Every finding on record at Pines of Sarasota

Based on record review, facility policy review, residents and staff interviews, the facility failed to provide necessary care and services to maintain good personal hygiene for 2 (Residents #23 and #199) of 3 sampled residents who require assistance with activities of daily living.The findings included: Review of the Facility provided Policy Activities of Daily Living (ADLs) Maintaining Abilities effective date 11/28/17 documented Policy: It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs. Procedure: 1) Based on comprehensive assessment of a residents needs and choices, the facility will provide the necessary care and services to ensure . 3) The facility will provide care and services for the following ADL's: a) Hygiene – bathing, dressing, grooming, and oral care. 4) A resident who is unable to carry out ADL's will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . On 8/4/26 at 9:31 a.m., in an interview, Resident #199 said that the staff clean him but he does not get a shower and his hair has not been washed in a few weeks. Resident #199's hair looked greasy and unkempt. Review of the clinical record revealed Resident #199 was admitted to the facility on [DATE] with diagnoses including urinary tract infection, heart failure, benign prostatic hyperplasia (enlarged prostate) without lower urinary tract symptoms, essential tremor, and depression. Review of the Minimum Data Set (MDS) End of PPS Part A Stay with an assessment reference date of 7/23/26 documented that Resident #199 required Substantial/Maximal assistance with shower/bathing. The MDS documented that Resident #199 scored 13 of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the care plan for ADL (Activities of Daily Living) revealed the resident requires staff assistance with ADLs related to general weakness and limited mobility secondary to poor cardiac status. On 8/5/26 at 12:30 p.m., in an interview, Certified Nursing Assistant (CNA) Staff S said she checks the shower book to see residents' shower days. She said there is a shower sheet that should be filled out after each shower and showers are also documented in the computer. CNA Staff S said Resident #199 shower days are Tuesdays and Fridays on the 3-11 shift. Upon review of the shower book, CNA Staff S said there was only 1 shower sheet dated 7/17/26 for Resident #199. Review of the facility provided CNA Documentation for July 2026 revealed the time for ADL-Bathing was PRN (as needed). There was no documentation Resident #199 received the scheduled showers on 7/2, 7/7, 7/9, 7/14, 7/16, 7/21, 7/23, 7/28 and 7/30. On 7/5/26 and 7/19/26, N/A (Not applicable) was entered for the night shift (11:00 p.m. to 7:00 a.m.). On 8/5/26 at 4:53 p.m., in an interview, Unit Manager Registered Nurse Staff S said that Resident #199's shower schedule was not added to electronic record, therefore the showers did not show up in the CNA task. She said the CNAs are supposed to check the shower book daily. Upon reviewing the resident's clinical record and shower book, the Unit Manager said that the only documented shower for Resident #199 for July 2026 was on 7/17/26. She said she did not have any other shower sheets for the resident. Review of the clinical record for Resident #23 revealed an admission date of 9/22/23 and a readmission date of 2/21/24. Diagnoses included: mild dementia, need for assist with personal care, and type 2 diabetes mellitus. Review of the Annual Minimum Data Set (MDS) with a date of 8/2/26 revealed that Resident #23 scored 15 of 15 on the Bried Interview for Mental Status, indicating intact cognition. The MDS documented Resident #23 required partial to moderate assistance with toileting hygiene, showers/bathing, and set up for personal hygiene and refusal of care occurred 1-3 times a week. Review of Resident #23's care plan revealed that the resident required assistance with activities of daily living (ADLs) related to decreased mobility, general weakness, and impaired cognition. On 8/3/26 at 3:03 p.m., Resident #23 was observed sitting on the side of his bed. He said that he was getting dressed. Resident #23 had an incontinent brief on and his pants were around his knees. The resident's fingernails were jagged and extended approximately 1/2 inch from the fingertip with a brown substance under the nails. The room had a foul, pungent odor. A towel smeared with feces was observed on the resident's wheelchair. On 8/4/26 at 9:46 a.m., Resident #23 was observed in his room sitting on the side of the bed eating breakfast. The room remained with a strong, pungent odor. The towel smeared with feces remained on the wheelchair. A urinal approximately three-quarters full of urine was observed stored inside a trash can next to the resident's bed. On 8/5/26 at 12:39 p.m., Resident #23 was observed in his room in bed, under the covers. He did not answer to interview questions. A towel smeared with feces was laid across the resident's wheelchair cushion. On 8/5/26 at 12:45 p.m., in an interview, Licensed Practical Nurse (LPN) Staff I said that Resident #23 refused care sometimes but you would have to ask the CNA (Certified Nursing Assistant). On 8/5/26 at 12:55 p.m., in an interview, CNA Staff J said Resident #23 was a slow riser and liked to sleep in. CNA Staff J said that the resident's scheduled showers were on the evening shift (3:00 p.m., to 11:00 p.m.). When asked about pungent odor in the resident's room, CNA Staff J said, Yes, the room stinks. On 8/5/26 at 1:47 p.m., in an interview, CNA Staff K said that Resident #23 occasionally refused care but was able to do a lot for himself. She said, If he tells me no, I will ask him again later. Review of the CNA documentation for July 2026 revealed that Resident #23 was scheduled for showers on the evening shift (3:00 p.m., to 11:00 p.m.) shift on Wednesdays, Fridays and Sundays. The CNA documentation showed that Resident #23 refused his scheduled showers on 7/1, 7/3, 7/10,7/15 and 7/31/26. On 8/5/26 at 5:16 p.m., in an interview Licensed Practical Nurse (LPN) Staff L said that she knew Resident #23 well but was not aware that he refused care. On 8/5/26 at 5:36 p.m., in an interview CNA Staff M said that Resident #23 will refuse care. She said, At mealtimes if you open his milk or uncover the food for him, he will throw it at you. He does not like it when you do that. He does not always let you shower him. I try and talk to him but if he keeps saying no, I don't do it. He gets angry fast. If he says no, it is no. On 8/6/26 at 9:28 a.m., in an interview, the Assistant Director of Nursing (ADON)/Risk Manager said he was not aware that Resident #23 refused care. On 8/6/26 at 9:32 a.m., Unit Manager LPN Staff N said that no one told her the resident was refusing care or showers. She verified there was no care plan and interventions in place to address the refusal of care and ensure the resident received the necessary care and services to maintain personal hygiene.

Based on observation, clinical record review, facility policy and procedures review, residents and staff interviews, the facility failed to provide the necessary care and services, including supervision to prevent unnecessary falls for 2 (Residents #76 and #215) of 3 residents reviewedThe findings included: Review of the facility provided policy for Mechanical Lift for Transfer with revision dates of 7/11, 7/12 and 12/17 revealed, Purpose: To safely transfer between surfaces such as the bed or chair to prevent injury to both the staff and resident. Policy: Two (2) staff members must be present during the transfer for all mechanical lifts. On 8/4/26 at 10:22 a.m., Certified Nursing Assistant (CNA) Staff Q was observed lowering Resident #215 into a wheelchair with a full body mechanical lift. In an interview, CNA Staff Q said that she had requested another CNA's assistance but she decided not to wait and transferred the resident alone. CNA Staff Q said that approximately one month ago, during orientation, she learned that 2 staff are always required for all residents' transfers with a mechanical lift. She said a resident could get injured if a CNA transfers a resident with the mechanical lift alone. Review of the clinical record for Resident #215 revealed an admission date of 7/3/26. Diagnoses included chronic obstructive pulmonary disease, heart failure, generalized anxiety disorder, and depression. Review of the 5 Day Minimum Data Set (MDS) assessment with an assessment reference date of 7/9/26 revealed that Resident #215 was dependent on staff for transfers. Resident #215 scored 14 of 15 on the Brief Interview for Mental Status, indicating intact cognition. The MDS noted that Resident #215 was dependent on staff for transfers. The physician's orders dated 8/1/26 included non-weight bearing and the use of a full body mechanical lift. The baseline care plan dated 8/1/26 documented that Resident #215 was dependent for transfers. On 8/4/26 at 10:35 a.m., in an interview, Registered Nurse (RN) Staff R, said 2 staff are required when transferring a resident with a mechanical lift. He said a resident can be injured when only 1 staff uses a mechanical lift alone. RN Staff R said the staff are educated on having 2 staff for mechanical lift transfers. Review of the facility provided skills checklist for CNA Staff Q revealed that on 7/17/26 CNA Staff Q successfully completed a Mechanical Lift Competency Skills. The checklist included, Two staff members are used during transfer at all times, no exception. CNA Staff Q signed the Mechanical Life Competency Skills Checklist on 7/17/26 acknowledging her competency and understood that it was her responsibility to sustain competencies in the areas documented on the skills checklist. Review of the facility provided Fall Management Policy and Procedure with an effective date of 4/11/2022 and revision date of 09/2025 revealed, Residents are evaluated for fall risk. Patient centered interventions are initiated, based on resident risk. Purpose: Is to identify residents at risk for falls and establish/modify interventions to decrease the risk of a future fall(s) and minimize the potential for a resulting injury. Process: Fall Mitigation. Residents to be evaluated for fall risk on admission/re-admission, quarterly, annually or upon identification of a significant change in status. Fall risk is based off results of the Fall Risk Assessment. Contributing factors i.e. medications, diagnosis . Environmental factors i.e. lighting. The facility's Fall Management Policy and procedure included a Falling Star Program. The program noted, The Falling Star Program is a comprehensive program designed to identify and address residents 'actively at risk' for falls. The Falling Star Program will be a full facility program including all disciplines 24 hours a day, seven days a week. Review of the facility's Quality Assurance and Performance Improvement (QAPI) Risk Management guidelines documented that the Risk Manager is responsible for reviewing incident reports for completeness, completing investigations, and presenting each incident during the stand up meeting the next business day for care plan review. The interdisciplinary team is expected to discuss causative factors, determine necessary interventions, make therapy referrals as appropriate, and revise the plan of care when needed. Review of the clinical record for Resident #76 revealed an admission date of 2/27/26 with re-admissions on 3/12/26 and 6/3/26. Diagnoses included seizures, lack of coordination, repeated falls, muscle weakness, severe morbid obesity, depression, and bipolar disorder. Review of the Significant Change in status Minimum Data Set (MDS) assessment with an assessment reference date of 6/5/26 revealed that Resident #76 scored 03 of 15 on the Brief Interview for Mental Status, indicating severe cognitive impairment. The MDS noted that the resident used a wheelchair and required partial to moderate assistance with transfers, and ambulation up to 10 feet. Review of the care plan initiated on 2/26/26 and revised 8/5/26, revealed that Resident #76 was at risk for falls and fall related injuries related to general weakness, limited mobility, seizure disorder, fall history and use of psychotropic medications. The goal was for the resident to have interventions in place that will minimize the risk of falls and major injury Interventions included anticipating and meeting her needs, conducting approximately hourly safety checks after a fall, assisting the resident in maintaining a clutter free environment, educating her to call and wait for assistance, providing non skid footwear, ensuring the call bell was in reach, implementing the Falling Star Program, placing visual reminders to encourage her to call for assistance, and following facility seizure and fall protocols. The care plan noted that Resident #76 sustained 9 falls from April 2026 to August 5, 2026. Review of the falls revealed: Fall #1 A Post Fall evaluation progress note dated 5/3/26 at 7:15 p.m., noted that Resident #76 sustained an unwitnessed fall in the bathroom. Resident was attempting to self-toilet at the time of the fall. The resident stated, I slid down. Interventions added to review shoes and slippers for appropriate tread and replace if needed. Fall #2 An interdisciplinary progress note dated 4/21/26 at 11:24 a.m., noted that on 4/21/26 at approximately 6:40 a.m., Resident #76 was found lying on the floor in her room on her abdomen. She stated that she stood up, fell backwards and hit her head. She was sent to the Emergency Room. Neurological checks were initiated and were within normal limit. The progress note documented that Resident #76 had decreased safety awareness and remained at risk for falls. The care plan was reviewed and the interventions in place were appropriate. Fall #3 A Nurse's note dated 5/4/26 noted that the resident was reviewed in IDT (Interdisciplinary team) incident meeting related to fall which occurred on 5/3/26 at approximately 6:15 p.m. The resident was found on the floor on the right side in her room, between the recliner and the bed. She stated that she lost balance attempting to move laundry from top of bed. A head to toe assessment at time of the fall revealed complaint of low back pain. X-rays performed which were negative for fracture. Resident with decreased safety awareness and remains at risk for falls. The care plan was reviewed and the interventions in place and appropriate. The note documented that additional interventions were added to include hourly safety checks status post fall and rehab screen. Fall #4 A progress note dated 5/6/26 noted that Resident #76 sustained an unwitnessed fall in her room on 5/6/26. The reason for the fall was that the resident was ambulating without assistance. A progress note dated 5/7/26 noted that the resident was reviewed in IDT meeting related to a fall that occurred on 5/6/26 at approximately 9:21 a.m. The resident was found lying on her back beside the bed with arms under her head. The resident sustained no injuries. Resident has decreased safety awareness and remains at risk for falls. The care plan was reviewed. Interventions were in place and appropriate. Intervention added was for Psych review status post fall. Fall #5 A progress note dated 5/19/26 documented that Resident #76 was reviewed in IDT incident meeting related to a fall which occurred on 5/16/26. Resident #76 was found sitting on the floor in front of her bed. She stated that she was trying to ambulate to the bathroom. The resident did not sustain any injuries from the fall. The progress note documented Resident #76 had cognitive alteration, decreased safety awareness and remained at risk for falls. Care plan reviewed and interventions were in place and appropriate. Interventions added to include prompted toileting, offer toileting in morning and bedtime, before and after meals and as needed. Fall #6 A progress note dated 6/1/26 documented that Resident #76 was reviewed in IDT incident meeting related to a fall which occurred on 5/31/26 at approximately 9:55 a.m. Resident #76 was found on the floor next to bed, cluttered environment noted with shoes on the floor. The resident stated she attempted to obtain item from the closet and did not ask for assistance. Resident #73 did not sustain any injuries. The progress note documented that the resident had alteration in cognition, decreased safety awareness, and remained at risk for falls. The care plan was reviewed and interventions were in place and appropriate. Intervention added to include assist to maintain clutter free environment. Fall #7 A progress note dated 7/15/26 revealed that Resident #76 was reviewed in IDT incident meeting related to a fall that occurred on 7/14/26 at approximately 10:40 p.m. The resident was found lying on the back on the floor in her room. The floor was wet as her drink had spilled. Resident had alteration in cognition, decreased safety awareness, and remained at risk for falls. Intervention added to include Dycem (non-slip mat) to bedside table to lessen risk of drink spillage. Fall #8 A progress note dated 7/22/26 documented that Resident #76 had an unwitnessed fall in her room. The resident was attempting to self-transfer. Resident #76 hit her head and sustained a skin tear to the right knee from the fall. Resident #76 was transferred to the Emergency Room. Fall #9 A progress note dated 8/5/26 documented that on 8/5/26 at 6:45 a.m., Resident #76 was found on the floor in her room and sustained an abrasion to the left knee. On 8/5/26 at 8:20 a.m., in an interview, Licensed Practical Nurse (LPN) Staff I stated Resident #76 does fall frequently. She acknowledges reminders to use the call light, but the resident performs tasks independently despite staff instruction. On 8/5/26 at 10:03 a.m., in an interview, Certified Nursing Assistant (CNA) Staff K stated that Resident #76 fell that morning while attempting to walk to the bathroom without assistance. She said that they did hourly rounds on the resident. She said the hourly rounds consisted of checking as we pass by. On 8/5/26 at 10:25 a.m., Resident #76 was observed lying in bed. In an interview, Resident #76 said I don't know why I keep falling. I don't remember to look at the sign to use the call bell, I just don't think of it. I get up to go to the bathroom, trying to do it myself and I just go because I have to go to the bathroom. The resident said, I fell this morning. I think I was going to the bathroom right there and I thought I could just go and make it but I fell. When I have to go, I have to go. She stated she forgets to use the call light and attempts to toilet independently because she feels urgency and believes she can manage it herself. On 8/5/26 at 5:15 p.m., CNA Staff M stated Resident #76 has a lot of falls. She said that monitoring the resident consisted of staff checking on her when passing by her room. On 8/6/26 at 9:18 a.m., in an interview, the Assistant Director of Nursing/Risk Manager stated that fall reviews occur daily and weekly. Hourly checks are conducted for 72 hours after a fall, and that no root cause had been identified for Resident #76's frequent falls. On 8/6/26 at 9:32 a.m., in an interview, Unit Manager LPN Staff N stated that Resident #76 attempts to perform tasks independently, does not call for assistance. LPN Staff N said that the resident had been moved closer to the nursing station and provided environmental safety measures. LPN Staff N said no root cause had been determined.

Based on observation, review of facility policy and procedure, resident and staff interviews, the facility failed to ensure the safe storage of medications to prevent unauthorized access for 3 (Residents #66, #167 and #76) of 3 residents observed with unsecured medications at bedside.The finding included:Review of the Facility provided policy and procedure for storage of medications with revision dates of 2/03, 3/04 and 6/15 revealed that the policy was to ensure that the storage of all medications was in accordance with currently accepted principles, laws, policies and regulations. The procedure noted that all medications are stored in a locked room, cabinet or cart.On 8/3/26 at 11:44 a.m., observation of Resident #66's room revealed an opened, undated bottle of normal saline and 2 syringes were observed stored on the counter next to the sink in the bathroom. Photographic evidence obtained.On 8/4/26 at 9:54 a.m., an opened undated bottle of saline and a syringe were observed on the counter, next to the sink in the resident's bathroom.Photographic evidence obtained.On 8/4/26 at 10:17 a.m., observation of Resident #76's room revealed a box of pain relief patches stored unlocked on the resident's bedside table. In an interview, Resident #76 said she has been having pain in her left side from her shoulder down to her abdomen and they applied a pain relief patch the night before.Photographic evidence obtained.On 8/4/26 at 9:56 a.m., in an interview, the Assistant Director of Nursing said that saline bottles and saline flushes should be dated when opened and stored in the treatment cart. He said those items should not be in the resident's room and should be locked up.On 8/5/26 at 9:00 a.m., observation of Resident #167's room during Medication Administration revealed a bottle of saline nasal spray, a bottle of fluticasone Propionate suspension (medication used to treat season allergies), a bottle of artificial tears (eye drops) and a bottle of Systane Eye Drops on resident's overbed table. Photographic evidence obtained. On 8/5/26 at 9:05 a.m., in an interview, Registered Nurse (RN) Staff P said residents are allowed to keep medications at bedside if they have a physician order to self-administer. RN Staff P said to speak with the Unit Manager since she was not sure if the medications needed to be locked up or not.On 8/5/26 at 4:19 p.m., in an interview, RN Staff E, Unit Manager (RN, UM) said medications should never be left in a resident's room. They should always be locked in the medication or treatment carts.

Based on record review and staff interviews, the facility failed to ensure that an allegation of resident-to-resident abused involving 2 (Residents #2 and #21) of 2 residents reviewed was reported to the State Agency as required. The findings included: Review of the facilities Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property Prevention Policy dated 11/28/17 (revised 5/19/19 and 4/24/21) Defines Sexual Abuse as; includes, but is not limited to sexual harassment, sexual coercion or sexual assault. VII. Reporting/Response: In response to allegations of abuse, neglect, exploitation, or mistreatment the facility will: 1. ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source.are reported immediately, but not later than 2 hours after the allegation is made.in accordance with State Law through established procedures.4. Report results of all investigations to the Administrator or his designated representative and to other officials in accordance with State Law, including State Survey Agency, within 5 working days of the incident.Review of the facilities Summary of Occurrence dated 7/24/26 revealed that on 7/23/26 at approximately 2:20 p.m., Certified Nursing Assistant (CNA) Staff B discovered Resident #2 lying unclothed in Resident #21's bed. CNA Staff B observed Resident #21 observed unclothed and sitting in her wheelchair next to the bed. The facility summary documented that Staff B, Staff D and Staff A separated the Residents and assisted them to put their clothes on.Review of the medical record revealed Resident #2 had diagnoses including dementia without behavioral disturbance. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated severely impaired cognition.Review of Resident #21 medical record revealed diagnoses including dementia without behavioral disturbance, anxiety and major depressive disorder. The MDS assessment dated [DATE] reflected severe cognitive impairment.Review of the Summary of Occurrence completed by the Risk Manager revealed that Staff E assessed Resident #2 and Resident #21. Resident #21 had no skin problems, issues or discomfort.Review of the facility provided investigation documentation did not establish how Resident #2 entered Resident #21's room, how long the Residents had been together, whether physical contact had occurred or whether either Resident could reliably describe the event.Review of the facilities incident reporting log revealed no evidence that the incident had been reported to the State Agency. The Director of Nursing and Administrator were unable to provide documentation that a report had been submitted within the federal reporting timeframes.On 8/4/26 at 1:45p.m. in an interview with the Director of Nursing (DON) she stated that she has not had any 1 day or 5 day reportable incidents in the last 6 months.On 8/4/26 at 1:41p.m. in an interview with the Administrator he stated that he was not sure if they had any 1 or 5 day reportable incidents. He said that I would have to get with the DON.On 8/5/26 at 10:20a.m. in an interview with the Social Worker, she said she did not recommend reporting the incident externally. She said she was not aware if it was reported. She said that she was aware that the facility has a protocol for allegations involving possible sexual abuse, but she was not sure if they were followed because she has not had to report anything since she has been working here.On 8/5/26 at 8:39 a.m., in an interview with the DON she said, We wouldn't notify the police because they were caught so quickly that we didn't feel it rose to that level to report.On 8/5/26 at 8:45 a.m., in an interview with the Administrator he said, It wasn't abuse, that's why we didn't need to report it.

Based on observation, record review, and staff interviews, the facility failed to develop and implement an individualized, person centered plan of care to address the ongoing refusal of care for 1 (Resident #23) of 32 residents reviewed for care planning. The findings included:On 8/3/26 at 3:03 p.m., observation of Resident #23's room revealed a foul, pungent odor in the resident's room. Resident #23 was seated at his bedside wearing a brief with his pants around his knees, stating he was getting dressed. His urinal, half full of urine, was placed in the trash can. A towel on the wheelchair seat was smeared with feces. His fingernails extended approximately 1/2 inch from the fingertip, were jagged, with brown debris under the nails. In an interview during the observation, Resident #23 stated that he completes his own care except for showers. The room was cluttered with boxes and personal items on the floor.On 8/4/26 at 9:46 a.m., Resident #23 was observed eating breakfast in his room. The room remained with a pungent odor. The towel smeared with feces remained on the wheelchair. The resident's fingernails remained untrimmed, jagged, with an accumulation of brown substance under the nails. The resident's urinal was almost filled with urine and remained in the trash can.On 8/5/26 at 12:39 p.m., Resident #23 was observed in bed under the covers. He did not respond to interview questions. The towel smeared with feces remained on the wheelchair. The urinal was half full of urine and remained in the trash can.On 8/5/26 at 12:45 p.m., in an interview, Licensed Practical Nurse (LPN) Staff I stated that Resident #23 sometimes refuses care but recommended speaking with the Certified Nursing Assistant (CNA).On 8/25/26 at 12:55 p.m., in an interview, CNA Staff J stated that Resident #23 was a slow riser, preferred to sleep in, and received showers on the 3-11 shift. CNA Staff J verified the strong ongoing odor in the resident's room. She said that Resident #23 did not exhibit behaviors with her.On 8/5/26 at 1:47 p.m., in an interview, CNA Staff K stated that Resident #23 received afternoon showers, occasionally refused care, and was able to perform many tasks independently. She stated that if the resident refuses care initially, she attempts to provide the care again later.Record review for Resident #23 revealed an original admission date of 9/22/23 and a readmission date of 2/21/24. Diagnoses included mild dementia, need for assistance with personal care, and type II diabetes mellitus.Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed Resident #23 scored 15 of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognitive skills for daily decision making. The assessment documented that the resident requires partial to moderate assistance with toileting hygiene and bathing, setup assistance for personal hygiene, and refuses care 1-3 times per week.Review of the resident's care plan revealed the resident required staff assistance with Activities of Daily Living (ADLs) related to decreased mobility, general weakness, and impaired cognition. The stated goal was for the resident to participate in self care activities to the highest level to maintain optimal performance and quality of life. Interventions included monitoring for decline in ADLs and reporting changes to nursing, praising self care efforts, encouraging participation, and providing assistance with bed mobility and repositioning. However, the care plan did not include individualized interventions to address the resident's ongoing refusal of care or his associated behaviors.Review of the CNA documentation for July 2026 revealed that Resident #23's scheduled showers were on Wednesdays, Fridays, and Sundays during the 3-11 shift. The CNA documentation noted that Resident #23 refused his scheduled shower on 7/1, 7/3, 7/10, 7/15, and 7/31.On 8/5/26 at 5:16 p.m., , LPN Staff L stated that Resident #23 frequently refused medications. She said he refused to take his evening medications and she notified the physician. She said that she was not informed that he was refusing care or concerns with room odor. Upon entering the room, LPN Staff L acknowledged the strong odor in the resident's room. She observed the resident's urinal stored in the trash can and said it was an infection control risk. On 8/5/26 at 5:36 p.m., in an interview, CNA Staff M stated that Resident #23, will refuse care. He gets angry if staff open or uncover food items without permission. He sometimes refuses showers. She stated that if the resident refuses, she does not proceed. She said, If he says no, it is no.On 8/6/26 at 9:28 a.m., in an interview, the ADON/Risk Manager said that he was not aware that Resident #23 was refusing care, or that he was placing his urinal in the trash can.On 8/6/26 at 9:32 a.m., in an interview, LPN Unit Manager Staff N reported that she was not aware that Resident #23 was refusing care or his scheduled showers. She said that she was not told that he was placing his urinal in the trash can. LPN Unit Manager Staff N verified that there was no care plan addressing Resident #23's refusal of care and showers. On 8/6/26 at 11:47 a.m., in an interview the MDS Coordinator stated that care plans are completed by the interdisciplinary team., with the entire team's input. He reviewed Resident #23's care plan and verified that there were no interventions in place to address the resident's refusal of care or behaviors. He said he would notify Social Services who typically completes the behavior care plans. He said he was not aware of Resident #23's behaviors and refusal of care.

Based on observations, interviews, and record review, the facility failed to ensure resident food allergies were accurately communicated and honored for two residents (Resident #144 and Resident #12) out of two residents reviewed for food allergies, from a total sample of 49 residents.The findings include: On 08/03/2026 at 11:00 AM, during an interview with Resident #144, he stated he is allergic to berries and cherries and reported receiving a blueberry muffin on his breakfast tray on two recent occasions. He stated he did not eat the muffins because he breaks out in hives when he consumes berries or cherries. He stated he had informed staff of his allergies more than once.On 08/03/2026 at 12:45 PM, Resident #144 was observed with his lunch tray. His printed meal ticket listed an allergy to cherries, but did not list berries, despite his stated allergy.On 08/04/2026 at 9:05 AM, Resident #144 was observed with his breakfast tray. The meal ticket again listed cherries only. When asked to confirm his allergies, he stated he was allergic to berries, all berries-blueberries, strawberries, gooseberries, anything with berry. He stated he had received a blueberry muffin a couple other times, although not on the prior day.A review of Resident #144's electronic medical record revealed the following documented allergies in the allergy tab: Penicillin (12/12/23), Berries (12/12/23), and Cherries (01/10/25). The quarterly Minimum Data Set, dated [DATE] documented a Brief Interview for Mental Status score of 13, indicating intact cognition.His person centered care plan included a focus area identifying increased nutritional risk related to food allergies to cherries and berries, with interventions to avoid exposure to food allergens.On 08/06/2026 at 8:45 AM, during meal tray service on the nursing unit, Resident #12's meal tray was observed with a printed ticket listing allergies to blueberries, strawberries, raspberries, berries, seeds, and corn. When the plate cover was lifted, a muffin was observed. Employee W, a Licensed Practical Nurse (LPN), initially stated it was chocolate chip but, after checking with the kitchen, confirmed the muffin was blueberry, which contained an allergen listed on Resident #12's tray ticket. A corn muffin was offered by the kitchen as an alternative, but the nurse declined it because Resident #12 also had a documented allergy to corn. Interviews with dietary and nursing staff revealed inconsistent processes for communicating resident food allergies. On 08/05/2026 at 4:50 PM, Employee G, Certified Dietary Manager, demonstrated that Resident #144's allergy to berries was documented in the electronic medical record but not carried over to the dietary software used to generate meal tickets, which displayed only cherries. He stated he had completed the resident's most recent nutrition evaluation on 07/27/2026, which noted allergies to cherries and berries, but acknowledged berries had not been entered correctly into the dietary system.On 08/06/2026 at 8:30 AM, Employee W, LPN, stated that nurses are responsible for checking trays against tickets before meals are served and confirmed that meal tickets should accurately reflect all resident food allergies.A review of the facility's Food Allergies policy indicated that resident food allergies must be identified, documented in the medical record, and clearly communicated to the Food and Nutrition Services department. The policy directs that food allergies must be listed on the meal identification card or tray ticket used during meal service.

Based on observations, interviews, and record review, the facility failed to ensure staff followed required transmission based precautions when entering a Contact Precautions room for one resident out of one resident (#36) reviewed for Contact Precautions, from a total sample of 49 residents.The findings include: On 08/03/2026 at 11:45 AM, an observation was made of Resident #36's room with a Contact Precautions sign posted on the door. The sign directed all individuals entering the room to perform hand hygiene before entering and upon exiting, don gloves and a gown prior to entry, and remove personal protective equipment (PPE) before exiting. A PPE cart outside the room contained gloves, gowns, and other PPE. Employee V, Licensed Practical Nurse, stated the resident was on Contact Precautions for Clostridium difficile [a bacterium that causes diarrhea and inflammation of the colon; commonly abbreviated as C. difficile].On 08/04/2026 at 9:10 AM, an observation was made of Employee H, Certified Nursing Assistant, entering Resident #36's room without performing hand hygiene and without donning gloves or a gown. Employee H assisted the resident to sit up in bed and was cutting the resident's breakfast food. When asked why she entered without PPE, Employee H stated she was told she only needed PPE if providing patient care, not for the meal tray. When asked whether she was aware of the reason for the precautions, she stated she was not.On 08/06/2026 at 12:00 PM, during an interview with the Director of Nursing, she stated Resident #36 was on Contact Precautions for C. difficile. She stated staff receive orientation and annual education instructing them to read and follow posted Transmission Based Precaution signage and confirmed that staff are required to don gloves and a gown before room entry and wash their hands before entering and before exiting. She stated all staff are expected to follow posted precautions and ask questions if unsure.A review of Resident #36's electronic medical record revealed a physician order dated 05/16/2026 for Contact Isolation related to C. difficile. The infection care pathway documented enterocolitis due to Clostridium difficile initiated 03/31/2026. The person centered care plan included a history of C. difficile under Bowel and Bladder with interventions for prompt incontinence care. Laboratory results showed positive stool cultures for C. difficile dated 06/18/2026, 06/25/2026, and 06/27/2026.A review of the facility's policy titled Clostridium Difficile (dated 10/2016) stated residents with C. difficile infection will be placed on special Contact Precautions requiring the use of gowns and gloves upon entry to the room and hand hygiene with soap and water after contact with the resident or their environment.

Based on observation, resident and staff interviews, the facility failed to keep the wheelchair used by 2 (Resident #14 and Resident #155) of 11 residents reviewed in good repair.The findings included: On 8/3/26 at around 1:00 p.m. during the initial tour of the facility, while interviewing Resident #14, she was observed sitting in her wheelchair with both armrests torn and the foam padding showing through the torn areas.In an interview, Resident #14 said the armrests on her wheelchair had been torn for a long time. She said she told a staff member a long time ago, but the armrests were never repaired.On 8/3/26 at around 3:25 p.m. during the initial tour, Resident #155 was observed sitting in her wheelchair. Observation of Resident #155's wheelchair noted both armrests were worn and cracked with the foam padding showing through the openings. Due to Resident #155's impaired cognition, she was unable to be interviewed.On 8/6/26 at 9:25 a.m. observation of Resident #14 and Resident #155's wheelchair noted their wheelchair arms were still torn with the foam padding showing as noted on 8/3/26. Photographic evidence obtained.On 8/6/26 at 10:11 a.m., in an interview, Unit Manager Staff N said all needed repairs to include resident equipment when identified, were required to be documented by staff in the TELS electronic computer system, so it was documented in the maintenance tracking system to be repaired. He said even when staff put the needed repair into the TELS system, he would continuously check on the item needing repair to ensure it was completed in a timely manner.On 8/6/26 at 10:25 a.m., Unit Manager Staff N observed Resident #14 and Resident #155's wheelchair and confirmed both wheelchair armrests were torn with the foam showing. He confirmed the wheelchair armrests needed to be repaired due to the risk of a potential skin tear to Residents #14 and #155 due to their fragile skin.On 8/6/26 at 1:18 p.m. during an interview with the Assistant Administrator and the Director of Plant Operation (DPO), they said all employees were required to document all facility damage and resident care equipment damage into the TELS computer system. The DPO said he and his staff review the TELS several times throughout the day, so they are aware of all needed repairs. He said this was to ensure the repairs were addressed in a timely manner to ensure residents and staff safety at all times. The Assistant Administrator said the facility did not have a policy and procedure related to maintaining all mechanical, electoral, and patient care equipment in a safe operating condition, but they do follow the Federal and State regulations for patient care equipment always being kept in a safe operating condition. The Assistant Administrator and the DPO reviewed the photographic evidence of Resident #14 and Resident #155's wheelchair armrests and stated the damaged/torn wheelchair arms were not placed into the TELS system as required causing a delay in the repair/replacement of the damaged wheelchair armrests in a timely manner which could potentially cause an injury to Resident #14 and Resident #155's arms due to their fragile skin condition.

Based on observations and interviews, the facility failed to ensure the safe storage of oxygen cylinders in 1 (West 1) of 4 units observed.The findings included:On 4/29/26 at 9:03 a.m., observation of the [NAME] 1 unit revealed 4 unsecured oxygen cylinders stored directly on the ground, not in the secured oxygen cylinder storage rack.The sign above the oxygen canisters read FULL OXYGEN CYLINDERS. Photographic evidence obtained.On 4/29/26 at 9:18 a.m., the Assistant Director of Nursing (ADON) verified the observation of the 4 cylinders of oxygen stored unsecured, directly on the ground. In an interview, the ADON verified that the oxygen cylinders were full and said they should not be stored on the ground.Review of the NFPA99 (2021) edition, 11.6.2.3 (11) revealed that, Cylinders shall be protected from damage by means of the following specific procedures: Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device . Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.On 4/30/26 at 11:27 a.m., in an interview, the Director of Nursing (DON) said oxygen cylinders should be stored in a secure rack. The DON said oxygen cylinders should never be stored directly on the ground. The DON said oxygen cylinders stored unsecured on the floor were a safety risk. On 4/30/26 at 11:50 a.m., in an interview, the Maintenance Director said that oxygen cylinders should be in a secure rack and never stored directly on the ground. The Maintenance Director said oxygen cylinders that are stored directly on the floor can fall over and do some damage.

Based on observations, interviews, and facility document review, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents for 2 (Residents #42 and #75) of 2 residents reviewed for medication storage. The findings included: Review of the facility policy titled Medication Storage in the Facility with an effective date of March 2019, showed Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 1. On 4/30/2024 at 9:40 a.m., Resident #75 was observed with 1 small circular white pill on the nightstand and 9 pills in a medication cup on his bedside tray table. Resident #75 said the small circular white pill is his diuretic pill. Resident #75 said he waits to take his diuretic pill after his physical therapy. Resident #75 said his doctor told him he could take it later so he will not have to use the bathroom during therapy. On 4/30/24 at 10:03 a.m., an interview with Agency Registered Nurse (RN) Staff E said she could not recall if she observed Resident #75 take his medications. RN Staff E confirmed the small circular white pill was on the nightstand of Resident #75. On 4/30/2024 at 10:10 a.m., Assistant Director of Nursing, Infection Control Preventionist, Risk Manager (ADON, ICP, RM) reviewed the Medication Administration Record (MAR) and confirmed RN Staff E signed off that 10 pills to Resident #75 were administered. The ADON said the nurse should stay with a resident to ensure all pills are taken at the time of administration. The ADON confirmed there was a small circular white pill on the nightstand. 2. On 5/01/24 at 9:50 a.m., an observation with the ADON was made of artificial tears medication sitting on the caddy bin in the hallway outside of Resident #42's room. * On 5/1/24 at 9:54 a.m., ADON said medications should not be left in the hallway. *Photographic Evidence Obtained

Based on record review and interview, the facility failed to ensure training was appropriate and effective as determined by staff need, following an incident resulting in 1 (Resident #19) sustaining a burn from over-heated food. The findings included: Facility policy titled Re-Heating Resident Food and Beverages effective 4/22/24 indicated: 4. Staff will set microwave to 30 seconds on initial and the 15 seconds on any additional, stirring with clean utensil to ensure even heating throughout and check temperature. 5. When the temperature of 165 degrees F (Fahrenheit) is reached, allow to sit covered for 2 minutes prior to serving. Item not to be greater than 140 degrees F at the time of service. On 04/29/24 at 12:31 p.m., Resident #19 picked up his shirt and pointed at a dressing on his abdomen. Resident #19 said it was from spilling hot soup on himself. He said he didn't like that. He said the dressing was changed daily. Record review of Resident #19's chart found a progress note dated 4/21/24 that indicated Resident #19 was found with burns on the lower right abdomen which had raised into vesicles. The Doctor and family were notified, dressing order was obtained, and wound care consult was ordered. On 5/1/24 at 3:29 p.m., Staff D Licensed Practical Nurse Unit Manager (LPN) said Resident #19 was discovered with a burn on his abdomen and said it was from soup his family had brought in. He said a Certified Nurse Assistant (CNA) had heated the soup in the microwave and when he went to eat it, he spilled it on himself. She said Resident #19 did not need to be sent out to the hospital and the wound was being treated in-house. On 5/2/24 at 10:10 a.m., the Director of Nursing (DON) said the incident had occurred because the CNA had not followed procedure and had not checked the temperature of the soup before serving it to Resident #19. The DON said the Assistant Director of Nursing Risk Manager (ADONRM) had provided training for the staff on re-heating food and the ADON was conducting audits to ensure policy is followed. The DON said Agency staff were trained by going through an orientation book and were included in in-services. The DON said the policy was also posted at the nurses' stations, break rooms and nutrition rooms. On 5/2/24 at 10:11 a.m., the ADON said she had been conducting audits by watching staff if they rewarm residents' food. She said she checks to ensure they temp after reheating and clean the thermometer. On 5/2/24 at 9:35 a.m., Staff A (CNA) said he wouldn't reheat food but if he had to, he would make sure it fits their diet. He said he wouldn't do over 30 seconds. He said he had training, but it was about a year ago. He said there was a thermometer in the nourishment room and when asked how hot food should temp, he said nothing over 100 degrees F. On 5/2/24 at 9:50 a.m., Staff B (Agency CNA) said she thought dietary would reheat food. She said she did not know if she could reheat food. Said she did some computerized training but doesn't remember anything about reheating food. On 5/2/24 at 9:54 a.m., Staff C (Agency CNA) said she had not had to heat up food and asked can she heat it up? She said she knows she is not allowed to take food out of the room once it's in there. She said if they ask to heat up the food, she honestly did not know what to do. She said she was not aware of any training on reheating food. On entry to nourishment room, the policy was posted on the cabinet and Staff C said no one had ever gone over that with her. On 5/2/24 at 10:15 a.m., the Director of Nursing (DON) was informed 3 CNAs were unable to explain the procedure for reheating food safely. The DON said they will have to begin retraining again.

Based on observation, and staff interviews, the facility failed to store a urinary catheter drainage bag in a sanitary manner to prevent infection for 1 (Resident #117) of 3 residents sampled with indwelling catheters. The findings included: On 1/9/23 at 10:09 a.m., a urinary catheter drainage bag was observed hanging from the handrail in Resident #117's bathroom. The drainage bag's tubing was wrapped around the handrail. The tip of the tubing was not capped and rested against the wall. Photographic evidence obtained. On 1/11/23 at 9:51 a.m., Certified Nursing Assistant (CNA) Staff A said the urinary catheter drainage bag belongs to Resident #117. She said CNA's were responsible to clean the tubing with soap and water, rinse the drainage bag, and store the bag, and the tubing in a plastic bag in the bathroom. On 1/11/23 at 10:04 a.m., Licensed Practical Nurse (LPN) Staff B said the CNAs do routine catheter care with soap and water. When they change the catheter bag to a leg bag, they are to rinse the bags, store them in a plastic bag, and hang them from the bathroom hand rails.

Based on observation, record review, and interviews, the facility failed to provide oxygen therapy as ordered to meet the needs of 1 (Resident #82) of 2 residents reviewed for oxygen administration. The findings included: Record review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 11/11/22 revealed Resident #82's cognition was intact. Diagnoses included heart failure. Resident #82 required extensive physical assistance of two persons for bed mobility. The physician's orders dated 12/27/22 included to administer Oxygen at 2 liters via nasal cannula as needed to keep saturation above 91% for shortness of breath. On 1/9/23 at 9:45 a.m., Resident #82 was observed on his back in bed, receiving Oxygen at four liters via nasal cannula. Resident #82 said he should be receiving oxygen at two liters, and was not able to reach the flow meter. On 1/10/23 at 8:56 a.m., Resident #82 was observed in bed receiving oxygen at four liters via nasal cannula. The flow meter was not within reach of the resident. On 1/11/23 at 7:54 a.m., resident #82 was observed in bed sleeping with oxygen on at four liters via nasal cannula. On 1/11/23 at 9:15 a.m., Registered Nurse (RN) Staff W verified Resident #82's oxygen was set at four liters. She confirmed the physician's order specified to administer oxygen at 2 liters via nasal cannula.

Based on observation, record review, policy review, staff and resident interviews, the facility failed to ensure 2 (Resident #58, and #141) of 6 residents observed with siderails were assessed for alternative interventions prior to the use of the siderails and informed consent explaining the risks and benefits was obtained prior to installation of the bedrails. The facility failed to have documentation of routine maintenance of the bed rails to ensure they remained safe for residents' use. The findings included: The facility policy Bedrails, (revised 9/19) specified: 1. The facility will attempt to use appropriate alternatives prior to installing a side or bed rail. 2. If a bed or side rail is used, the facility will ensure correct installation, use and maintenance of bed rails, including but not limited to the following elements. a. Assess the resident for risk of entrapment from bed rails prior to installation. B. Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent. ac. Ensure that the beds dimensions are appropriate for the resident's size and weight. d. Follow the manufacturers recommendations and specifications for installing and maintaining bed rails. 1. Review of the clinical record revealed Resident #58 had an admitted [DATE] with diagnoses including dementia and Alzheimer's disease. On 1/9/23 at 1:43 p.m., Resident #58 was observed in bed with grab bar/side rails on both sides in the raised position. Resident #58 said she did not know what the side rails were. Further review of the clinical record showed no documentation of a signed consent or alternatives attempted prior to the use of the grab bars. On 1/11/23 at 10:49 a.m., the Director of Nursing verified the lack of documentation of alternatives attempted and informed consent prior to the use of the side rails for Resident #58. 2. Review of the clinical record revealed Resident #141 an admitted [DATE] with diagnoses including dementia, delirium and wandering. Resident #141 resided in the secured unit of the facility. The Annual Minimum Data Set (MDS) assessment with a target date of 10/12/22 noted the resident scored a 5 on the Brief Interview for Mental Status, indicative of severe cognitive impairment. On 1/9/23 at 1:22 p.m., and 1/10/23 at 8:27 a.m., Resident #141 was observed in bed with grab bars on both sides of the bed in the raised position. Resident #141 was not able to answer questions. Further review of the clinical record showed no documentation of alternatives attempted or an informed consent was obtained prior to the use of the side rails. On 1/11/23 at 10:49 a.m., the DON verified the lack of documentation of alternatives attempted and informed consent prior to the installation of the side rails. The DON provided a siderail evaluation and consent form obtained and dated 1/11/23 for Resident #58 and #141. The form did not list alternatives attempted prior to the installation of the siderails for the residents. 3. On 1/11/23 at 10:50 a.m., the Maintenance Director said he had no documentation of periodic maintenance for the grab bars or siderails. He confirmed he did not check to see if the grab bars were loose, needed repair or were safe. 46824 4. On 1/11/2023 at 10:50 a.m., the Maintenance Director stated the beds are checked for zones of entrapment once a year, and are not resident specific. The Maintenance Director said the facility did not keep documentation of the inspection and maintenance of the bed rails.

Based on Observation and interviews the facility failed to ensure the medication cart remained secured when not in direct view of the nurse for 1 (5100 hall Medication cart) of 9 medication carts. The findings included: On 1/9/23, at 3:50 p.m., observed an unlocked, unattended medication cart in the 5100 hall with the top drawer opened. The screen of the computer mounted on the medication cart was opened displaying residents' private information. Registered Nurse Staff Q was observed in a resident's room administering medication. The medication cart was not within eyesight of the nurse. The Nurse was completely in the resident's room administering medication. Photographic evidence obtained On 1/9/22, at 3:55 p.m., Registered Nurse Staff Q verified the medication cart was unlocked and unattended and the medications in the cart were easily accessible to unauthorized staff, visitors or residents. The nurse also verified the computer screen was left opened displaying residents' private health information. Staff Q said the medication cart should be locked when unattended.

Based on observation, interview and record review, the facility failed to ensure all staff were fully vaccinated and failed to identify an appropriate clinical reason for the contraindication of the COVID-19 vaccine for three of eleven staff reviewed. This deficient practice had the potential to affect a limited number of residents that reside within the facility. Findings included: The facility had 215 employees and 6 were not vaccinated due to a medical exemption. Three of the 6 medical exemptions reviewed revealed that they did not have an appropriate clinical reason or inadequate documentation to show why these staff could not receive the COVD-19 vaccine. The staff vaccination rate was 98.6%, because these three staff were not vaccinated and did not have an appropriate medical exemption. Nursing staff A had a medical exemption for an allergy. There was no other documentation on the form regarding the nature of the allergy. Nursing staff B had Lichen Sclerosis which is not on the list of contra-indications to justify not receiving the COVID-19 vaccine according to the guidance provided by the Centers for Disease Control (CDC) through a medical exemption. Certified Nurse's Aide B had severe hypertension as a reason for the medical exemption which is not on the CDC list of contra-indications to justify not receiving the COVID-19 vaccine through a medical exemption. On 5/23/22 at 3:00 PM Administrative Staff A and Nursing Staff A confirmed these were the only exemptions they had on file for these three staff on their list of employees.

Based on interview and record review the facility failed to report a serious bodily injury of unknown origin within two hours to the State Agency for 1 (Resident #5) of 4 residents surveyed for abuse. The findings included: The facility's abuse policy effective on 11/28/17 and revised on 4/24/21 reads, In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source. are reported immediately, but not later than 2 hours after the allegation is made. Resident #5 is an [AGE] year-old female with physical and cognitive decline who is noncommunicative and unable to make her needs known. On 4/20/22 record review revealed a progress note dated 2/17/22 at 2:34 p.m. stating Continue with signs of pain, (grimacing) on the Right leg when staff are providing care, MD [Medical Doctor] ordered new x-ray two views of the right knee and right tibial [sic]. Further review revealed a progress note dated 2/17/22 at 10:45 p.m. stating X-ray result came, and MD notified, N.O. [New Order] received for need to be immobilized and see ortho. Send to hospital if in pain. Review of the x-ray results dated 2/17/22 shows Resident #5 had a fracture of the right Tibia (a bone between the knee and the ankle) and this was reported to the facility on [DATE] at 3:48 p.m. Further record review revealed no evidence the injury of unknown origin was reported to the State Agency within the required time frame as per regulation. On 4/20/22 at approximately 3:00 p.m. the Director of Nursing said she was not able to provide a documented date and time as to when she reported Resident #5's injury of unknown origin. Review of the Federal Five-Day Report Manager revealed the facility did not report Resident #5's fracture of unknown origin until 2/18/22 at 2:48 p.m.

Based on observation and staff interview, the facility failed to maintain food preparation equipment in a clean and sanitary manner; failed to ensure food is maintained at a safe internal temperature; failed to maintain a minimum wash temperature in the dishwasher to ensure effective sanitization of dinnerware. The findings included: On 5/24/21 at 9:30 a.m., during the initial kitchen tour with the Director of Dietary Services the following was observed: The floor in the kitchen, dry storage room, and both walk-in refrigerators were heavily soiled with grime and debris. The walk-in freezer door contained heavy condensation on the bottom exterior of the door. The tilt skillet was broken, heavily soiled, and in disrepair. The kitchen ovens were all heavily soiled with grime and debris, with 2 of the kitchen ovens broken, and in disrepair. The 2 top kitchen ovens that were being used to prepare food for the facility were heavily soiled with grime and debris, on the interior and exterior. The kitchen stove was heavily soiled with grime and debris. An uncovered container of vegetables was on the top of the stove. A box containing plastic wrap was placed on the top of the uncovered vegetables. The clean dish area and floor were observed to be heavily soiled with grime and debris. The hand washing area dispenser contained no soap, and a container of food was sitting on the top of the paper towel dispenser. The dishwasher area and floor were observed to be heavily soiled with grime and debris. The wall surrounding the dishwasher was soiled with black, bio growth and heavily soiled. A dietary aide was observed operating the high temperature dishwasher. The wash temperature rose to 140 F which is below the minimum of 160 F and the rinse temperature rose to 90 F which is below the required minimum of 180 F. The sink in the cooking area was observed to be leaking onto the kitchen floor. Observation of trash compactor area revealed that the area around the trash compactor was littered with trash (soiled gloves, rags, paper, plastic, and food debris). On 5/24/21 at 10:00 a.m., in an interview, the Director of Dietary Services confirmed the equipment was soiled, broken, and in disrepair. She stated they would be moving into the new kitchen next door when construction was completed, and it would have all new equipment then. On 5/25/21 at 9:15 a.m., in an interview with the Director of Dietary Services, she stated the technician came to fix the dishwasher previously, but the machine was not maintaining consistent water temperature for sanitizing when in use. On 5/26/21 at 9:16 a.m., in an interview, the technician from the service/repair company reported the dishwasher jets where clogged. He stated all the dishwasher machine jets needed to be replaced. On 5/26/21 at 11: 25 a.m., during tray-line observations, the Director of Dietary Services measured the food temperature. The Dijon chicken temperature was 196 degrees F. The bowtie pasta noodles temperature was 172 degrees F. The chicken noodle soup temperature was 175 degrees F. The tomato soup temperature was less than 173 degrees F. On 5/26/21 at 11:50 a.m., 25 minutes into the tray-line, the Director of Dietary Services measured the temperature of the food on the steam table and found the following: The Dijon Chicken temperature was 122 degrees F. The bowtie pasta noodles temperature was 131 degrees F. The chicken noodle soup temperature was 120 degrees F. The tomato soup temperature was 110 degrees F. On 5/26/21 at 11:55 a.m., the Director of Dietary Services confirmed the food temperature had decreased. The Director of Dietary Services verified the steam table was not working properly and did not maintain the food at safe temperature. On 5/26/21 at 3:30 p.m., in an interview, the Director of Dietary Services stated the problem with the steam table occurred when it was reset after cleaning. The knobs were replaced incorrectly and even though they were turned to the on position it was not actually heating.

Based on observation and interview, the facility failed to ensure medications were secured, locked and inaccessible to unauthorized staff, residents, and visitors, or under direct observation of authorized staff by 1 (LPN Staff A) of 4 staff observed administering medications. The facility also failed to remove expired medications from active supply for 1 (Memory care) of 3 medication carts observed and failed to document the opened date of a multi-dose vial of medication for 1 (Second floor medication room) of 2 medication storage rooms observed. The findings included: Facility policy titled, Medication Administration, revised 11/03, 11/06, 7/18 indicated: The nurse is to '' take the medication cart to the vicinity of the resident's room. The cart should be visible to the nurse administering medication. it may remain unlocked only when it is in the direct line of sight of the nurse . Facility Policy titled, Medication Storage in the facility, effective date January 2017 indicated: All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining . when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date. 1. On 5/25/21 at 9:16 a.m., Licensed Practical Nurse (LPN) Staff A was observed preparing medications for Resident #369. LPN Staff A placed several medications in a medication cup, placed some of the medications back in the cart, locked the cart, and left a blister pack of [MEDICATION(S)] (narcotic pain medication) on top of the med cart containing 11 pills of [MEDICATION(S)]. LPN Staff A entered Resident #369's room and was out of direct line of sight of the medication cart and the blister pack of [MEDICATION(S)]. Upon return to the cart at 9:26 a.m., LPN Staff A said she had left the [MEDICATION(S)] on top of the cart because she was nervous. 2. On 5/26/21 at 12:14 p.m., a random audit was made of the medication cart in the Memory Care unit with LPN Staff B. Expired medications were found for Resident #95 including: 2 blister packs of [MEDICATION(S)] (for high blood pressure) expired 4/17/21, 1 blister pack of [MEDICATION(S)] (diuretic) expired 4/17/21, 1 blister pack of Potassium (supplement) expired 4/17/21, and 1 blister pack of [MEDICATION(S)] (treats [CONDITION(S)]/restless leg) expired 4/17/21. ** Photographic evidence on file** The cart also contained a blister pack of [MEDICATION(S)] (pain medication) for Resident #25 that had expired on 3/12/21. LPN Staff B said all nurses on all shifts should monitor the medication carts for expired medications. 3. On 5/26/21 at 12:45 p.m., a random audit was made of the second-floor medication refrigerator with LPN Staff C. An opened vial of insulin was found in the refrigerator for Resident #83. The vial had a sticker attached that said, discard after 42 days, with a place to write the expiration date. No one had dated when the vial had been opened or when the vial expired. LPN Staff C said the process was to date the bottle when it was opened. ** Photographic evidence on file** On 5/27/21 at 11:56 a.m., in an interview the Director of Nursing (DON) said medications should always be put away and locked in the cart if it was out of the line of sight. DON said night shift nurses were supposed to check the medication carts for expired medications every day and the unit manager was supposed to check for compliance and that all insulin vials should be dated with the date opened and the expiration date based on the date opened.

Based on observation and interview the facility failed to safeguard residents' well-being in the Dementia Unit by failing to follow current infection control standards related to COVID-19 recommendations set forth by Centers for Disease Control and Prevention (CDC). Refer to https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html The findings included: On 7/14/20 at 11:20 a.m., during observation of the residents on the Dementia Unit, twenty-five residents were observed sitting in a circle in the common area. Twenty of the residents were sitting in wheelchairs and five residents were sitting in regular chairs. The wheelchairs were almost touching each other, and the regular chairs were positioned almost touching the next chair. There was no social distancing encouraged by the staff for the residents. The Dementia Unit was fully staffed. On 7/14/20 at 11:50 a.m., observed staff setting up tables in the common area for the twenty-five residents. There were small tables set up seating four residents per table who were not six feet apart. On 7/14/20 at 11:50 a.m., in an interview the Administrator said it was difficult to try and encourage the Dementia Unit residents to wear masks and difficult for staff to keep residents six feet apart from one another. The Administrator said she was aware there was communal dining and group activities for twenty-five residents in the Dementia Unit . On 7/14/20 at 1:15 p.m., in an interview Licensed Practical Nurse Staff B said the Dementia Unit staff had not received any education since May 2020 instructing them to encourage the Dementia Unit residents to wear masks. She said the staff has had no instructions regarding social distancing the residents on the Dementia Unit for group activities or communal dining. On 7/14/20 at 1:20 p.m., in an interview Certified Nursing Assistant (CNA) Staff C said there had been no instructions for Dementia unit staff to socially distance (six feet apart) the residents for group activities or communal dining. On 7/14/20 at 1:30 p.m., in an interview CNA Staff D said the staff in the Dementia Unit were not instructed to encourage the residents to wear masks or to keep residents socially distant. She said there was no social distancing (six feet apart) of residents during group activities or dining. On 7/14/20 at 1:35 p.m., in an interview Activity Coordinator (Dementia Unit) Staff E said the Dementia Unit staff had not had been given instructions that residents were to wear masks or keep socially distant during group activities or communal dining. She said she was not aware the staff needed to do that. On 7/14/20 at 1:40 p.m., in an interview CNA Staff F said the Dementia Unit staff had not had any instructions to encourage the residents to wear masks. She said she was told two or three weeks ago to separate the Dementia Unit residents six feet apart. On 7/14/20 at 2:20 p.m., in an interview Registered Nurse Staff G said her job was Staff Education, she trained the staff on CDC guidelines. She said she had done training for staff to keep six feet apart from other staff, but she did not instruct staff on the Dementia Unit that residents were to wear masks or to keep residents six feet apart.