Every finding on record at Presidential Oaks

Based on observation, interview, and record review, it was determined that the facility failed to implement Enhanced Barrier Precautions (EBP) in 2 of 2 residents reviewed for pressure ulcers (Resident Identifiers are #55 and #30). The facility failed to follow hand hygiene policy with 1 of 1 dressing change observation (Resident identifier is #55). The facility failed to follow identified interventions for water management: legionella prevention and update Infection Prevention Policies annually.Findings include: Resident #30 Review on 1/30/26 of Resident #30's wound note, dated 1/29/26, revealed a stage II pressure ulcer to the left heel and a stage II pressure ulcer to the sacrum. Review of Resident #30's physician orders did not indicate the resident was on EBP was in place. Observation on 1/30/26 at approximately 9 a.m. of Resident #30's room revealed no signage indicating EBP usage. Review on 1/30/26 of Resident #30's January 2026 Treatment Administration Record revealed an active order for Wound to Sacrum: Apply hydrogel to the wound bed. Apply foam dressing. Change daily. dated 1/8/26. Further review of Resident #30's January 2026 TAR revealed: Wound orders Left heel, apply skin prep to the peri wound, collagen sheet to wound bed, and cover with bordered foam dressing. Change Tuesday, Thursday, Saturday, and PRN. Interview on 1/30/26 at approximately 10:45 a.m. with Staff A (Unit Manager) confirmed that Resident #30 did have pressure ulcers and EBP should have been in place. Interview on 1/30/26 at approximately 10:50 a.m. with Staff B (Director of Nursing) confirmed that Resident #30 did have pressure ulcers EBP should have been in place. Resident #55 Review on 1/29/2026 of Resident #55's provider orders revealed a daily dressing change for a stage 2 pressure injury. Observation on 1/29/2026 at approximately 12:00 p.m. of Resident #55's room revealed no sign for EBP and no cart available for personal protective equipment. Review on 1/29/2026 of Resident #55's care plan for pressure injury care revealed no indication for enhanced barrier precautions to be followed during high contact care activities. Review on 1/30/26 of facility policy titled Enhance Barrier Precautions Policy and Procedure dated 10/10/2025 revealed Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of the transmission of multidrug-resistant organisms (MDROs).High-contact resident activities include: Dressing bathing/showering transferring providing hygiene changing linens changing briefs or assisting with toileting.wound care: any skin opening requiring a dressing.Wound.pressure ulcers.Procedure:.2. Post clear signage on the door or wall outside the resident room.a. Signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves.6. Enhanced barrier precautions should be used for the duration of a resident's stay in the facility or until resolution of the wound. Interview on 1/30/2026 at approximately 11:30 a.m. of Staff E (Infection Preventionist) confirmed that Resident #55 should have been on EBP for pressure ulcers. Observation on 1/30/2026 at approximately 9:30 a.m. of Staff F (Licensed Practical Nurse (LPN)) completing Resident #55's dressing change revealed Staff F changed his/her gloves between dirty and clean tasks but did not complete hand hygiene with glove removal after removing old dressing and prior to applying new gloves to clean the wound. Interview on 1/30/26 at approximately 9:40 a.m. with Staff F (LPN) above observation. Review on 1/30/26 of facility policy titled Hand Hygiene Policy undated revealed Policy: It is the policy of [facility name omitted] to ensure that appropriate preventative measures are taken to prevent the spread of infection. Procedure: 1. Appropriate hand washing must be used under the following conditions:.After removing gloves.6. An alcohol-based solution may be used unless hands are visibly soiled. Interview on 1/30/2026 at approximately 11:30 a.m. with Staff E (Infection Preventionist) confirmed hand hygiene should be done with glove removal. Review on 1/30/2026 of facility Water Management Plan revealed identified risk areas and interventions to be the faucets: run 5-6 minutes and toilets flushed; the water heater: monitored and logged weekly. Aerators: visually inspected weekly, removed and disinfected annually. Eye wash stations: visually inspected, taken down and disinfected quarterly. Further review revealed no documentation that preventative interventions were performed. Interview on 1/30/2026 at approximately 10:00 a.m. with Staff G (Maintenance Director) revealed that the facility was unable to provide evidence of any interventions being completed. Further interview confirmed there had been no actions taken to prevent legionella. Review on 1/30/2026 of facility Infection Prevention policies revealed a policy titled Antibiotic Stewardship Program undated, Infection Surveillance dated 9/12/24, Antibiotic Use Assessment and Documentation dated 7/11/24, all not within the past year. Interview on 1/30/2026 at approximately 8:30 a.m. with Staff E (Infection Preventionist) confirmed policies had not reviewed annually per requirement.

Based on interview and record review, it was determined that the facility failed to implement a system to monitor antibiotic use use for 3 of 5 resident's reviewed in a final sample of 18 residents (Resident identifiers are #11, #57, and #7).Findings include:Review on 1/30/2026 of facility policy titled Antibiotic Stewardship Program undated revealed .Policy Interpretation and Implementation.to improve the use of antibiotics in an effort to decrease antibiotic resistant organisms. The center shall follow McGeer criteria for identifying the presence of infections.nursing partners will be active in the Quality Assurance program to enhance the use of antibiotics and for following approved guidelines established by this center based on the McGeer Criteria.Review on 1/30/2026 of facility antibiotic line list for November 2025, December 2025, and January 2026 revealed the log was missing infection symptoms and no there documentation that the antibiotics were appropriate and it McGeer's criteria.Resident #11Review on 1/30/26 of Resident #11's provider orders revealed an order dated 11/19/2025 for ertapenem 500mg, IV [intravenous] daily for 7 days.Review on 1/30/2026 of November 2025 antibiotic line list revealed antibiotic treatment was for a Urinary Tract Infection (UTI) with symptoms for treatment being GI [gastrointestinal] complaints and pain.Review on 1/30/2026 of antibiotic worksheet provided by the facility with McGeer's Criteria definitions undated revealed the definition for treatment of a UTI must fulfill both 1 AND 2. 1.At least one of the following sign or symptom: Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate. 2.At least one of the following microbiologic criteria: equal to or more than 100,000 cfu [colony forming units]/ml [milliliter] of no more than 2 species of organisms in a voided urine sample or equal to or more than 100 cfu/ml of any organism(s) in a specimen collected by an in-and-out catheter.Interview on 1/30/2026 at approximately 12:00 p.m. with Staff E (Infection Preventionist) confirmed there was no assessment completed of McGeer's criteria or antibiotic appropriateness for Resident #11's antibiotic.Resident #57Review on 1/30/2026 of Resident #57's provider orders revealed an order dated 12/12/2025 for Augmentin 875mg-125mg orally every 12 hours for 7 days.Review on 1/30/2026 of December 2025 antibiotic line list revealed antibiotic treatment was for a Urinary Tract Infection with symptoms for treatment not noted.Interview on 1/30/2026 at approximately 12:00 p.m. with Staff E confirmed there was no assessment completed of McGeer's criteria or antibiotic appropriateness for Resident #57's antibiotic.Resident #7Review on 1/30/26 of Resident #7's provider orders revealed an order dated 1/12/2026 for nitrofurantoin 50mg orally every day. Review on 1/30/2026 of January 2026 antibiotic line list revealed antibiotic treatment was for a Urinary Tract Infection with symptoms for treatment noted to be altered mental status, fatigue, malaise.Review on 1/30/2026 of facility provided McGeer's Criteria worksheet for Resident #7's antibiotic treatment dated 1/13/2026 revealed a blank worksheet.Interview on 1/30/2026 at approximately 12:00 p.m. with Staff E confirmed there was no assessment completed of McGeer's criteria or antibiotic appropriateness for Resident #7's antibiotic.Interview on 1/30/2026 at approximately 8:15 a.m. with Staff E revealed he/she has not tracked antibiotic treatments that do not fit McGeer's criteria. Further interview revealed there is no reporting or discussion in Quality Assurance Performance Improvement (QAPI) regarding infections that are treated outside of the criteria or for prophylactic (preventative) treatment.

Based on interview and record review, it was determined that the facility failed to follow its grievance policy for generating grievances, investigating, and resolution of grievances for 1 of 1 resident reviewed abuse in a final sample of 18 residents. (Resident identifier is #46).Findings include:Review on 1/30/26 of the facility's policy Grievance Process undated revealed, .2. Staff member receiving the concern generates a grievance form and completes the top section of the form (date of grievance/concern, received by, resident name, room number, name of person reporting concern, relationship to resident, and description of concern). 3. Staff member receiving the concern delivers the form to the Director of Social Services. 4. Director of Social Services logs the grievance/concern, assigns a person to investigate/take action on the grievance/concern, scans the grievance/concern form, and emails the person(s) assigned to investigate/take action on the grievance/concern with cc to Acting Administrator and Director of Nursing . *Resident, family members, or responsible party does not need to formally ask for a grievance/concern to be filed. The grievance/concern form should be generated by any concerns. Resident, family member, or responsible party should not be given the form to complete themselves, the staff learning of the concern or hearing the concern should generate the form.Interview on 1/28/26 at 10:15 a.m. with Resident #46 revealed that he/she felt staff were busy and rushed her during incontinence care. Resident #46 stated that he/she told a staff member recently about how he/she felt but nothing was done.Review on 1/30/26 of Resident #46's progress note, dated 1/5/26, revealed that Staff C (Licensed Practical Nurse) spoke with Resident #46 about a licensed nursing assistant (LNA) on duty. Review further revealed that Resident #46 felt rushed and sometimes staff were not nice to him/her.Interview on 1/30/26 at 12:43 p.m. with Staff D (Administrator in Training) revealed that Resident #46's concerns did not generate a grievance and no investigation was done.

Based on observation, interview and record review, it was determined that the facility failed to notify the physician of medications not administered to the residents for 1 of 4 residents reviewed for hospitalizations in a final sample of 18 residents (Resident Identifiers is #71).Findings include:Review on 1/30/26 of Resident #71's January 2026 Medication Administration Record (MAR) revealed physician's orders for the following:Aspirin 81 oral tablet delayed release, give one tablet my mouth at bedtime related to Paroxysmal Atrial Fibrillation. Further review revealed that Resident #71 refused the medication on 1/1/26, 1/2/26, 1/3/26, and 1/4/26.-sosorbide Dinitrate oral tablet 5 milligrams (mg), give two tablets by mouth at bedtime related to Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. Further review revealed that Resident #71 refused the medication on 1/1/26, 1/2/26, 1/3/26, and 1/4/26.Losartan Potassium oral tablet 50 mg, give one tablet by mouth one time a day related to Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. Further review revealed that Resident #71 refused the medication on 1/3/26,and 1/4/26.Verapamil HCI ER oral tablet extended release 120 mg, give 1 tablet by mouth two times a day related to Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. Further review revealed that Resident #71 refused the medication on 1/1/26 and 1/2/26 at 8:00 p.m. and 1/3/26 and 1/4/26 at 9:00 a.m. and 8:00 p.m.Interview on 1/30/26 at 1:39 p.m. with Staff B (Director of Nursing) confirmed the above finding. Staff B revealed that there was no documentation the provider was notified of the refused medications prior to 1/5/26. Review on 1/30/26 of Resident #71's provider note, dated 1/5/26, revealed that Resident #71 had been refusing their hypertensive medication and had severe chest pain. Resident agreed to go to the hospital for further evaluation.

Based on observation, interview and record review, it was determined that the facility failed to ensure that residents were provided with a private space for a resident group to meet on a regular basis, make residents aware of upcoming meeting and to make prompt efforts to resolve resident and group grievances, keep residents apprised of the progress towards resolution, and maintain evidence demonstrating the response and rationale for the response for 6 residents out of a facility census of 71 (Resident identifiers are #6, #14, #26, #30, #41 and #54).Findings include:Interview on 1/28/26 at approximately 8:15 a.m. with Staff D (Administrator in Training) revealed that the Resident Council president was not a long term resident. Staff D revealed resident group consists of the organization's long term and their other facilities (independent living and assisted living) and the Resident President is from the independent living. Observation and interview on 1/28/26 at approximately 1:00 p.m. during a Resident Group Meeting revealed that five of the six residents (Resident #14, #26, #30, #41 and #54) in attendance were not aware of a Resident Council group meeting. Resident #54 was not aware that they could elect a President for the Resident Council for SN and LTC, he/she stated that the president was for the entire building. Resident #6 was admitted to the facility in October 2025 and was never told about a monthly meeting where residents would come to discuss issues they were having or seeing in the facility. He/she would have attended. Resident #41 stated that he/she had not been asked to attend group meeting until today. He/she would like to attend moving forward.Review on 1/28/26 of the Resident Council meeting minutes revealed the following:On 10/28/25, LTC residents had concerns with activities, nursing care, and food. On 12/30/25, LTC residents had concerns with missing items.Interview on 1/30/26 at approximately 2:00 with Staff D confirmed the above findings and that there was no response to the LTC residents' concerns. Review on 1/30/26 of the facility policy Resident Council Meetings not dated, revealed: Resident Council is the political voice of the individuals who reside in the facility. Many of the residents are unable to voice their opinions and/or concerns and need to rely on the residents who are capable and interested in facility events to speak for them. 6. Activity staff and nursing staff be responsible for inviting and encouraging appropriate residents from third and second floors to attend, 9. Activity staff will document any issues or concerns not resolved at the meeting with a Department Response Form to the specific department. Forms with be put in each Director's mailbox within forty-eight hours (48) hours. 10. Once the issue has been resolved, the Director will return the completed Departments Response Form to the Activity Director within 10 (ten) days. 11. These issues will be brought up at the following meeting and documented as resolved.

Based on interview and record review, it was determined that the facility failed to implement interventions in accordance with the resident's assessed needs that address the identified limitations in the resident's ability to perform transfers in 1 of 5 residents reviewed in a final sample of 6 residents (Resident identifier is #1).Findings include: Review on 10/2/25 of Resident #1's Physical Therapy (PT) notes revealed the following; On 8/15/25 a Treatment Encounter Note that revealed, . Educated aide that pt [patient] would be appropriate to hoyer [mechanical lift]. Staff is using various techniques including bear hugging pt which is unsafe for both pt and staff. To avoid injury to pt and staff a hoyer lift would be appropriate. Unit Manager notified about this and that pt should be a hoyer. This was signed by Staff A (Physical Therapy Assistant) and Staff E (Physical Therapist) on 8/15/25. On 8/29/25 a Treatment Encounter Note that revealed . pt is essentially D [dependent] for xfers [transfers]. Does not participate in xfers, unable to bear weight through LE [lower extremities]. Again recommend pt be a hoyer for pt and staff safety. [Nursing] notified. This was signed by Staff A on 8/29/25. On 9/12/25 a Treatment Encounter Note that revealed .Nsg [nursing] notified that hoyer should be utilized . This was signed by Staff A and Staff E. Interview on 10/2/25 at 10:20 a.m. with Staff C (Licensed Nursing Assistant) revealed that he/she had taken care of Resident #1 on 9/20/25 and 9/21/25 and that on 9/20/25 they had done a stand-pivot of 1 person to place Resident #1 back into bed after lunch. Staff C revealed that it was their understanding that Resident #1 could be transferred by a stand pivot and that a mechanical lift could be used if needed. Staff C revealed that Resident #1 said Ow during this transfer and during incontinence care and the nurse was made aware. Staff C revealed that on 9/21/25 that Resident #1 was kept in bed that morning due to complaints of pain and holding his/her left leg and that the Resident would hold their left leg during incontinent care on 9/21/25. Review on 10/2/25 of Resident #1's nursing progress note dated 9/22/25 at 10:41 a.m. revealed, . Lnas [Licensed Nursing Assistants] reported that [Resident #1] appeared to be in pain and had swelling/redness to [left lower extremity], upon examination this writer noticed a reddened area just above the ankle on the left leg, the area was warm, red, and tender to the touch. [Resident #1] also had swelling of the lower left leg and foot. The [Advanced Practice Registered Nurse] was notified and ordered an x-ray which revealed a spiral fracture of the mid [middle part of a bone] to distal tibia. Rev/iew on 10/2/25 of Resident #1's radiology report dated 9/22/25 revealed results minimally displaced spiral oblique fracture of the mid [middle] to distal left tibial diaphysis. Review on 10/2/25 of Resident #1's Activities of Daily Living Care Plan revised intervention date of 9/16/25 revealed TRANSFER: The resident requires 2 staff hoyer transfer assist to move between surfaces as necessary. Interview on 10/2/25 at 9:45 a.m. with Staff A (Physical Therapy Assistant) confirmed that he/she had been providing physical therapy to Resident #1 and that the resident should be transferred via a mechanical lift for both the Resident's and Staff's safety. Staff A confirmed that they had communicated Resident #1's transfer status verbally to nursing staff since 8/15/25.

Based on interview and record review, it was determined that the facility failed to complete a thorough investigation of an alleged violation for 1 of 6 residents reviewed for alleged abuse. (Resident identifier is #1).Findings include:Review on 10/2/25 of Resident #1's nursing progress note dated 9/22/25 at 10:41 a.m. revealed, . Lnas [Licensed Nursing Assistants] reported that [Resident #1] appeared to be in pain and had swelling/redness to [left lower extremity], upon examination this writer noticed a reddened area just above the ankle on the left leg, the area was warm, red, and tender to the touch. [Resident #1] also had swelling of the lower left leg and foot. The [Advanced Practice Registered Nurse] was notified and ordered an x-ray which revealed a spiral fracture of the mid [middle part of a bone] to distal tibia. Review on 10/2/25 of Resident #1's radiology report dated 9/22/25 revealed: minimally displaced spiral oblique fracture of the mid] to distal left tibial diaphysis. Interview on 10/2/25 at 10:20 a.m. with Staff C (Licensed Nursing Assistant) revealed that he/she had taken care of Resident #1 on 9/20/25 and 9/21/25. Staff C revealed that on 9/20/25 that Resident #1 said Ow during a stand pivot transfer. Staff C revealed that on 9/21/25 that Resident #1 was kept in bed that morning due to complaints of leg pain and that the Resident #1 would hold their left leg during incontinence care. Staff C revealed that he/she had not been interviewed or asked to make a statement by the facility regarding Resident #1 above injury on 9/22/25. Interview on 10/2/25 at 2:10 p.m. with Staff D (Director of Nursing) revealed that he/she did not interview any LNA who worked with Resident #1 on 9/20/25 and 9/21/25 regarding Resident #1's fracture and did not identify a cause of the fracture. Review on 10/2/25 of the facility's undated policy titled Resident Abuse and Reporting Policy revealed, .It is the policy of [the Facility] to. investigate. alleged abuse, neglect, mistreatment. 3. The facility will investigate all allegations and prevent further potential abuse while the investigation is ongoing. Definitions. Injuries of unknown source: Source of the injury was not observed and could not be explained by the resident; and the injury is suspicious because: the extent of seriousness of the injury. Policy. Investigating – The Administrator or Director of Nursing will conduct an investigation of alleged abuse. The DON will . c. Interview all nursing department witnesses/suspects and record their statements. The Administrator will. c. Review the Nursing report, suspect interview, witness interview(s), and Social Services interview, and other investigative documentation.

Based on observation and interview, it was determined that the facility failed to ensure that food was stored in accordance with professional standards for food service safety for 1 of 1 kitchen observed. Findings include: Observation on 10/28/24 at approximately 8:40 a.m. Staff F (Chef Manager) and Staff G (Assistant Chef Manager) revealed a box containing an open, undated bag of frozen rib patties in the walk-in freezer. Observation in the walk-in refrigerator revealed a box of tomatoes with black spots visible and a bag of cubed moldy pepper jack cheese. Interview on 10/28/24 at approximately 8:45 a.m. with Staff F and Staff G confirmed the above findings. Review on 10/28/24 of the FDA 2022 Food Code, retrieved from https://www.fda.gov/media/164194/download?attachment, revealed: .Preventing Food and Ingredient Contamination 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation .FOOD shall be protected from cross contamination by .storing the FOOD in packages, covered containers, or wrappings; .Preventing Contamination from the Premises 3-305.11 Food Storage .FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location (2) Where it is not exposed to splash, dust, or other contamination .

Based on record review and interview, it was determined that the facility failed to provide written notice of a transfer or discharge for 4 of 4 residents reviewed for hospitalization in a final survey sample of 17 residents (Resident Identifiers are #6, #16, #48, and #64). Findings include: Resident #48 Review on 10/30/24 of Resident #48's medical record revealed that on 10/27/24, Resident #48 was transferred to the hospital. Further review of Resident #48's medical record revealed that there was no documentation of a notice of transfer. Interview on 10/30/24 at approximately 11:20 a.m. with Staff E (Social Services) revealed that the facility had not provided Resident #48, or Resident #48's representative, with a notice of transfer because Resident #48's hospital stay was less than 24 hours. 37488 Resident #6 Review on 10/29/24 of Resident #6's nursing note dated 10/20/24 revealed that Resident #6 was transferred to the hospital. Further review of Resident #6's medical record revealed that there was no written notice of transfer and discharge. Interview on 10/30/24 at approximately 8:50 a.m. with Staff A (Social Worker) confirmed that the facility did not provide the resident or resident's representative with written notice of transfer and discharge. Staff A further confirmed that the facility only faxes the notices to the Office of Long Term Care Ombudsman. Interview on 10/30/24 at approximately 9:57 a.m. with Staff D (Administrator) confirmed the above findings. Resident #64 Review on 10/29/24 of Resident #64's medical record revealed that Resident #64 was transferred to the hospital on 9/10/24 for a scheduled procedure. Further review of Resident #64's medical record revealed that there was no written notice of transfer and discharge. Interview on 10/30/24 at approximately 8:49 a.m. with Staff A confirmed that the facility does not provide the resident or resident's representative with written notice of transfer and discharge. Interview on 10/30/24 at approximately 9:57 a.m. with Staff D confirmed the above findings. 45419 Resident #16 Review on 10/29/24 of Resident #16's medical record revealed that Resident #16 had an activated power of attorney for healthcare and that Resident #16 was sent out to the hospital and admitted on the following dates: 4/10/24, 5/26/24, 6/7/24, and on 9/21/24 was sent but not admitted to the hospital. Further review revealed that there was no written notice of transfer discharge that was given to the resident or resident's representative for any of the transfers to the hospital. Interview on 10/30/24 at 1:45 p.m. with Staff A revealed that the facility does not provide written notice of transfer discharge to the residents or residents representatives.

Based on record review and interview, it was determined that the facility failed to notify residents of the bed hold policy before a transfer for 4 of 4 residents reviewed for hospitalization s in a final survey sample of 17 residents (Resident Identifiers are #6, #16, #48, and #64). Findings include: Resident #48 Review on 10/30/24 of Resident #48's medical record revealed he/she had been discharged to the hospital on 10/27/24. Further review of Resident #48's medical record revealed no evidence that the bed hold policy was provided to Resident #48, or their representative, upon transfer to the hospital. Interview on 10/30/24 at approximately 11:20 a.m. with Staff E (Social Services) confirmed the above findings. 45419 Resident #16 Review on 10/29/24 of Resident #16's electronic medical record revealed that Resident #16 had been transferred out to the hospital and admitted on [DATE], 5/26/24, 6/7/24, and on 9/21/24 was sent to the hospital but not admitted . Further review revealed that there was no bed hold notice information present in their record. Interview on 10/29/24 at 1:45 p.m. with Staff A (Social Services) revealed that they do not notify the residents or representatives of the facility bed hold policy. 37488 Resident #6 Review on 10/29/24 of Resident #6's nursing note dated 10/20/24 revealed that Resident #6 was transferred to the hospital after being found on the floor next to their bed. Further review of Resident #6's medical record revealed that there was no documentation that a bed-hold notice was provided to Resident #6 or their representative. Interview on 10/30/24 at approximately 9:00 a.m. with Staff H (Business Office) revealed that residents are not provided with bed-holds at each transfer. Interview on 10/30/24 at approximately 10:00 a.m. with Staff D (Administrator) confirmed the above findings. Resident #64 Review on 10/29/24 of Resident #64's medical record revealed that Resident #64 was transferred to the hospital on 9/10/24 for a scheduled procedure. Further review of Resident #64's medical record revealed that there was no documentation that a bed-hold notice was provided to Resident #64 or their representative. Review on 10/29/24 of the facility policy titled, Attachment B - Payment During Absences, undated, revealed: .It is the policy of this facility to permit residents to retain their beds when they are discharged to a hospital or for therapeutic leave .1. The social worker or designee will contact the resident and/or representative to determine if he/she wishes to hold the resident's bed for him/her while out of the facility .4. Requests for holding or releasing the bed will be kept in the resident's business office file as well as the resident's medical record .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that a resident remained free of accident hazards in regards to assessments of bedrail use for 1 of 3 residents reviewed for accidents (Resident identifier is #13). Findings include: Observation on 10/24/23 at 10:01 a.m. with Resident #13 revealed that Resident #13 had a dark red and dark purple discoloration on the left cheek. Further observation also revealed that Resident #13's hospital bed had the half rails (bed rails/side rails) up and in use on both sides of the bed. Interview on 10/24/23 at 10:01 a.m. with Resident #13 confirmed the above observation. Resident #13 stated that he/she hit his/her left cheek on the bed rail/side rail after using the bed pan in bed. Review on 10/24/23 of Resident #13's medical records revealed that Resident #13 was admitted to the facility on [DATE]. Further review of Resident #13's medical record revealed an incomplete bed rail assessment dated [DATE]. Further review of Resident #13's medical record also revealed no documentation of a completed bed rail assessment. Review on 10/25/23 of Resident #13's Brief Interview for Mental Status (BIMS) score, dated 9/26/23, revealed a score of 15 which indicated an intact cognition. Observation and interview on 10/26/23 at approximately 10:00 a.m. with Staff F (Licensed Practical Nurse) and Resident #13 confirmed that Resident #13 had a dark red and dark purple discoloration on his/her left cheek and that Resident #13 stated it was from hitting the bed rail/side rail. Further observation and interview with Staff F revealed that Resident #13's half rails on both sides of the bed were in use. Staff F stated that Resident #13 utilized it for repositioning in bed. Review on 10/26/23 of Resident #13's current care plan revealed that Resident #13 uses the half rails to maximize independence with turning and repositioning in bed. Interview on 10/26/23 at approximately 10:30 a.m. with Staff B (Director of Nursing) revealed that a bed rail assessment was to be done quarterly. Staff B was unable to provide documentation of Resident #13's completed bed rail assessments. Staff B stated that the facility utilized the electronic medical record system assessment called Bed Rail Assessment for residents utilizing the bed rails/side rails. Review on 10/26/23 of the facility's policy titled, Siderail use/Reduction, dated 11/8/05, revealed .Each resident will be assessed for siderail use on admission, readmission, change in status, and at least quarterly using the Siderail Assessment Form .

Based on interview and record review, it was determined that the facility failed to ensure that residents with a mental disorder received an accuracte Level I Pre-Admission Screening and Resident Review (PASARR) for 2 of 4 residents reviewed for PASARR in a final sample of 19 residents (Resident identifiers are #14 and #48). Findings include: Resident #14 Review on 10/25/23 of Resident #14's medical record revealed that Resident #14 was admitted to the facility on [DATE]. Review on 10/25/23 of Resident #14's diagnosis list in the electronic health record revealed that #14 had a diagnosis of Schizophrenia on admission to the facility. Review on 10/25/23 of Resident #14's Level I PASARR form (completed 2/9/22) revealed: Section 2: Screening for Mental Illness (MI), No was checked. Section 3: Screening for Intellectual Disability/Developmental Disability (ID/DD), No was checked. Section 4: Screening for Related Condition (RC), No was checked. Section 5: Undiagnosed Condition No was checked. Section 8: Level I Screening Summary, Not requiring PASARR involvement Not MI, Not ID/DD, and Not RC checked. Interview on 10/26/23 at approximately 9:00 a.m. with Staff A (Social Worker) revealed that the PASARR dated 2/9/22 was not accurate and a new PASARR should have been completed reflecting a diagnosis of Schizophrenia. 47129 Resident #48 Review on 10/24/23 of Resident #48's electronic medical record revealed that Resident #48 was initially admitted to the facility on [DATE]. Review on 10/24/23 of Resident #48's Level 1 PASARR dated 5/24/22 revealed that the PASARR form, under Section 6 Exemption/Exclusion, Hospital discharge was checked and dated 5/24/22, which indicated that the physician certified that Resident #48 required less than 30 days of nursing facility (NF) services. Under the date read Note: If the NF stay is 30 days or longer, a new PASARR screen and resident review must be performed within 40 calendar days of admission. Interview on 10/26/23 at 8:30 a.m. with Staff A confirmed the above findings. Staff A confirmed that Resident #48 remained in the facility longer than 30 days and there was no additional PASARR performed. Review of the facility's policy titled, Presidential Oaks Policy on Pre-Admission Screening and Annual Resident Review, dated 2022/2023, revealed .that every resident with a known or suspected primary or secondary diagnosis of a serious mental illness or developmental delay will be screen by PASSAR .6) Be aware that if a resident's length of stay is suspected to extend past 30 days .

Based on interview and record review, it was determined that the facility failed to ensure that a resident had a comprehensive person-centered care plan for a Post-Traumatic Stress Disorder (PTSD) diagnosis for 1 of 1 resident reviewed for behavioral-emotional (Resident identifier is #11). Findings include: Review on 10/24/23 of the facility's matrix revealed that Resident #11 triggered for PTSD/Trauma. Review on 10/24/23 of Resident #11's medical records revealed that Resident #11 was admitted to the facility on [DATE]. Further review of Resident 11's medical records revealed that Resident #11 had a diagnosis on admission of PTSD. Review on 10/26/23 of Resident #11's psychiatric consult notes from 1/11/23 to 9/12/23 revealed that on 1/11/23 Resident #11 reported extensive history of sexual trauma and was seeking to re-establish for therapy. Resident #11 reported nightmares, hypervigilance, and guarding/flashbacks throughout the day. On 1/23/23, Resident #11 reported improved symptoms, as mentioned above, and that Resident #11 was working with the social worker to re-establish with his/her community therapist. Resident #11 had no other concerns of PTSD symptoms after 1/23/23. Review on 10/26/23 of Resident #11's medical records revealed no other assessments of Resident #11's PTSD such as past trauma and/or triggers. Further review of Resident #11's medical records revealed no follow up with a community therapist, as mentioned on above psychiatric consult notes. Review on 10/26/23 of Resident #11's current care plan revealed no care plan for Resident #11's PTSD diagnosis such as what was mentioned by psychiatrist on 1/11/23, or triggers and interventions to mitigate re-traumatization. Interview on 10/26/23 at approximately 1:00 p.m. with Staff D (Social Worker) confirmed the above findings.

Based on interview and record review, it was determined that the facility failed to ensure that a residents pressure ulcer was evaluated weekly for 1 of 2 residents reviewed for pressure ulcers (Resident identifier is #40). Findings include: Review on 10/24/23 of the facility matrix revealed that Resident #40 had a facility acquired unstageable pressure ulcer. Review on 10/24/23 of Resident #40's active physician orders revealed a wound treatment order for the left heel pressure injury with a start date of 9/26/23. Review on 10/24/23 of Resident #40's current care plan revealed that Resident #40 has an eschar wound on left heel. Review on 10/26/23 of Resident #40's wound specialist notes revealed that on 5/24/23 Resident #40 has a left heel deep tissue injury with persistent non-blanchable deep red, maroon or purple discoloration. Wound measurement was 3 centimeters (cm) length by 5 cm width with no measurable depth. On 6/7/23 Resident #40's left heel progressed to an unstageable pressure injury with obscured full-thickness skin and tissue loss. Wound measurement was 4 cm length by 5 cm width and wound bed has 100 percent eschar. Further review of the wound specialist notes revealed that there was no documentation of Resident #40's weekly wound evaluation after 8/16/23. Review on 10/26/23 of Resident #40's medical records revealed no weekly evaluation with description, progress, and measurements of Resident #40's left heel unstageable pressure injury after 8/16/23. Review on 10/26/23 of the facility's policy titled, Skin Care Protocol, revision date of 6/8/11, revealed . Wound Care Nurse will assess and document weekly. Weekly wound rounds will include: Measuring and staging weekly and assessing wound healing and treatment modalities . Interview on 10/26/23 at approximately 11:42 a.m. with Staff E (Licensed Practical Nurse) confirmed the above findings. Staff E also confirmed that there were no weekly pressure ulcer evaluations (wound description and wound measurements) for Resident #40's left heel unstageable pressure ulcer after 8/16/23.

Based on record review and interview, it was determined that the facility failed to ensure that as needed (APRN) psychotropic drugs were limited to 14 days for 1 resident in a final sample of 19 residents (Resident identifier is # 28). Findings include: Review on 10/26/23 of Resident #28's current physician orders revealed an order for Lorazepam 0.5mg [milligrams] by mouth every 4 hours PRN for anxiety/insomnia-moderate and Lorazepam 0.5mg 2 tabs [tablets] by mouth every 4 hours PRN anxiety /insomnia-severe that was initiated on 9/24/23. Review on 10/26/23 of Resident #28's October Medication Administration Record (MAR) revealed that no doses of as needed Lorazepam had been given in the month of October. Review on 10/26/23 of Hospice Communication/Continuation Note revealed the following recommendation: 1. Lorazepam 0.5mg 1 tab PO [by mouth] every 4 hours PRN anxiety/insomnia-moderate 2. Lorazepam 0.5mg 2 tabs PO every 4 hours PRN anxiety/insomnia Interview on 10/26/2023 at approximately 1:00 p.m. with Staff B (Director of Nursing) confirmed that there was no 14 day stop date or evaluation for continued use for the PRN Lorazepam since its origination date of 9/24/23. Staff B further confirmed that there should have been either an evaluation of the need to continue the order or a stop date 14 days after the start date of 9/24/23.

Based on interview and record review, it was determined that the facility failed to ensure that the State Long Term Care (LTC) Ombudsman received a copy of a written notice of transfer/discharge for 1 of 2 residents reviewed for hospitalization s (Resident identifier is #17). Findings include: Review on 10/26/23 of Resident #17's medical records revealed that Resident #17 was initially admitted to the facility on [DATE]. Further review of Resident #17's medical records revealed that Resident #17 was transferred to the hospital on 2/5/23, 3/28/23, and 7/2/23. Interview on 10/26/23 at approximately 2:00 p.m. with Staff A (Social Worker) revealed that he/she would send a copy of the written notice of transfer/discharge to the LTC Ombudsman the day the resident was transfer/discharged from the facility. Staff A was unsure if he/she sent a copy of a written notice of transfer to the LTC Ombudsman for Resident #17. Staff A was unable to provide any documentation that a copy of a written notice of transfer/discharge was provided to the State LTC Ombudsman for Resident #17 on above mentioned dates.

Based on record review and interview it was determined that the facility failed to have a Registered Nurse (RN) in the facility for 8 consecutive hours 7 days a week for 2 of 28 days reviewed. Findings Include: Review on 11/21/22 at 11:33 a.m. of the facility's nursing schedule from October 23, 2022 to November 19, 2022 revealed that on 10/29/22 and 10/30/22 there was no Registered Nurse coverage in the facility. Interview on 11/22/22 at 10:30 a.m. with Staff F (Human Resource Manager/Scheduler) confirmed the above findings.

Based on interview and record review, it was determined that the facility failed to ensure that alleged violation involving abuse or neglect, including injuries of unknown origin, are reported to the State Survey Agency (SSA) for 1 out of 4 accidents reviewed. (Resident identifier is #106.) Findings include: Review on 11/21/22 of the facility's policy titled, Resident Abuse Policy, dated 9/8/22, revealed .Any allegation of abuse (of any form) will be reported to the State Survey Agency within 2 hours of the allegation .injuries of unknown origin: source of the injury was not observed and could not be explained by the resident; AND the injury is suspicious because: the extent or seriousness of the injury, or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) . Review on 11/22/22 of Resident #106's hospital note dated 6/8/22 revealed the following: -Resident #106 was complaining of acute chest pain that was located under left breast describing it as a pressure sensation. -Resident #106 reported to facility nursing staff of intermittent lung pain. Resident #106 was hypoxic with oxygen saturation fluctuating between 85% to 90%. Was sent to hospital for further evaluation and found to have multiple rib fractures on his/her left side. -Resident #106 had some slight tenderness of the left lateral chest with palpation and an area of ecchymosis on the left lateral chest wall. -Resident #106 had Computed Tomography (CT) scan on 6/8/22 which showed acute non displaced fractures involving the anterior aspects of the left 6th through 8th ribs. -Resident #106 has a diagnoses of dementia and an activated Durable Power of Attorney (DPOA). -Resident #106 mentioned that he/she had a fall however was unable to provide more details. Resident #106's DPOA mentioned that the only fall that was reported to her/him was on 5/31/22. Review on 11/22/222 of Resident #106's medical records revealed that Resident #106 was admitted to the facility on [DATE]. Review also revealed that Resident #106's care plan indicated Resident #106 was a fall risk and that the fall risk care plan was initiated on 6/1/22. Further review of Resident #106's medical records revealed a primary diagnoses of dementia. Review on 11/22/22 of Resident #106's progress notes revealed the following: -On 5/31/22, Resident #106 was found on the floor on his/her back and was bleeding from his/her head. Resident #106 was sent to the hospital for further evaluation and had his/her scalp laceration treated with staples and went back to the facility. -On 6/8/22, Resident #106 was complaining of left lung pain and tingling in left arm. Resident #106 had low oxygen saturation (85%-91% room air). Resident #106 was sent to hospital for evaluation. -On 6/10/22, Resident #106 returned to facility with diagnoses of 6th to 8th rib fractures. -There was no documentation of any falls or accidents between 6/1/22 to 6/8/22. -There was no documentation of any pain to left chest or left ribs before 6/8/22. -Resident #106 complained of left lung pain 9 days after the last documented fall of 5/31/22. Interview on 11/22/22 at approximately 1:00 p.m. with Staff C (Licensed Practical Nurse (LPN)) and Staff D (LPN) revealed that Resident #106 was complaining of left side pain and that they were not aware nor witnessed any incident(s) which would have caused trauma to Resident #106's left ribs. Interview on 11/22/22 at approximately 2:00 p.m. with Staff A (Administrator) revealed that he/she was unaware of any report submitted to the SSA related to Resident #106's injury of unknown origin (left rib fractures).

Based on observation, interview, and record review it was determined that the facility failed to label 3 insulin pens with an open date, failed to remove 1 insulin pen after it's discard date, and failed to remove inhaler medication after it had been discontinued on 2 of 2 med carts observed (Resident identifiers are #2, 3, 44, 159). Findings include: Second Floor East Medication Cart Observation on 11/21/22 at 8:28 a.m. revealed the following: -Resident #2's Lantus (insulin glargine injection) pen with no open date or use by date; -Resident #44's Lantus SoloStar pen with no open date or use by date; -Resident #44 Humalog KwikPen Lispro insulin that was dated opened 10/11/22 (41 days prior). Further observation revealed that the above 3 insulin pens had all been opened and used. Review on 11/21/22 at 8:28 a.m. of Resident #2's Lantus pen revealed manufacturer's instructions to use within 28 days after initial use. Review on 11/21/22 at 8:28 a.m. of Resident #44's Lantus SoloStar pen and Humalog KwikPen revealed that there were stickers covering the manufacturer's instructions which were unreadable. Interview on 11/21/22 at 8:28 a.m. with Staff G (Licensed Practical Nurse (LPN)) confirmed the above. Interview on 11/21/22 at 3:53 p.m. with Staff G confirmed that Lantus pens should be discarded after 28 days of opening. Third Floor Skilled Nursing Medication Cart Observation on 11/21/22 at 8:40 a.m. revealed the following; -Resident #159 Humalog insulin pen with no open date or use by date; -Resident #3 Advair Diskus (Fluticasone Propionate and Salmeterol inhalation powder) with no open date or use by date. Further observation revealed that the above insulin pen and diskus were opened and used. Review on 11/21/22 at 8:40 a.m. of Resident #3's Advair Diskus box revealed manufacturer's instructions to discard 1 month after opening the foil pouch. Interview on 11/21/22 at 8:40 a.m. with Staff H (LPN) confirmed the above. Staff H stated that Resident #3 did not have a physician's order currently for Advair and was unsure why it was in the med cart. Review on 11/22/22 of Resident #3's physician's orders revealed that the Advair had been discontinued on 7/6/22. Interview on 11/21/22 with Staff I (Assistant Director of Nursing) confirmed that the above medications had not been dated when opened and Resident #44's humalog was dated 10/11/22 and was beyond the 28 days after opening. Review on 11/21/22 of the facility's policy titled Storage of Medications dated August 2020 revealed, .Medications . are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Expiration Dating (Beyond-use dating) . C. Certain medications or package types, such as . multiple dose injectable vials . once opened, require and expiration date shorter than the manufacturer's expiration date to insure medication purity and potency . c. Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: 1. In a multi-dose vial 3. An item for which the manufacturer has specified a usable life after opening. D when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1). The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration . E. The nurse will check the expiration date of each medication before administering it Review on 11/21/22 of the manufacturer's instructions for use of Humalog KwikPen, provided by the facility, revealed .Storing your Pen . In-use Pen . Throw away the Humalog Pen you are using after 28 days, even if it still has insulin left in it . Review on 11/21/22 of the manufacturer's instructions for use of Lantus Solostar prefilled Pen, provided by the facility, revealed, Storage instructions . Once you take your SoloStar out of cool storage . you can use it for up to 28 days . Do not use it after this time .

Based on interview and record review, it was determined that the facility failed to have evidence that alleged violations involving abuse or neglect, including injuries of unknown origin, were investigated related to an injury of unknown origin for 1 of 4 residents reviewed for accidents in a final sample of 22 residents (Resident identifier is #106). Findings include: Review on 11/21/22 of the facility's policy titled, Resident Abuse Policy, dated 9/8/22, revealed .the facility will investigate all allegations and prevent further potential abuse while investigation is ongoing .injuries of unknown origin: source of the injury was not observed and could not be explained by the resident; AND the injury is suspicious because: the extent or seriousness of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) .Investigating - The Administrator or Director of Nursing an investigation of alleged abuse . Review on 11/22/22 of Resident #106's hospital note dated 6/8/22 revealed the following: -Resident #106 had Computed Tomography (CT) scan on 6/8/22 which showed acute non displaced fractures involving the anterior aspects of the left 6th through 8th ribs. Review on 11/22/22 of Resident #106's progress notes revealed the following: -On 5/31/22, Resident #106 was found on the floor on his/her back and was bleeding from his/her head. Resident #106 was sent to the hospital for further evaluation and had his/her scalp laceration, treated with staples, then went back to the facility. -On 6/8/22, Resident #106 was complaining of left lung pain and tingling in left arm. Resident #106 had low oxygen saturation (85%-91% room air). Resident #106 was sent to hospital for evaluation. -On 6/10/22, Resident #106 returned to facility with diagnoses of 6th to 8th rib fractures. -There was no documentation of any falls or accidents between 6/1/22 to 6/8/22. -There was no documentation of any pain to left chest or left ribs before 6/8/22. -Resident #106 complained of left lung pain 9 days after the last documented fall of 5/31/22. Interview on 11/22/22 at approximately 1:00 p.m. with Staff C (Licensed Practical Nurse (LPN)) and Staff D (LPN) revealed that Resident #106 was complaining of left side pain and that they were not aware nor witnessed any incident(s) that would have caused trauma to Resident #106's left ribs. Staff C and Staff D also stated that they were unaware that the event mentioned above was investigated. Interview on 11/22/22 at approximately 2:00 p.m. with Staff A (Administrator) revealed that Staff A was unable to provide any documentation of any investigation for the above mentioned event related to Resident #106 left rib fracture (injury of unknown origin).

Based on observation and interview it was determined that the facility failed to put a plan in place for protecting residents from potentially seriously harmful hot water temperatures in 3 of 5 resident hallways that were initially reported in January 2015 resulting in an immediate jeopardy situation for resident safety. Findings include: Observation on 3/11/15 at approximately 12:30 p.m. revealed that the hot water temperature in the men's staff/visitors rest room to be unbearable to the touch. A second observation of was also unbearable to the touch. This potentially harmful hot water temperature was observed in the bathroom of a resident's room on the second floor a few minutes later. As a result of these potentially harmful hot water levels Staff C(Maintenance Mechanic) was requested to record hot water temperatures in several resident's rooms. Observations on 3/11/15 at approximately 1:00 p.m. of water temperatures taken by Staff C in residents' rooms revealed unsafe hot water temperatures of between 122-139 degrees Fahrenheit in 7 of 14 sampled rooms. Interview on 3/11/15 with Staff C at approximately 1:30 p.m. revealed that the facility maintenance department received a concern in January of 2015 of the water temperature being "too hot in a staff bathroom." Staff C confirmed that the hot water temperatures in this staff bathroom were not found to be in "a safe range." Staff C acknowledged that there was no investigation to determine the extent of the unsafe hot water temperatures which potentially posed a problem in residents' areas. Staff C revealed that water temperatures in resident's rooms were taken, but hadn't been documented. The facility could provide no documentation of any water temperatures being taken in residents' rooms to ensure the residents' safety since learning of a problem regarding unsafe water temperatures in January 2015. Interview on 3/11/15 at 2:25 p.m. with Staff B (Nursing Home Administrator) revealed that maintenance checks the water temperatures at the mixing valves. Temperature checks in resident rooms are done sporadically, but not documented in a log. Staff B confirmed that no residents had received skin burns since the report of the water being too hot in January 2015. Staff B confirmed that staff had not been made aware that water temperatures needed to be checked prior to use for residents. As of 3/11/15, the mixing valve had been replaced and the facility was waiting for a new recirculating pump to arrive. Staff B acknowledged that from January 2015 until 3/11/15 there was no plan put into place by the facility to ensure the safety of the residents regarding unsafe hot water temperatures. Interview on 3/11/15 at 2:45 p.m. with Staff C revealed maintenance received a report in January 2015 of the water being too hot in the staff bathroom. It was checked and found to not be in a safe range. Maintenance responded and had mixing valve ordered and replaced. Staff C checks the water temperatures at the mixing valve at the boiler in the morning which has been between 114 degrees to 118 degrees. Staff C confirmed that he does not keep temperature logs for each time he checks this temperature. Staff C revealed that due to the water being on a recirculation system the water temperatures should remain consistent with each of the residents ' rooms and the temperature at the mixing valve. Staff C also confirmed that the facility is still waiting for a new recirculating pump to arrive that the outside vendor had identified as needing to be replaced. Interview on 3/12/15 at 8:00 a.m. with Staff B and Staff D (Chief Executive Officer) revealed following the identification of Immediate Jeopardy, the water temperatures were lowered and maintained at a safe level (below 120 degrees) for residents until 10:00 p.m. when water temperatures spiked to 120 degrees. The maintenance staff investigated the situation to determine the cause. It was discovered that 2 valves were open that normally are closed to prevent hot water for the kitchen (140 degrees) and for the retirement living heat (160 degrees) from " back feeding " into the water for residents' rooms on the nursing home side of the building. These two valves were closed and with each hourly temperature check the water temperatures lowered again below 120 degrees for residents.