pm, Certified Nursing Assistant (CNA) BB confirmed R10 was not allowed to have any medications at the bedside. In an interview on 12/4/2024 at 12:21 pm, Licensed Practical Nurse (LPN) CC confirmed that medications are not allowed at the bedside unless specifically authorized by the physician. LPN CC confirmed the medications at R10's bedside and removed the medications. LPN CC stated staff members should be vigilant about medications at the bedside and notify the charge nurse immediately if any were found. In an interview on 12/4/2024 at 11:50 am, the Director of Nursing (DON) revealed there should never be any medications at the bedside. The DON stated there was a risk of overdose if medications were left at the bedside. The DON further stated if a resident wished to take vitamins or other supplements, the physician should be contacted, and the appropriate protocol should be followed. In an interview on 12/4/2024 at 12:36 pm, the Administrator confirmed residents were not allowed to have medications at the bedside table. The Administrator stated allowing medications at the bedside posed a risk, and various negative outcomes could occur. The Administrator stated staff members were expected to remove medications they observed at the bedside to ensure the safety of the residents.

Based on observations, staff interviews, and review of the facility policies titled, Sanitation Inspection and Date Marking for Food Safety, the facility failed to ensure that opened food items in the dry storage area were dated with the open date and expiration date, pots and pans were not facing outward, the dishwasher was free of spilled detergent, the freezer floor was free of rust, the stove was free of spills and stains, and the kitchen floor was clean. The deficient practice had the potential to affect 93 of 99 residents receiving an oral diet. Findings include: A review of the facility policy dated 8/20/2019 titled, Sanitation Inspection, revealed the food service area should be maintained in a clean and sanitary manner. Under policy revealed: All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects. Review of the facility policy dated 8/20/2019 titled, Date Marking for Food Safety revealed it is the policy of this facility, as part of the department's sanitation to program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations and the facility adheres to a date marking system to ensure the safety of ready to eat, time/temperature control for food safety. Initial walk through on 7/27/2023 at 8:42 a.m. of the kitchen with the Dietary Manager (DM) revealed the kitchen floor was dirty. Further observation in the dry storage area revealed a barrel containing rice, flour and sugar that were not dated with the open date and expiration date. The pots and pans by the three-compartment sink were hanging on the racks facing outward, making them vulnerable to dust and particles. Continued observation revealed the dishwasher had spilled detergent on top of the dishwasher, the freezer floor was rusted, and the back of the stove was filled with spills and stains. A follow up walk through on 7/29/2023 at 8:10 a.m. of the main kitchen revealed all previous observations: A barrel containing rice, flour and sugar that were not dated with the open date and expiration date, the pots and pans by the three-compartment sink were hanging on the racks facing outwards, and the spilled detergent on top of the dishwasher was cleaned but still had some residual detergent left on top of the dishwasher. Further observation revealed the freezer floor was rusted and the back of the stove was filled with spills and stains. Interview on 7/29/2023 at 8:15 a.m. with the DM, she acknowledged the containers of rice, flour, and sugar were not dated with the open and expiration dates, the pots and pans were facing outwards, the stains and spills behind the stove, and the kitchen floor was dirty. When asked how often the containers were cleaned, she stated daily. When asked about her expectations from the kitchen staff, she stated that she expected the staff to clean the kitchen floor and behind the stove every day.

Based on observation, staff interviews, and review of the facility policies titled, Maintenance Inspection and Housekeeping Services, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in six of 61 resident rooms (rooms D4, D6, D8, D9, D12, and D13) on one of five hallways (D Hall) related to grime build-up on room air conditioner (AC) units, dust build-up on room AC unit filters, and an area of missing and uneven flooring. Findings include: Review of the facility policy titled, Maintenance Inspection revealed: 1. The Director of Maintenance Services will perform random and/or routine inspections using the Maintenance checklist. Last reviewed 11/21/2017. Review of the facility policy titled, Housekeeping Services revealed: 1. The Director of Housekeeping will perform random and/or routine inspections using the Environmental Room Attendants checklist. Last reviewed 11/21/2017. Observations on 7/28/2023 at 8:00 a.m. on the D-hall revealed: Rooms: D4 A/C unit had dark brown/black grime buildup on the unit and the unit had cracked slats with broken and jagged areas. D6 A/C unit had dirt and grime buildup on the A/C unit and vents, machine had cracked slats with broken and jagged areas. D8 A/C unit air filters were noted with a large amount of dust build up and dirt and grime buildup on the A/C unit and vents. D9 A/C unit air filters were noted with a large amount of dust build up and dirt and grime buildup on the A/C unit and vents. D12 A/C unit air filters were noted with a large amount of dust build up and dirt and grime buildup on the A/C unit and vents. D13 A/C unit had dried brown/black grime and dust build up. An area on the D-hall near room D10 revealed a large area of flooring missing with uneven flooring and cement near a drainage pipe. Observations on 7/29/2023 at 12:40 p.m. on the D-hall revealed: Rooms: D4's A/C unit had dark brown/black grime buildup on the unit and the unit had cracked slats with broken and jagged areas. D6 A/C unit had dirt and grime buildup on the A/C unit and vents, machine had cracked slats with broken and jagged areas. D8 A/C unit air filters were noted with a large amount of dust build up and dirt and grime buildup on the A/C unit and vents. D9 A/C unit air filters were noted with a large amount of dust build up and dirt and grime buildup on the A/C unit and vents. D12 A/C unit air filters were noted with a large amount of dust build up and dirt and grime buildup on the A/C unit and vents. D13 A/C unit had dried brown/black grime and dust build up. Interview on 7/29/2023 at 12:40 p.m. with the Administrator revealed they had a plumbing leak a few weeks ago and the plumber had to dig the floor up to remove a blockage in the drainage pipe. Interview and observation on 7/30/2023 at 8:49 a.m. with the Maintenance Supervisor and the Housekeeping Supervisor revealed maintenance was responsible for cleaning the A/C unit air filters and the housekeepers were to clean the unit itself. Maintenance indicated he does not have a schedule for cleaning the filters, but he tries to clean them monthly. The Housekeeper Supervisor indicated the housekeepers should be cleaning the A/C units during normal day cleaning. They both would expect them to be clean.

Based on observations, staff interviews, and record review, the facility failed to submit an application for a Level II PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for one of 27 sampled residents (R) (R#73). Findings include: The facility does not have a policy on PASRR. Review of electronic medical records (EMR) for R#73 revealed diagnoses including but not limited to bi-polar disorder and anxiety disorder. Review of R#73's annual Minimum Data Set (MDS) dated [DATE] revealed: Section A-Identification 1500: no PASRR; Section C-Cognition: Brief Interview of Mental Status (BIMS) score of 14 indicating R#73 was cognitively intact; Section D-Mood: score of two indicating minimal depression. Review of R#73's care plan dated 7/30/2023 revealed: Resident at risk for drug related side effects due to use of psychotropic drugs and indication for use for bi-polar disorder and anxiety. Resident has a mood/behavior impairment related to diagnosis of bi-polar disorder with noted episodes of greeting upset with staff when he cannot do things his way, cursing at staff, chronic complaints of medical concerns, and refusing care. Review of R#73's Physicians Orders include but not limited to: lithium carbonate oral tablet 300 milligrams (MG) give one (1) tablet by mouth (PO) 1 time a day (QD) for bi-polar disorder for seven (7) days. Start date 7/21/2023, seroquel oral tablet 100 MG give 1 tablet PO QD in a.m. related to bi-polar disorder, seroquel oral tablet 200 MG give 1 tablet PO at bedtime (HS) related to bi-polar disorder, and buspirone tablet 15 MG give 1 tablet PO two times a day (BID) related to bi-polar disorder. Review of R#73's Progress Notes revealed a note dated 7/19/2023 indicating the Physician visited R#73 and gave a new order for lithium 300 MG QD for 1 week then increase to BID. Ordered labs for lithium level and other labs in three (3) weeks. R#73 was not receiving psych services. Review of the admission PASRR Level 1 dated 8/29/2022, completed at the hospital prior to admission revealed no diagnosis of bipolar disorder. Interview on 7/29/2023 at 9:30 a.m. with the Social Services Director revealed that she had been employed at the facility for three months and had not had training on the process and procedure for submitting and or ensuring residents are screened for level II PASRR and was unsure of who was responsible for obtaining that information. During the interview it was revealed that the training received for the Social Worker position at the facility was and continues to be from the facility Administrator and the MDS Coordinator. There had not been any training on the PASRR process. Further interview also revealed that residents that were exhibiting any behaviors were discussed in the morning staffing meeting, daily. If residents were exhibiting behaviors, the Social Worker would assess the resident and try to determine the cause of the behaviors, whether it was medications that needed to be adjusted, any family concerns, or if the resident was in any pain that had not been addressed. Once the assessment is completed, the family and the Physician are notified, and the findings are documented under the Social Services note. Interview on 7/29/2023 at 9:45 a.m. with the MDS Coordinator revealed that she was not responsible for ensuring that residents have a level II PASRR on file and that it was the responsibility of the Social Worker. Further interview also revealed that if during a scheduled assessment it was noted that a resident was exhibiting behaviors with supporting diagnoses, then the Social Worker and Administrator would be notified so that the level II application could be submitted. Interview on 7/29/2023 at 9:50 a.m. with the Administrator revealed that there was no one in the facility at this time to ensure that residents that require a level II PASRR application are submitted to the appropriate state agency. Further interview also revealed that she was currently training the new Social Worker on her duties as the Social Services Director and had not educated her on PASRR level I and/or level II process and requirements.

Based on observations, staff interviews, and review of facility's policy titled, Comprehensive Care Plan, the facility failed to follow the care for three of 27 sampled residents (R) (R#7, R#18, and R#80) related to the use of a restraint. Findings include: Review of facility policy titled, Comprehensive Care Plan implemented 12/6/2018 revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. Review of the electronic medical record (EMR) revealed R#7 was admitted with diagnoses including but not limited to dementia, anxiety disorder, psychosis, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for R#7, section C-Cognitive Pattern revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive decline. Section P-Restraints indicated R#7 did not use restraints. Review of R#7's care plan revealed a problem: R#7 is physical mobility impaired with h/o [history of] multiple falls prior to admission and remains at potential for falls/edema/pain/skin breakdown with dx [diagnosis] of dementia/Alzheimer's with actual falls on 12/23/2022, 12/25/2022, 12/30/2022 w [with]/injury, 1/2/2023 and 3/24/2023 w/o [without] injury noted with a wedge compression fracture to left vertebra during hospitalization , last revised on 5/1/2023, with an intervention that stated R#7 to be out of bed in geri-chair without lap tray, last revised on 2/18/2023. Observation on 7/28/2023 at 11:10 a.m. revealed R#7 sitting up in a geri-chair with a tray table secured in place to the geri-chair. Observation on 7/29/2023 at 9:10 a.m. revealed R#7 sitting in a geri-chair with a tray table secured in place to the geri-chair. Observation on 7/29/2023 11:38 a.m. revealed R#7 sitting in a geri-chair with a tray table secured in place to the geri-chair. Interview on 7/29/2023 at 11:42 a.m. with the Director of Nursing (DON) confirmed staff were not following R#7's care plan. 2. Review of EMR revealed R#18 was admitted with diagnoses including but not limited to dementia and major depressive disorder. Review of quarterly MDS dated [DATE], section C-Cognitive Patterns revealed a BIMS score of zero out of 15, indicating severe cognitive decline. Section P-Restraints indicated R#18 did not use a restraint. Observation on 7/29/2023 at 12:25 p.m. revealed R#18 being pushed down the hall by a CNA in a geri-chair with tray table secured to the chair. An interview with CNA EE revealed the tray table is used to keep resident from falling out of chair or attempting to get out of chair on her own. Review of the EMR revealed R#80 was admitted with diagnoses that included but not limited to traumatic subdural hemorrhage with loss of consciousness of unspecified duration, and pressure ulcer of sacral region, stage 3. 3. Review of R#80's quarterly MDS dated [DATE], section C-Cognitive Patterns revealed a BIMS score of four indicating R#80 was severely cognitively impaired. R#80 had behaviors to include physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, verbal/vocal symptoms like screaming, and disruptive sounds. Behaviors of this type occurred daily. Further review revealed R#80 was not assessed for the use of a restraint. Review of care plans for R#80 revealed there was not a care plan to address the use of restraints. Observation 7/28/2023 at 7:55 a.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/28/2023 at 9:26 a.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/28/2023 at 11:00 a.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/28/2023 at 12:15 p.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/28/2023 at 2:00 p.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/29/2023 at 7:45 a.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/29/2023 at 9:30 a.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/29/2023 at 10:15 a.m. of R#80 sitting in a geri-chair in their room with a tray table connected over the geri-chair. Observation 7/29/2023 at 11:47 a.m. of R#80 sitting in a geri-chair in their room with a tray table connected over the geri-chair. Observation 7/29/2023 at 12:50 p.m. of R#80 sitting in a geri-chair in their room with a tray table connected over the geri-chair. Observation 7/29/2023 at 1:55 p.m. of R#80 sitting in a geri-chair in their room with a tray table connected over the geri-chair. Observation 7/29/2023 at 2:30 p.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left.

42464 Based on observations, staff interviews, and review of facility policies titled, Restraints, Physical and Restraints, Consent For Use, the facility failed to ensure three of 27 sampled Residents (R) (R#7, R#18, and R#80) were free from the use of physical restraints. Specifically, geri-chairs (reclining, geriatric chair) with tray tables secured to the front of the chairs and wedges put underneath mattresses to raise them up were used, preventing R#7 and R#18 from getting up from the geri-chair and R#80 from getting out of the bed. Findings include: Review of facility policy titled, Restraints, Physical last update 3/16/2022 revealed: POLICY: Upon admission Residents and family is made aware that this facility strives to be Restraint Free. Our policy is in compliance with State and Federal regulations that the Resident has a right to be free from any physical or chemical restraint imposed for purposes of discipline or convenience and not required to treat the Residents medical symptoms. We will use restraint free methods such as: Low beds, low chairs, bean bag, door alarms, floor mats, cushions, and other adaptive devices as needed. PROCEDURE: If a Resident becomes physically abusive, which will cause harm to self or other, and Emergency physical restraint will be used at this time, only, until further measures can be obtained or met, (Soft Belt Restraint only). RESTRAINT= Vest, Soft Belt, Side Rails, and any other mechanism which limits/restricts movements of the Resident including Chemical Restraints. Review of facility policy titled, Restraints, Consent For Use last updated 3/16/2022 revealed: POLICY: It is the policy of this facility to maintain the residents as restraint free as possible. Written consent shall be obtained for application of physical restraints. PROCEDURE: 1. The attached form shall be completed by both nursing and the resident or responsible party. 2. Restraints will be applied only with a Physician's order and consent of the resident or responsible party EXCEPT when the situation warrants emergency application of a restraint for 'the safety and/or protection of the resident. In such instances, the physician shall be notified as soon as possible after application of the restraint to obtain appropriate orders. The responsible party shall be notified also. A consent will be obtained at that time. 3. The following restraint protocols shall be observed: a. the resident shall be checked every 30 minutes. b. the restraint shall be released every 2 hours for exercise or ROM. c. the residents will receive ongoing evaluations for entry into restraint free trial or restraint reduction by the Rehab Nurse. Review of the electronic medical record (EMR) revealed R#7 was admitted to the facility with diagnoses including but not limited to dementia, anxiety disorder, psychosis, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE], section C-Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive decline. Section P-Restraints indicated R#7 did not use restraints. Observation on 7/28/2023 at 11:10 a.m. revealed R#7 sitting up in a geri-chair with tray table secured in place to geri-chair. Observation on 7/29/2023 at 9:10 a.m. revealed R#7 sitting in geri-chair with tray table secured in place to geri-chair. Observation on 7/29/2023 11:38 a.m. revealed R#7 sitting in geri-chair with tray table secured in place to geri-chair. Review of R#7's Physician Orders revealed no order in place for tray table over geri-chair. Review of R#7's EMR and physical chart revealed no consents from R#7's responsible party (RP) for restraint use and no restraint assessments. Review of R#7's care plan revealed a problem: R#7 is physically mobility impaired with h/o [history of] multiple falls prior to admission and remains at potential for falls/edema/pain/skin breakdown with dx [diagnosis] of dementia/Alzheimer's with actual falls on 12/23/2022, 12/25/2022, 12/30/2022 w/injury, 1/2/2023, and 3/24/2023 w/o injury noted with a wedge compression fracture to left vertebra during hospitalization , last revised on 5/1/2023 with an intervention that stated R#7 to be out of bed in geri-chair without lap tray [tray table] last revised on 2/18/2023. Interview on 7/29/2023 at 11:38 a.m. with Certified Nursing Assistant (CNA) EE revealed the tray table is used on R#7's geri-chair to make sure she does not fall out of the chair because she wiggles around a lot. CNA EE stated the tray table was used when R#7 was out of bed and removed when resident was put to bed. Interview on 7/29/2023 at 11:42 a.m. with the Director of Nursing (DON) revealed the facility has no residents with restraints. It was further revealed R#7 should not have a tray table over her except during meals. The DON confirmed R#7 does not have an order or assessment for restraint use. 2. Review of EMR revealed R#18 was admitted with diagnoses including but not limited to dementia and major depressive disorder. Review of quarterly MDS dated [DATE], section C-Cognitive Patterns revealed a BIMS score of zero out of 15, indicating severe cognitive decline. Section P-Restraints indicated R#18 did not use a restraint. Observation on 7/29/2023 at 12:25 p.m. revealed R#18 being pushed down the hall by a CNA in a geri-chair with tray table secured to the chair. An interview with CNA EE revealed the tray table is used to keep resident from falling out of chair or attempting to get out of chair on her own. Interview on 7/30/2023 at 12:27 p.m. with the DON revealed R#18 should not have the tray table in place. The DON stated the facility does not use restraints. The DON confirmed R#18 had a tray table secured in place and did not have an order, care plan, or assessment done. 3. Review of the EMR revealed R#80 was admitted with diagnoses that included but not limited to traumatic subdural hemorrhage with loss of consciousness of unspecified duration, and pressure ulcer of sacral region, stage 3. Review of R#80's quarterly MDS dated [DATE], section C-Cognitive Patterns revealed a BIMS score of four indicating R#80 was severely cognitively impaired. R#80 had behaviors to include physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, verbal/vocal symptoms like screaming, and disruptive sounds. Behaviors of this type occurred daily. Further review revealed R#80 was not assessed for the use of a restraint. Review of care plans for R#80 revealed there was not a care plan to address the use of restraints. Observation 7/28/2023 at 7:55 a.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/28/2023 at 9:26 a.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/28/2023 at 11:00 a.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/28/2023 at 12:15 p.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/28/2023 at 2:00 p.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/29/2023 at 7:45 a.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/29/2023 at 9:30 a.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/29/2023 at 10:15 a.m. of R#80 sitting in a geri-chair in their room with a tray table connected over the geri-chair. Observation 7/29/2023 at 11:47 a.m. of R#80 sitting in a geri-chair in their room with a tray table connected over the geri-chair. Observation 7/29/2023 at 12:50 p.m. of R#80 sitting in a geri-chair in their room with a tray table connected over the geri-chair. Observation 7/29/2023 at 1:55 p.m. of R#80 sitting in a geri-chair in their room with a tray table connected over the geri-chair. Observation 7/29/2023 at 2:30 p.m. of R#80 lying on their right side in bed. The left side of R#80's bed was pushed up against the wall. The right side of the mattress was raised up with two blue wedges underneath. The mattress was tilted to the left. Observation 7/30/2023 at 7:45 a.m. of R#80 lying in bed with eyes open. The bed was lowered to the floor. Blue wedges noted in a chair in the room. Observation 7/30/2023 at 8:20 a.m. of R#80 out of bed sitting in geri-chair in room. There was not a tray table over the geri-chair. Interview on 7/28/2023 at 9:25 a.m. with the Director of Nursing (DON) revealed the DON does not consider the wedges underneath R#80's mattress to be a restraint. She stated that it does not seem to be uncomfortable. DON stated that she did not lie on the mattress, but it did not seem to be uncomfortable. She stated that R#80 can move around in the bed. The DON stated that they tried everything to include checking on him every 30 minutes. The DON stated that R#80 was coming out of the bed. She stated they tried him on a low bed but that did not work out well because he was crawling on the floor and pulling down things like the curtains. She stated they put him back in a regular bed and placed the wedges underneath the mattress so that he could not get out of bed. She stated that you would have to get to know him and know his history. DON stated that they were trying to keep him safe by putting the wedges underneath the right side of his mattress. The DON again stated that R#80 cannot get out of bed while the wedges are underneath it. She stated that was why it was there because they did not want him to get out of bed. Interview on 7/29/2023 at 11:57 a.m. with Licensed Practical Nurse (LPN) BB revealed she was familiar with R#80 and his care. She stated that she was not sure if the wedges underneath the mattress were a restraint or not. She stated that she did what her DON told her to do. LPN BB stated that R#80 cannot get out of bed when the wedges are underneath it. She stated that because he had a lot of falls, they do not want him to get up. LPN BB stated that R#80 cannot remove the lap tray from the geri-chair. She stated he can push it forward, but he cannot remove it. Interview on 7/29/2023 at 1:46 p.m. with the DON revealed that she does not consider the lap tray over the geri-chair a restraint. She stated that she considers it an enabler. The DON stated that if the tray was not over the geri-chair, R#80 would get up. She stated that R#80 falls a lot, and the lap tray prevents him from falling. The DON stated that R#80 was not able to physically remove the lap tray. She stated that they do not want him to remove it. Interview on 7/30/2023 at 8:21 a.m. with Licensed Practical Nurse (LPN) GG revealed that she was familiar with R#80 and his care. LPN GG stated that she considers the geri-chair with the lap tray over it a restraint. She stated that she also considers the bed with the wedges under the right side of the mattress to be a restraint. LPN GG stated that R#80 cannot get out of the bed while it has the wedges underneath the mattress. She stated that R#80 cannot remove the lap tray from the geri-chair. LPN GG stated that R#80 can move around in the chair and in the bed. Interview on 7/30/2023 at 10:53 a.m. with the Administrator revealed she was not aware that there were restraints in the facility. She stated that she heard a conversation yesterday about restraints. She stated that they try to keep the residents safe.