Every finding on record at Raleigh Center

Based on food tray temperatures, resident interviews and staff interview, the facility failed to serve food to residents that was attractive, palatable and at a safe and appetizing temperature to prevent foodborne illness. The facility failed to ensure cold foods were served cold. This failed practice was true for one (1) of one (1) meal tray tested for food temperatures throughout the survey process but had the potential to effect more than an isolated number of residents. Residents identified: #11, 15, 53, 48, 49, 1 and 69. Facility census: 65. Findings include: a) Policy Review Healthcare Services Group (HCSG) policy 016 titled Food Preparation states: All foods are prepared in accordance with the FDA Food Code. All foods will be cooked, held and served at the appropriate temperature. The Healthcare Services Group (HCSG) policy 004 titled Menus states: Menus will be planned in advance to meet the nutritional needs of the residents in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide. Menu cycles will include standardized recipes. b) Test Tray On 03/17/2026 at 12:30 PM, this surveyor asked the Healthcare Services Group (HCSG) District Manager (DM) for a regular consistency test tray to temp and another surveyor asked for an advanced consistency test tray to taste. The HCSG DM brought a new freshly made tray to the dining room, and he took the temperatures of the following food items: Egg Salad Sandwich - 50 degrees Fahrenheit (F) Baked Potato Soup - 157 degrees F Pasta Salad - 57 degrees F Sliced Peaches - 40 degrees F The Pasta Salad did not meet the point of service maximum temperature regulation for cold foods of 50 degrees F. The HCSG DM also gave the other surveyor an advanced consistency diet for the survey team to taste due to residents complaints. The baked potato soup was bland and was also thick and chunky without a soup like consistency. The pasta salad was visually not appealing, and looked to be pasta only. It smelled like white vinegar and tasted like white vinegar only. The egg salad sandwich was supposed to be on wheat bread, per the menu, and was on white bread instead. The HCSG DM stated that the pasta salad was cooked today, and was chilled for forty five minutes. The recipe states to cook the pasta and chill it until it reaches 41 degrees F and then add the vegetables and dressing, and chill for another two - three (2 - 3) hours before serving. He also stated that no one received wheat bread today, because Genesis wants them to order the frozen bread from Sysco, and the residents do not like the frozen wheat bread, so we do not buy it. On 03/17/26 at 12:45 PM, the HCSG DM brought another plate of pasta salad to the room where the survey team was located. He took the temperature in front of all of us, and it was 64 degrees F. On 03/17/26 at 1:10 PM, the HCSG DM and the Administrator came to the room where the survey team was located and stated we did not have enough green onions to complete the Baked Potato Soup recipe, but we used some. He also stated we made our own Italian dressing. The recipe calls for bulk Italian dressing. He also stated we did not have the fresh parsley for the Pasta salad as per the recipe. On 3/17/26 at 12:40 PM it was confirmed with both the District Manager and Administrator that the food had no flavor, that it was not palatable nor attractive. c) Resident Interviews On 03/16/26 at 11:55 AM, Resident #15 stated the food is bad. On 03/16/26 at 11:56 AM, Resident #53 stated the food is all bad. On 03/16/26 at 11:00 AM, Resident #49 stated sometimes the food is good and sometimes not so much. On 03/16/26 at 12:09 PM, Resident #48 stated the food is awful. I do like their meatloaf though. On 03/16/26 at 11:15 AM, during the initial interview process, Resident #1 reported she had lost weight and the food was awful. Resident #1 reported when she was sick and couldn't eat, she would drink cokes. The resident stated they will bring a substitute if they have it , but most of the time they don't have it. On 03/17/26, the state surveyor asked Resident #1 about the potato soup. Resident #1 looked at her tray and asked, Where's the potato soup? while she was eating her lunch tray. On 3/16/26 during the interview process of the initial long term survey process, when ask if the food was good, Resident #69 states, Well, I'm not going to lie about that, it sucks. She went on to state the food is bland, there are missing items that is suppose to be in the item.

Based on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. Additionally, the facility failed to follow the proper sanitation practices for the kitchen and the food preparation equipment. This practice had the potential to affect more than an isolated number of residents. Facility census: 65. Findings include: a) Policy Review Healthcare Services Group policy #019 titled Food Storage, states: All Time / Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. All residents personal food brought in from the outside, will have a date put on when received, when opened, and will be given a seven (7) day use by date, unless the manufacturers use by date is before the seven (7) days. HCSG policy #27 titled Equipment, states the following: All food service equipment will be clean, sanitary, and in proper working order. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. All staff members will be properly trained in the cleaning and maintenance of all equipment. All food contact equipment will be cleaned and sanitized after every use. All non-food contact equipment will be clean and free of debris. b) Initial walkthrough of the kitchen. On 03/16/26 10:00 AM an initial walkthrough of the kitchen was performed and the following issues were identified: One (1) container of rice with no label or date in the storage room.One (1) container of maraschino cherries expired on 03/03/26.One (1) opened package of brussels sprouts not dated in the freezer.The floor in the freezer had debris and needed to be swept.The walk- in refrigerator had water pooling in the floor.Two (2) convection ovens had debris and needed to be cleaned.Two (2) knife racks were dusty.The inside top of the microwave had food splatter that needed to be cleaned.The toaster crumb tray needed to be cleaned.Clean cups and bowls were not stored upside down above the coffee maker.The food scoop holding racks had debris and dust.There were four (4) spices not closed tightly.The refrigerator located in the nourishment room had one (1) bottle of balsamic dressing without an open or use by date.There were seven (7) bowls of applesauce in the nourishment room refrigerator that was outdated with a use by dates of 3/10/26 and 3/15/26.The Director of Dining Services said we will fix these concerns today. On 03/17/26 at 9:17 AM during a second visit to the kitchen the following issues were identified: he bottom of the reach in refrigerator was soiled and needed to be cleaned.The floor behind and underneath of the milk cooler, stove, steamer and oven was soiled and needed to be cleaned.The District Manager (DM) for Healthcare Services Group (HCSG) stated we will get these concerns taken care of as soon as possible.

Based upon observation and staff interviews. the facility failed to maintain a safe, clean homelike environment for residents. This was found to be true for three (3) of 26 residents reviewed during the long-term care survey process. Resident identifiers: #3, #13, #25. Facility census: 65.Findings include: a) Resident #3 During the initial visit with Resident #3 on 03/16/26 at approximately 10:00 AM, an observation was made of the air vent filters in the air conditioner/heating unit. A dust film of approximately one quarter of an inch in thickness could be seen attached to the vent filter. This was reviewed with the Nursing Home Administrator (NHA) on 03/16/26 at approximately 10:45 AM. The Nursing Home Administrator said she would get maintenance to clean this as soon as possible. b) Resident #13 During the initial visit with Resident #13 on 03/16/26 at approximately 10:20 AM, an observation was made of the air vent filters in the air conditioner/heating unit. A dust film of approximately one quarter of an inch in thickness could be seen attached to the vent filter. This was reviewed with the NHA on 03/16/26 at approximately 10:45 AM. The NHA said she would get maintenance to clean this as soon as possible. c) Resident #25 During the initial interview process initiated on 03/16/26, Resident #25's closet door was observed to be opened with a plastic bag with items hanging out and would not close. On 03/18/26 at 10:07 AM, the resident's closet door was still opened with items hanging out. At 10:10 AM, the Director of Nursing (DON) confirmed the door would not close and items were hanging out in a plastic bag and stated, I will clean it out. The DON asked the resident permission to straighten her closet and the resident stated, Yes, please.

Based on observation, record review and staff interview, the facility failed to meet the nutritional needs of the residents in accordance with established national guidelines, due to not following the menu, recipes, and prepping in advance. This had the potential to affect more than a limited number of residents who received their meals from the kitchen. Resident #11, #30, #63, and a sample tray sent to the survey team. Facility census: 65. Findings include: a) Policy Review The Healthcare Services Group (HCSG) policy 004 titled Menus, states: Menus will be planned in advance to meet the nutritional needs of the residents in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide. Menu cycles will include standardized recipes. A menu substitution log will be maintained on file. b) Resident #11 On 03/16/26 at 12:50 PM, Resident #11 had a piece of plain unfrosted angel food cake setting on top of what appeared to be finely chopped and grated fresh carrots . He was supposed to have received carrot cake per the menu, and his tray ticket. Employee #9 was in the room and did verify that the cake did not look like a traditional carrot cake. On 03/17/26 at 12:40 PM, Resident #11 did not receive wheat bread for his egg salad sandwich as per the menu, recipe and his tray ticket. Employee #9 was in his room and did verify that he had white bread instead of the wheat bread that was on his tray ticket. On 03/18/2026 at 11:06 AM, the HCSG District Manager (DM) brought this surveyor a copy of the menu substitution log and the carrot cake recipe. The recipe did not match what the residents received. The menu substitution log did not have the cake substitution on 03/16/26 or the bread substitution for the egg salad sandwich on 03/17/26. c) Resident #30 and Resident #63 On 03/19/26 at 12:10 PM, Resident #30 and #63 received a pureed diet and did not receive the key lime pie that was on the menu for lunch. They received vanilla pudding instead. On 03/19/26 at 12:15 PM, the administrator accompanied me to the kitchen to ask for a serving of the purred key lime pie, that was on the menu today. The HSCG DM gave us a bowl of vanilla pudding and said we served the pureed diets vanilla pudding today instead of pureed key lime pie. The tray ticket also stated key lime pie.

Based on record review, observation and staff interviews, the facility failed to ensure a safe and sanitary environment was provided to prevent the development and transmission of communicable diseases and infections. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #33, #50, #58 and #40. Facility Census: 65.Findings include: a) During the Dining Room initial observation conducted on 03/16/26, the ice scoop remained in the ice storage container while the residents were served. On 03/16/26 at 11:53 AM, the ice scoop, not being placed in a holder after each use, was confirmed by Licensed Practical Nurse (LPN) #24. The ice scoop on B Hall was not placed in a separate container , but remained in the ice storage container during meal service. At 12:10 PM. the Administrator confirmed the ice scoop was in the ice storage container and stated, They have a cup .they should have moved it over. At 12:11 PM, the ice scoop wad observed in the ice storage container on A Hall. The Admissions Director confirmed the ice scoop was in the ice storage container and stated, Okay. b) On 03/16/2026 at 11:20 AM, the dining room observation was initiated. Three residents were observed not to receive hand hygiene before the meal. LPN #24 reported all residents received hand hygiene prior to the lunch meal by the activities department. No resident hand hygiene was observed or provided in the dining room after the state surveyor entered at 11:20 AM. When asked about residents that come later after initial hand hygiene was complete by the activities department or leave and come back into the dining room, LPN #24 stated, I don't know. The following residents were not provided hand hygiene during the dining room observation: 1) Resident #50 was brought into the dining room after 11:20 AM. No hand hygiene was observed by any staff member prior to giving the resident her drinks and meal. 2) Resident #58 walked out of the dining room and later returned. No hand hygiene was performed upon their return. 3) Resident #40 rolled her wheelchair throughout the dining room and down the hallway before returning to the dining room for the lunch meal. No hand hygiene was performed after her return to the dining room. c) Resident #33 On 3/16/26 at 12:15 PM, Resident #33was observed in room [ROOM NUMBER]-B and was in contact precautions due to Clostridioides Difficile Infection (C-diff). There was a Contact Precaution sign on the door indicating the resident was in contact precautions. There was Personal Protective Equipment (PPE) by the doorway to room [ROOM NUMBER]-B. The sign indicated the resident could not come out of the room. That families, visitors, and staff please report to the nurse before entering and ask the Nurse or Infection Preventionist if you have any questions. Clean hands before entering the room and before leaving. Staff to wear gown and gloves, required to use dedicated equipment to the patient and do not remove it from the room, clean and disinfect ay shared equipment before using with next patient. The resident did have an active order dated 3/10/26 for Contact Precautions. She also was on Vancomycin HCL Suspension 50 MG/ ML Give 150 mg by mouth four times a day for suspected C-diff for 10 days (3/10/26 through 3/20/26). On 3/16/26 at 12:15 PM it was observed the Director of Nursing (DON) exiting Resident #33's room and use hand sanitizer. According to the Center for Disease Control and Prevention (CDC) Clostridioides difficile (C. diff) is a common cause of antibiotic-associated diarrhea (AAD). They also state In addition it is recommended not to use hand sanitizer as it does not kill C. diff. It is recommended by the CDC to perform hand hygiene by using antibacterial soap and water to eliminate C. diff spores. At the time the DON exited the room (3/16/26 at 12:15 PM) she was approached by the Surveyor and ask if she was to use hand sanitizer or soap and water for this room. There was no response, and the Surveyor informed her that for C Diff residents, soap and water must be used. It was also confirmed with the Administrator, as she was in the hallway, at which time she agreed.

Based on observation, record review and staff interview, the facility failed to store and dispose of garbage and refuse properly. This was a random opportunity for discovery that has the potential to affect more than a limited number of the residents currently residing at the facility. Facility census: 65. Findings include: a) Policy Review The Healthcare Services Group Policy #30 titled Dispose of Garbage and Refuse states: All garbage and refuse will be collected and disposed of in a safe and efficient manner. The Dining Services Director will ensure that there are appropriately lined containers available within the food service area for disposal of garbage or other refuse. Appropriate lids are provided for all containers. b) Initial Walkthrough of the kitchen On 03/16/2026 at 10:00 AM during the initial walkthrough of the kitchen the following was identified: Two (2) trash cans not in constant use, were without a lid in the kitchen. The trash can in the dish room was not in constant use and did not have a lid on it. The trash can located by the hand washing sink was soiled on the outside. c) Second visit to the kitchen. On 03/17/26 at 9:17 AM during the second visit to the kitchen the following was identified: The trash can in the kitchen was not in constant use, and the lid was off. The outside of the trash can beside the hand washing sink still needed to be cleaned. There was no liner in that trash can, with debris / trash inside of it.

Based upon record review and staff interview, the facility failed to accurately record a diagnosis of bipolar on a resident's Minimum Data Set (MDS). This was found to be true for one (1) of 26 residents reviewed during the long term care survey process. Resident identifier: #12. Facility census: 65.Findings include: a) Resident #12 Resident #12's medical record was reviewed and found their active diagnoses included: - Schizoaffective disorder, Bipolar type , with an onset date of 05/17/24. The resident's most recent MDS was conducted on 12/31/25. Section I for Active Diagnoses was reviewed and found Bipolar Disorder was not marked for this resident. A review of the MDS completed on 09/22/25, found Section I, was not marked for bipolar disorder, and the MDS completed on 07/23/25 was also not marked for bipolar disorder. This discrepancy was reviewed with the Nursing Home Administrator on 03/19/26 at 12:10 PM. She acknowledged the error on all three MDSs.

Based on observation, record review and staff interview the facility failed to implement a personalized care plan to provide adaptative equipment (plate guard) for Resident #26. This was a random opportunity for discovery and was only true for Resident #26. Resident Identifiers: Resident #26. Facility Census: 65 Findings Include: a) Resident #26 On 3/16/26 at 12:20 PM an observation found Resident 26 did not have a plate guard provided with her noon time meal. Resident #26 has a medical diagnosis which includes hemiplegia, affecting the left non dominant side as well as legal blindness. Resident #26 has an order for a regular/liberalized diet, regular texture, standard thin liquids consistent. Plate guard and built up utensils with meals, no salt packet, sugar sub.(Substitute) A plate guard is an assistive dining device designed to foster independence for individuals with limited dexterity, tremors, or one-handed capability (e.g., due to stroke, Parkinson's, or cerebral palsy). Its primary purpose is to prevent food spills by offering a high, curved, or straight edge (often 1-1.5 inches high). This allows users to push food onto their utensils without pushing it off the plate, reducing mess and simplifying the feeding process. The diet ticket which was in place on her noon meal on the date of the observation (3/16/26) read: Built up foam utensils and plate guard. The plate guard was not on her tray. Upon review, her care plan read: Focus: Resident is at nutritional risk: Severe Protein-energy malnutrition, history of Osteomyelitis sacrum, hypertension, MS, diabetes Type 2, hypokalemia, Goal: Resident will consume 75% of at least 3 meals every day over the next review.She will maintain adequate nutritional status as evidenced by maintaining weight with no significant changes, promote wound healing and or skin integrity, no s/s of malnutrition, aspiration, or dehydration and consuming at least 50-100% of most meals daily through next review.Interventions: including but not limited to: Provide Regular/liberalized diet, regular texture, standard thin liquids consistency, plate guard and built up utensils with meals, no salt packet, sugar sub as ordered.Observe for changes in nutritional status (changes in intake ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated. On 03/26/26 at 12:23 PM it was confirmed with the Administrator this resident was to have a plate guard, it was on her meal ticket but missing from her tray. The Administrator agreed the plate guard was not provided in order to help the resident with her ability to obtain food on her utensils as necessary. On 03/26/26 at 1:10 PM it was confirmed with the Administrator the care plan was not implemented in this case, at which time she agreed.

Based on record review and staff interview, the facility failed ensure a care plan was revised and updated when a nutritional supplement was discontinued. This was true for one (1) of 26 sampled residents reviewed during the long term care survey process. Resident Identifier: #2. Facility Census: 65.Findings include: a) Resident #2 A Nutrition assessment dated [DATE] was reviewed and stated, Sig (Significant) change and wt. (weight) review. Average po (by mouth) intake 65% meeting around 90% est. (established) needs. Sig wt. loss x 30 and 180 days; resident desires wt. loss w/ (with) goal wt. of 150#; hx (history) ozempic not currently ordered; diuretic recently reordered and wt. fluctuations may occur; hx sig wt. loss and sig wt. gain. BMI indicates obesity. Therapeutic diet d/t (due to) modular protein tid (three times a day); refusing most of modular protein. Rec. (recommend) d/c (discontinue) modular protein d/t refusals. Will f/u (follow up) prn (as needed). Resident #2's care plan was reviewed and found the following: Protein supplement as ordered Date Initiated: 05/19/25 Created on: 05/19/25.Resident #2's order stated, Protein Liquid two times a day give 1oz Supplement Discontinued7/26/25.On 03/17/26 at 3:17 PM, the Director of Nursing (DON) confirmed the resident's care plan with ordered supplement was not revised and stated, I will look into that,On 03/17/26 at 3:39 PM, the DON reported the supplement had been resolved under skin breakdown on the resident's care plan, but the nutritional part was missed.

Based on observation, record review and staff interview the facility failed to provide adaptative equipment (plate guard) for Resident #26 as ordered. This was a random opportunity of discovery and was true for only Resident #26. Facility Census: 65Findings Include: a) Resident #26 On 3/16/26 at 12:20 PM an observation found Resident #26 did not have a plate guard provided with her noon meal. Resident #26 has medical diagnoses which includes hemiplegia, affecting the left non dominant side as well as legal blindness. Resident #26 has an order for a regular/liberalized diet, regular texture, standard thin liquids consistent. Plate guard and built up utensils with meals, no salt packet, sugar sub (substitute). A plate guard is an assistive dining device designed to foster independence for individuals with limited dexterity, tremors, or one-handed capability (e.g., due to stroke, Parkinson's, or cerebral palsy). Its primary purpose is to prevent food spills by offering a high, curved, or straight edge (often 1-1.5 inches high). This allows users to push food onto their utensils without pushing it off the plate, reducing mess and simplifying the feeding process. The diet ticket which was in place on her noon meal on the date of the observation (3/16/26) read: Built up foam utensils and plate guard. The plate guard was not on her tray. On 03/26/26 at 12:23 PM it was confirmed with the Administrator this resident was to have a plate guard, it was on her meal ticket but missing from her tray. The Administrator agreed the plate guard was not provided in order to help the resident with her ability to obtain food on her utensils as necessary.

Based on record review and staff interview, the facility failed to ensure a resident's Physician Orders for Scope of Treatment (POST) form was signed by the resident's Power of Attorney (POA). This was true for one (1) of three (3) residents reviewed for the care area of advance directives during the long term care survey process. Resident Identifier: #39. Facility Census: 65. Findings include: On 03/16/26 at 2:12 PM, during Resident's #39's electronic medical record review, the POST form was reviewed. A verbal consent was obtained by the POA on 01/19/26. A signed POST form was not in the electronic medical record. The state surveyor requested documentation or records to indicate the POST form had been mailed for the signature to be obtained. No documentation or records to indicate the form had been mailed to be signed or follow-up was attempted for signature until state surveyor intervention. On 03/16/26 at 3:20 PM, the Social Worker confirmed there was no signature on Resident #39's POST form. The Social Worker stated, I did follow-up and she said she would mail it. She has the admission paperwork. A copy of the progress note documenting the follow-up was given to the state surveyor dated 03/16/26 at 2:21 pm.

Based on observation and staff interview the facility failed to maintain an accident and hazard free environment by leaving a medicine cart unlocked and unattended. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing in the Long-Term Care Facility. Facility census: 65. Findings include: a) During med pass observation, on 05/14/25 at 8:20 AM, LPN # 47 was observed preparing medicine on the cart, then turned and went into the resident's room leaving the medicine cart unlocked. During an interview on 05/14/25, at 8:26 am with LPN # 47, the LPN stated, I realized when I came out of the room and saw the cart that I left it unlocked. 05/14/25 9:00 AM the administrator confirmed the medication cart should have been locked if not in direct line of cite from the Nurse.

Based on observation and staff interview, the facility failed to ensure food was stored/prepared and served in a sanitary manner, due to items sitting on the floor, an oven not being cleaned, and stacking serving pans and bowls while still wet. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents residing in the facility. Facility census: 65. Findings include: a) At approximately 9:30 AM on 5/13/2025 a case of oats and a case of grits were observed sitting on the floor in the dry stock room. Both items were dated for 05/06/25. This was confirmed by [NAME] #56. On 05/13/25 at 9:48 AM the following observations were observed, five (5) trays with blue serving bowls were sitting near the area where food is plated. The bowls were still wet. Further observations revealed the large, medium, and small pans that go on the steam table and holds the food being served were stacked on a shelf near the steam table; after pulling two pans from each stack, all pans pulled for observations was wet. When holding the pans up a steady small stream of water ran off the pans into the floor. During an interview, on 05/13/25 at 10:00 AM, Dietary Staff #56 stated, We just brought them out from the dish room. I will get it fixed. On 05/13/25 at 10:05 AM an observation of the facilities cook range with double ovens underneath was completed. When the bottom right side oven door was opened there was evidence of crumbs and burnt substances in the bottom. Along the back of the oven there was evidence of a white/yellow dried substance appearing to be old grease drippings. An interview completed on 05/13/25 at approximately 10:10 AM Dietary Staff #56 stated, We do not use those bottom ovens on the stove. When asked about the oven not being cleaned, Dietary Staff #56 stated, I don't use the bottom ovens. I'm not sure how it got like that, but will get it cleaned shortly.

Based on observation, staff interview and the facility policy, the facility failed to ensure the residents had a comfortable, homelike environment. Meal tray service without removal of tray, and staff storing trash bags in residents room on residents hand towel rack. This was a random opportunity for discovery and had the ability to affect a limited number of residents. Resident identifier: Meal tray service without removal of tray and staff storing trash bags in residents room on residents hand towel rack. Facility census: 63. Findings include: a) Meal tray service without removal of tray. During an observation of the serving of the meal trays on 08/25/24 at approximately 11:50 AM the trays were being placed on the table for the residents and not being removed. During an interview with the Assistant Director of Nursing (ADON) on 08/25/24 at approximately 11:53 AM the ADON acknowledged the trays were not being removed from the table and agreed that the trays should have been removed. During an interview with the Administrator on 08/25/24 at approximately 12:00 PM, the administrator agreed that the trays should have been removed. The Administrator then provided the facility policy titled NSG270 Meal Service This policy states that when serving meals in a dining room with tray service, they staff is to deliver the food to the patient, remove the plate cover and remove the tray. b) B hall residential rooms During a tour of entire Unit B hall way on 08/25/24 at 9:58 AM all the residents rooms on Unit B was observed to have numerous trash bags stored on the hand towel rack with clean towels and wash clothes above the residents sinks. During an interview with Licensed Practical Nurse (LPN) #50 on 08/25/24 at approximately 10:00 AM LPN #50 stated the staff keep them stored there for the staff personal use and agreed it did not create a homelike environment for the residents.

Based on observation and resident and staff interview, the facility failed to ensure residents of the facility were free from abuse and neglect due to a Nurse Aide (NA) neglecting their duties, not serving Resident #2 lunch in a timely manner, and ensuring other residents were free from abuse by Resident #16. These were random opportunities for discovery. Resident identifiers: #2, #6, #24, #16. Facility census: 63. Findings include: a) Nurse Aide (NA) #39 At approximately 11:30 PM on 08/26/24, NA #39 was observed sitting in the area labeled Resident Sitting Area on her cell phone while a call light in her assigned area was ringing. NA #39 continued to look down at her phone and not answer the call light until approximately 11:38 PM. At approximately 11:42 PM, NA #39 returned from the room to the Resident Sitting Area, set back down in the chair, and resumed usage of her cell phone. At approximately 11:58 PM, a call light was pressed in room [ROOM NUMBER], another assigned room for NA #39. The call light rang for approximately three (3) minutes and was answered by Registered Nurse (RN) #21, who had left the medication cart to answer the light. Upon exiting room [ROOM NUMBER], NA #39 was observed still sitting in the chair in the Resident Sitting Area, on her phone, while RN #21 answered the call light for her room. At approximately 12:05 AM on 08/27/24, NA #39 stood up from the seat in the Resident Sitting Area and went out the back door for a smoke break. NA #39 re-entered the facility at approximately 12:15 AM and immediately returned to the chair and resumed usage of her cell phone. b) Resident #2 At approximately 1:55 PM on 08/27/24, Resident #2 asked Licensed Practical Nurse (LPN) #17 for some food due to her sleeping through lunch. Resident #2's lunch tray was observed sitting on her bedside table with the lid still on the plate, untouched. Resident #2 stated her food was cold and she would like to have a hot dog. LPN #17 stated, I'm not sure if they can make a hot dog but we can probably do a grilled cheese. Resident #2 stated that would be fine and LPN #17 stated she would let the kitchen staff know to make a grilled cheese. At approximately 2:35 PM an interview was conducted with Resident #2. At this time, Resident #2 states she was hungry due to her not getting her food from the kitchen. At this time, an interview was conducted with the Dietary Manager (DM) regarding food for Resident #2. The DM stated no one had come to the kitchen with a request for food for Resident #2. At approximately 3:05 PM, Resident #2 still had not received her food. At this time, another interview was conducted with the DM regarding food for Resident #2. The DM stated there still had not been anyone to come request food for Resident #2, but the kitchen would go ahead and make it and deliver it. The DM delivered food to Resident #2 at approximately 3:15 PM, one (1) hour and twenty (20) minutes after the resident initially requested food. c) Resident #16 On 08/27/24 at approximately 12:00 PM, a record review was conducted for Resident #16. During the record review, Resident #16 was noted to have the following diagnoses: Anxiety disorder, unspecified, date 02/10/17 Insomnia, unspecified, date 03/25/17 Major depressive disorder, unspecified, date 02/10/17 Schizoaffective disorder, bipolar type, date 05/17/24 Psychotic disorder with hallucinations, date 12/15/23 Unspecified dementia, unspecified severity, date 02/10/27 Alzheimer's disease, unspecified, date 12/31.20 Vascular dementia with behavioral disturbance, date 12/31/20 Resident #16 was also noted to be receiving the following medications: Clonazepam 0.5 milligram (MG) 1 (one) tablet by mouth three times a day Cymbalta 60 MG 1 (one) capsule by mouth one time a day Nuplaid 34 MG 1 (one) capsule by mouth one time a day Remeron 15 MG 1 (one) tablet by mouth at bedtime In addition the following care plans related to behavioral patterns: Focus: (First Name of Resident #16) has impaired/decline in cognitive function or impaired thought processes related to a condition other than delirium. Resident becomes agitated and aggressive at times. verbally cursing: Dementia (other than Alzheimer's disease), Parkinson's disease, Short/long term memory loss, Impaired decision making. Her spouse serves as MPOA assisting with decision making Goal: (First name of Resident #16) will make daily decisions/choices about activities of daily living when provided with appropriate level cues and supervision by the next review date. Interventions: Observe and evaluate types of changes in cognitive status, e.g., confusion, orientation, forgetfulness, decision making ability, ability to express self, ability to understand others, impulsivity, mental status and notify physician as needed. Monitor for pain. Attempt non-pharmacological interventions to alleviate pain and document effectiveness. Administer pain medication as ordered by physician and document effectiveness/side effects. Evaluate responses from Brief Interview for Mental Status (BIMS) or Staff Assessment for Mental Status and address as indicated. Redirect resident/patient using external cues (e.g., calendar, date book, radio, television etc.), as needed. Provide consistent, trusted caregiver and structured daily routine, when possible. Personalize the resident's/patient's room with familiar items to assist him/her in identifying the room Explain all care, including procedures (one step at a time.), and the reason for performing the care before initiating. Call resident/patient by his/her preferred name for self identity. Focus: Resident/patient exhibits or is at risk for distressed/fluctuating mood symptoms related to : Anxiety/fear caused by move into/within Center and/or inability to return home, coping with acute/chronic illnesses, dx of anxiety and depressive disorder as evidenced by (AEB) she will verbalize her anxiousness, crying/tearful and verbalizing sadness, agitation AEB cursing hitting staff. Goal: Resident/Patient will express anxieties/fears to staff regarding coping with acute/chronic illnesses, care at facility, therapy services by next review. Interventions: Resident frequently asks for a cigarette to calm her nerves as this was her coping mechanism at home. Facility to provide resident with an imitation cigarette that she can hold when she becomes agitated or anxious. Resident has a cigarette pouch that the imitation cigarettes are kept in to mimic her previous smoking habits. An ashtray has been provided for resident to dispose of her imitation cigarette. Observe laboratory test results and report abnormal results to physician/advanced practice provider. Observe for pain and effectiveness of current interventions. Attempt non-pharmacologic interventions. Observe for signs of delirium, including delusions/hallucinations; notify physician/advanced practice practitioner as needed. Observe for signs/symptoms of worsening sadness/depression/anxiety/fear/anger/agitation. Determine the psychosocial cause for the residents/patients sadness/depression, anxiety/fear or persistent anger/agitation. Encourage resident/patient to seek staff support for distressed mood. Refocus resident/patient to something positive. Allow time for expression of feelings, voice her concerns and talk through the problems; provide empathy, encouragement and reassurance. Encourage resident/patient participation in activity preference. Provide resident/patient with opportunities for choice during care/activities to provide a sense of control. Social Service visits to provide support, as needed. Furthermore, during the record review, Resident #16 had several progress notes documented related to aggressive behavior towards staff and other residents. The following documentation is typed as written: eInteract Summary for providers 02/16/24 at 2:16 PM Resident #6 reported that Resident #16 approached her from behind in the dining room and pulled Resident #6's hair to the extent that Resident #6's head went backwards. When Resident #16 was asked, Resident #16 stated, yes, I pulled her hair, she is stealing all my stuff. Nursing documentation note 02/19/24 at 11:40 PM: Resident was cussing and try to hit another resident but was intervened and she missed. Resident trying exit doors. She was removed from situation and try to listen and offer food. Resident has delusions other residents are after husband. She threatened to hit staff because we removed her from other residents because she was verbally cussing along with staff. Was unsuccessful in interventions. Nursing documentation note 02/22/24 at 12:03 AM: Physical behaviors directed towards others occurs up to 5 (five) days a week. Verbal behaviors, directed towards others, occur up to 5 (five) days a week. Assessment 03/18/24 at 10:52 PM: Since the last evaluation there has been no change in behavior symptoms. Accusing others x5, cursing others x6, screaming at others x4, threaten 6, disruptive 1, enters others room [ROOM NUMBER], exit seeking 1, refusal 1, depression. eMAR (electronic medication administration record) for 05/29/24 at 07:41 AM: Was behavior observed? Yes eMAR (electronic medication administration record) for 6/27/24 at 08:42 AM: Was behavior observed? Yes eMAR (electronic medication administration record) for 07/23/24 at 08:18 AM: Was behavior observed? Yes eMAR (electronic medication administration record) for 08/04/24 at 08:53 AM: Was behavior observed? Yes On 08/28/24 at approximately 12:00 PM, the policy and procedure entitled, Abuse Prohibition was reviewed. This policy states that if suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. That the Center will provide adequate supervision when the risk of patient to patient altercation is suspected. The Center is responsible for identifying patients who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. The patient representative and physician will be notified and any follow up recommended will be completed. Furthermore, the policy states that allegations involving abuse (physician, verbal, sexual or mental) shall be reported not later than 2 (two) hours after the allegation is made to the appropriate state authorities. In addition, the policy states the investigation shall focus on the causative factors and interventions to prevent further injury. At approximately 12:30 PM on 08/27/24, while a fell ow Surveyor was observing tray pass for lunch, Resident #16 was observed hitting her roommate, Resident #24, in the face during an altercation in their room. Two nurse aides were assisting Resident #16 out of her room at the time and were attempting to break up the altercation. Nurse Aide (NA) #13 was pushing Resident #16's chair out of the room and NA #36 was trying to place a pillow between the two residents to keep Resident #16 from striking Resident #24 again. At approximately 12:40 PM, an interview was conducted with NA #13 who stated Resident #16 pulled Resident #6's hair for an unknown reason and Resident #16 started swinging at her. NA #13 stated, I thought someone was going to get hurt bad this time. At approximately 1:00 PM, an interview was conducted with NA #36 who stated, I did not see Resident #16 pull Resident #6's hair, but I did see Resident #16 slap Resident #24, causing me to grab a pillow and hold it up between them. I thought someone was going to get hurt. NA #36 then stated, This is not the first altercation Resident #16 has been in with other residents. On 08/28/24 at approximately 1:05 PM, an interview was conducted with the Director of Nursing(DON). During the interview, the DON stated, Resident #16 and Resident #24 had in fact had multiple altercations, however no intervention had been put into place, such as a room move, because the family did not wish them to be separated. At that time, this Surveyor requested the documentation. The DON was unable to provide documentation related to this. The DON was able to provide the reporting documentation, investigation and intervention put into place for the occurrence from 02/16/24, however acknowledged there was none for the occurrence from 02/19/24. Also, the DON was unable to identify the other resident mentioned in the documentation from 02/19/24, with the DON stating, There was no investigation, there was no physician intervention required for the occurrence from 02/19/24, I didn't have to report it. At that time, this Surveyor supplied the DON with the document entitled, Office of Health Care Facilities Licensure and Certification Long Term Care Reporting Requirement dated 12/04/19 which states that an allegation of abuse must be reported within 2 (two) hours. After reviewing the DON acknowledged this had not been done. Furthermore, the DON acknowledged, she was unable to say what the behavior and non-pharmacological intervention was documented for the eMAR notes dated 05/29/24, 6/27/24, 07/23/24 and 08/04/24. On 08/28/24 at approximately 2:20 PM, an interview was conducted with the facility Social Worker (SW) with the SW acknowledging she had not performed an investigation or reported the occurrence dated 02/19/24. On 08/29/24 at approximately 12:30 PM, an additional interview was conducted with the DON who acknowledged the facility policy entitled, Abuse Prohibition had not been followed. 50552

Based on observation and resident and staff interviews, the facility failed to offer snacks to residents who wished to revieve a snack at night time, and failed to ensure all ordered snacks were delivered to residents at night time. This was a random opportunity for discovery. Resident identifiers: #24, #28, #33, #51, #52, #22, #58. Facility census: 63. Findings included: a) Resident #24 At approximately 10:15 AM on 08/25/24, during a tour of the nourishment room at the facility, a sandwich was found in the refrigerator with a label dated 08/24/24 S3 (third shift, night shift), with the resident's name on it. A review of the task sheet for snacks offered for Resident #24 indicated Not Applicable was selected under question 2, titled Snack Accepted. At approximately 10:45 AM, an interview with the District Dietary Manager (DDM) confirmed the resident was ordered the snack, the S3 on the label meant third shift, or night shift, and they were not passed. At approximately 11:00 AM on 08/25/24, an interview was conducted with the Dietary Manager (DM) regarding snacks. The DM stated the last dietary employee leaves the facility at approximately 7:00 PM each evening and the snacks are delivered to the nurses station at that time. The DM stated They never deliver the snacks. I have pictures on my phone of the snacks still sitting there the next day. It happens all the time. At approximately 11:38 PM on 08/26/24, a sandwich labeled for third shift on 08/26/24 was found on the nurses station. At approximately 11:40 PM in interview was conducted with Nurse Aides (NA) #15 and #33. NA #15 and #33 confirmed they had not offered the snacks to residents during the shift. NA #15 stated, I haven't offered one to anyone and if they are still sitting there, no one from evening shift did either. NA #33 stated the employees were getting ready to throw the snacks in the trash because they have been sitting here all night. b) Resident #28 At approximately 10:15 AM on 08/25/24, during a tour of the nourishment room at the facility, a sandwich was found in the refrigerator with a label dated 08/24/24 S3 (third shift, night shift), with the resident's name on it. A review of the task sheet for snacks offered for Resident #28 indicated Not Applicable was selected under question 2, titled Snack Accepted. At approximately 10:45 AM, an interview with the District Dietary Manager (DDM) confirmed the resident was ordered the snack, the S3 on the label meant third shift, or night shift, and they were not passed. At approximately 11:00 AM on 08/25/24, an interview was conducted with the Dietary Manager (DM) regarding snacks. The DM stated the last dietary employee left the facility at approximately 7:00 PM each evening and the snacks weree delivered to the nurses station at that time. The DM stated, They never deliver the snacks. I have pictures on my phone of the snacks still sitting there the next day. It happens all the time. At approximately 11:38 PM on 08/26/24, a sandwich labeled for third shift on 08/26/24 was found on the nurses station. At approximately 11:40 PM an interview with Nurse Aides (NA) #15 and #33. NA #15 and #33 confirmed they had not offered the snacks to residents during the shift. NA #15 stated, I haven't offered one to anyone and if they are still sitting there, no one from evening shift did either. NA #33 stated the employees were getting ready to throw the snacks in the trash because they have been sitting here all night. At approximately 11:45 PM, an interview was conducted with Resident #28. During the interview, Resident #28 stated no one had brought or offered her the snack that evening. Resident #28 stated, I would have liked to have had it. I didn't even know it was there. c) Resident #33 At approximately 10:15 AM on 08/25/24, during a tour of the nourishment room at the facility, a house supplement shake was found in the refrigerator with a label dated 08/24/24 S3 (third shift, night shift), with the resident's name on it. A review of the task sheet for snacks offered for Resident #33 indicated Not Applicable was selected under question 2, titled Snack Accepted. At approximately 10:45 AM, an interview with the District Dietary Manager (DDM) confirmed the resident was ordered the snack, the S3 on the label meant third shift, or night shift, and they were not passed. At approximately 11:00 AM on 08/25/24, an interview was conducted with the Dietary Manager (DM) regarding snacks. The DM stated the last dietary employee leaves the facility at approximately 7:00 PM each evening and the snacks are delivered to the nurses station at that time. The DM stated They never deliver the snacks. I have pictures on my phone of the snacks still sitting there the next day. It happens all the time. At approximately 11:38 PM on 08/26/24, a melted cup of ice cream labeled for third shift on 08/26/24 was found on the nurses station. At approximately 11:40 PM in interview was conducted with Nurse Aides (NA) #15 and #33. NA #15 and #33 confirmed they had not offered the snacks to residents during the shift. NA #15 stated I haven't offered one to anyone and if they are still sitting there, no one from evening shift did either. NA #33 stated the employees were getting ready to throw the snacks in the trash because they have been sitting here all night. d) Resident #51 At approximately 10:15 AM on 08/25/24, during a tour of the nourishment room at the facility, a house supplement shake was found in the refrigerator with a label dated 08/24/24 S3 (third shift, night shift), with the resident's name on it. A review of the task sheet for snacks offered for Resident #51 indicated Not Applicable was selected under question 2, titled Snack Accepted. At approximately 10:45 AM, an interview with the District Dietary Manager (DDM) confirmed the resident was ordered the snack, the S3 on the label meant third shift, or night shift, and they were not passed. At approximately 11:00 AM on 08/25/24, an interview was conducted with the Dietary Manager (DM) regarding snacks. The DM stated the last dietary employee leaves the facility at approximately 7:00 PM each evening and the snacks are delivered to the nurses station at that time. The DM stated They never deliver the snacks. I have pictures on my phone of the snacks still sitting there the next day. It happens all the time. At approximately 11:38 PM on 08/26/24, a melted cup of ice cream labeled for third shift on 08/26/2028 was found on the nurses station. At approximately 11:40 PM in interview was conducted with Nurse Aides (NA) #15 and #33. NA #15 and #33 confirmed they had not offered the snacks to residents during the shift. NA #15 stated I haven't offered one to anyone and if they are still sitting there, no one from evening shift did either. NA #33 stated the employees were getting ready to throw the snacks in the trash because they have been sitting here all night. e) Resident #52 On 08/26/24 at 3:42 PM, an interview was conducted with Resident #52. At tist time, Resident #52 stated, I don't always get snacks before I go to bed. I would like them but they usually don't offer them. Its less than once every 2 (two) weeks I would say they even offer me something before bed. On 08/27/24 at 10:45 AM, a record review was conducted for Resident #52's Nurse Aide (NA) task list documentation related to provision of snacks which revealed Resident #52 was not offered a snack on the following dates: 07/28/24 07/29/24 07/31/24 08/01/24 08/02/24 08/03/24 08/04/24 08/05/24 08/06/24 08/07/24 08/09/24 08/10/24 08/11/24 08/12/24 08/13/24 08/14/24 08/15/24 08/16/24 08/17/24 08/18/24 08/19/24 08/20/24 08/21/24 08/23/24 08/24/24 08/25/24 08/27/24 On 08/27/24 at 2:55 PM, an interview was conducted with the Director of Nursing (DON) who stated, we offer snacks every evening, if the resident is not on the list for an ordered snack they can ask for it. On 08/28/24 at 10:22 AM, review of facility policy for meal/snacks revealed evening snack was planned as part of the menu. Food and Nutrition Services delivers snacks to nursing stations at specified times. Nursing or designated staff offer an evening snack to every resident. Snacks are passed within 15 minutes of delivery to the unit or are properly stored at the nursing station and offered at a later time. On 08/28/24 at approximately 1:30 PM, the DON acknowledged the facility had not been following the procedures as outlined in the policy and procedure for meal and snacks. F) Resident Council, Residents #22 and #58 On 08/26/24 at 12:00 PM, review of six (6) month's of resident council meeting minutes with no addressed concerns. On 08/26/24 at 1:10 PM, during resident council, Resident #22 and Resident #58 reported they were not offered snacks at bedtime. They reported staff lay the snacks down at the nurses station and do not pass them out in the evening. Maybe one day per week staff will go around from room to room and offer a snack was stated by Resident #58. On 08/28/24 at 1:13 PM a review of records task form for Resident #22 revealed residents were not offered a bedtime snack on the following evenings between 07/30/24 and 08/27/24: -7/31/24 -08/01/24 -08/2/24 -08/3/24 -08/4/24 -08/06/24 -08/08/24 -08/09/24 -08/10/24 -08/11/24 -08/12/24 -08/13/24 -08/15/24 -08/16/24 -08/17/24 -08/18/24 -08/19/24 -08/20/24 -08/21/24 -08/22/24 -08/23/24 -08/24/24 -08/25/24 -08/26/24 -08/27/24 On 08/27/24 review of recorded task form revealed, Resident #58 was not offered bedtime snacks on the following days between 07/30/24 and 08/27/24: -07/30/24 -08/1/24 -08/2/24 -08/4/24 -08/5/24 -08/07/24 -08/08/24 -08/09/24 -08/10/24 -08/11/24 -08/12/24 -08/13/24 -08/17/24 -08/18/24 -08/19/24 -08/20/24 -08/21/24 -08/24/24 -08/25/24 -08/26/24 -08/27/24 On 08/28/24 at 10:22 AM, review of facility policy for meal/snacks revealed evening snack was planned as part of the menu. Food and Nutrition Services delivers snacks to nursing stations at specified times. Nursing or designated staff offer an evening snack to every resident. Snacks are passed within 15 minutes of delivery to the unit or are properly stored at the nursing station and offered at a later time. 50551 50552

Based on observation and staff interview, the facility failed to ensure food was stored, prepared, and served in a sanitary manner. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents residing in the facility. Facility census: 63. Findings include: a) Kitchen Tour At approximately 9:45 AM on 08/25/24, during the initial tour of the kitchen, a jar of apple sauce was discovered in the reach-in refrigerator. The apple sauce had a discard date of 7/19/24 on it and was still in use. [NAME] #82 acknowledged the apple sauce, discard date, and that it was still in use. At approximately 11:00 AM, an interview was conducted with the Dietary Manager (DM) regarding the apple sauce. During the interview, the apple sauce was still in the refrigerator and acknowledged by the DM. b) Dining Observation On 08/25/24 at 12:00 PM, the Assistant Director of Nursing (ADON) #55 was observed assisting a resident with her fork, food and drink while the resident was eating. The ADON then turned and picked up a clean tray to serve another resident without sanitizing her hands. On 08/25/24 at 12:01 PM, ADON #55 was made aware she was observed assisting a resident with her food and didn't sanitize before continuing to pass trays and putting others at risk for cross contamination. ADON #55 acknowledged and stated I'm messing up, I am not usually in here. c) Placement of soiled tray. During a dining room observation on 08/25/24 at approximately 11:47 AM the Assistant Director of Nursing (ADON) was observed to taking a resident meal tray from the enclosed food delivery cart and placed the tray on the table in front of the resident. The resident was observed to refuse the tray and the ADON was observed to take the tray and place it back into the enclosed food delivery cart with other residents trays which had not yet been served. During an interview with the ADON on 08/25/24 at 11:50 AM the ADON agreed the tray being placed back in the food delivery cart after it was sat at the table does increase the potential of cross contamination and she knew she should not have done that but doesn't normally work in the dining room. She further stated the tray should have been taken to the kitchen. During an interview with the Administrator on 08/25/24 at approximately 12:00 PM, the Administrator stated the ADON should not have placed the tray back into the food delivery cart. 49650 50551

Based on observation, resident interview and staff interview the facility failed to ensure the environment was free of accident hazards. Residents fall mats were preventing a resident to safely make it to his bed in his wheelchair, oxygen was stored in resident sitting area with no signage, and medications were not stored in a safe manner. These were random opportunities for discovery during the long term care survey process and had the ability to affect a more than a limited number of residents currently resding in the facility. Identifier: Resident #26. Facility Census.: 63. Findings include: a) Resident #26 fall mats. During a tour of the facility on 08/25/24 at approximately 2:15 PM, Resident #26 was observed attempting to wheel himself in his wheelchair to his side of the room by the window. The resident stated, he was unable to safely go to his side because he can't get over the fall mats with his wheelchair. During this observation, fall mats were identified on the left and right side of the first bed entering the room and this resident was sitting in his wheel chair to the side of his bed on top of a fall mat. Resident #26 also had a fall mat to the front side of his bed with the left side of the bed placed against the wall. On 08/25/24 at approximately 2:20 PM, Licensed Practical Nurse (LPN) #50 was asked about Resident #26 not being able to safely wheel himself in his room. LPN #50 stated, we normally remove the floor mats when the residents are up out of the bed. LPN #50 assisted Resident #26 and the fall mats were removed off the floor. b) Oxygen stored in resident sitting area with no signage. During a tour of the facility on 08/26/24 at 10:51 PM there were three (3) oxygen tanks identified to be sitting unattended on the back of wheel chairs in the residents sitting area. All residents were in bed and the oxygen was not in use. Upon further review it is identified this room is not marked with signage which identifies it to be an area the oxygen is located and or stored. During an interview with the Registered Nurse (RN) #30 at 12:05 AM on 08/26/24, RN #30 stated they do not normally leave the oxygen stored in this room when the residents are not using them. She stated they are normally returned to the oxygen holder outside of the facility. RN #30 removed the oxygen tanks at this time. RN #30 agreed the room is not identified with signage for oxygen in use or oxygen stored. c) Medication Storage On 08/25/24 at 09:48 AM, a facility tour was conducted revealing the treatment cart unlocked with the key in the lock, with resident medications stored on top of it. At that time, RN #21 acknowledged the treatment cart should have been locked with the keys and medications securely stored out of resident reach. On 08/26/24 at 11:35 PM, an additional tour of the facility was conducted revealing A Hall medication cart unlocked with key in lock with the top drawer open. No nurse was present at the time. At 11:40 PM, RN #30 came out of a resident room and walked to the cart. At that time, RN #30 acknowledged this was her cart for the shift and the cart should have been locked with the keys securely stored out of resident reach. In addition, at 11:38 PM, B Hall medication cart was noted to have medications sitting on top of the cart with a white oblong pill in a pill cup, a bottle of Lactulose and a bottle of Melatonin. Again, no nurse was present at the time. LPN # 52 returned to the cart at 11: 43 PM stating the white oblong pill was a Norco, however LPN #52 was unable to tell me which resident this medication belonged too. In addition, LPN #52 stated, We just got a new admission to the facility I was working on. LPN #52 acknowledged the medications should not have been sitting on top of the cart unattended and should have been securely stored out of residents reach. On 08/27/24 at approximately 12:00 PM, a review of the policy and procedure entitled, Medication Storage was conducted which revealed that in order to limit access to prescription medications, only licensed nurses, pharmacy staff and those lawfully authorized to administer medications are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended to by persons with authorized access. On 08/27/24 at approximately 02:30 PM, an interview was conducted with the Director of Nursing who acknowledged the medication carts should have been locked when unattended and the medications should not have been left unsecured on top of the medication carts.

Based on resident interview, record review and staff interview, the facility failed to ensure each resident was treated with dignity. This was a random opportunity for discovery. Resident identifier: #12. Facility Census: 63. Findings include: a) Resident #12 On 08/25/24 at 11:40 AM, during an interview with Resident #12, she reported when she pressed her call light it often took staff up to 20 minutes to answer. Resident #12 had a privately paid care giver in the room with her who agreed with the statement of the resident. Resident #12 reported, if she asked to go to the bathroom, she required the use of a lift to put her in the bed to use the bedpan, and staff would make her go to bed for the remainder of the day and would not let her get back up until the following day. On 08/27/24 at 2:00 PM, observed Nurse Aide (NA) #51 exit Resident #12's room with a lift. She reported she had just put the resident on the bedpan. She stated, Resident #12 has a private sitter due to blindness. She stated the resident gets up out of bed around 10:30 AM, will do her therapy and eat. She then calls to use the bedpan around approximately 1:30 PM- 2:00 PM. She stated Resident #12 had to be transferred to bed using a lift. After using the restroom, the resident normally likes to stay in bed the rest of the day. On 08/27/24 at 3:08 PM, an additional interview was conducted with the resident and private care giver, different from the initial care giver interviewed. Resident #12 reported there were times she felt like she was being punished for needing to use the bathroom. She stated, when she asked to use the bedpan, she was told Once you go to bed you cannot get back up. Resident #12 reported that sometimes she wanted to get back up but was told, That is against the rules. Resident's care giver reported she has heard a nurse aide suggest resident pee herself (use her brief so she does not have to go back to bed.) On 08/27/24 at 3:38 PM, the information obtained from the interviews with the resident and the two (2) caregivers was reported to the Director of Nursing (DON) who stated, she was unaware of these issues and had never had a complaint from this resident but would report it to the proper channels and investigate. On 08/27/24 at 4:22 PM, review of Resident #12's care plan revealed the following: Resident at risk for falls. intervention: transfer assistance assist of 2 (two) total lift full body sling medium with purple binding. maximum physical activity to enhance general muscle tone, functioning of lower G.I. tract, and ability to mobilize to bathroom in response to urge to defecate. Encourage resident to attend activities that maximize their full potential while meeting their need to socialize.

Based on observation, staff interview and resident interview, the facility to ensure call light was placed in a position which would allow the resident to use it if she needed to call for help. This is true for one (1) of 22 sampled residents reviewed during the long term care survey process. Resident Identifier: Resident #35. Facility Census: 63. Findings include: a) On 08/26/24 at 10:55 AM, an observation found Resident #35 resting in her bed. Her call light button was clipped to the left side of her bed and was hanging down toward the floor. Resident #35 reported she was not able to use her left hand at all and was not able to use the call bell when it is clipped to the left side of her bed. On 08/26/24 at 11:00 AM, when Licensed Practical Nurse (LPN) #17 came into the room, she acknowledged the light was clipped to the non dominant side of the resident and moved it to the right side of the bed and placed it in HER dominant hand. She stated, resident had been working with physical therapy to try to strengthen the left hand. On 08/29/24 at 12:55 PM, The Director of Nursing (DON) #54 and Nurse Educator #34 acknowledged the resident's minimum data set (MDS) indicated the resident is dependent with upper extremities, physician believed maybe edema was causing the issue. No documentation on this from physician addressing Resident #35's use of her left hand could be found in the medical record. Both acknowledged the resident is not care planned nor does she have a diagnosis for inability to use her left hand but did acknowledge the resident was having difficulty using it. They reported therapy had been working with her with her use of the left hand. They stated they would change her call light to a flat device which could easily be used by the resident.