Every finding on record at Regalcare at Greenfield

Based on observations, record review, and interviews, the facility failed to maintain an effective pest control program so that the facility was free of pests, placing residents at risk for food, beverage and wound contamination. Specifically, the facility failed to repair/replace grout and tiles in the main kitchen dishwasher area, as initially recommended by the pest company in March 2023 [sic], and reviewed again in October 2025, January 2026, February 2026, and March 2026, resulting in an unresolved flying pests' presence and an optimal, ongoing area for flying pests to eat and breed. 2. implement effective pest control interventions when small flies bred and migrated from Resident #95's room into the Unit Four hallway and into Resident #22's room, placing residents on Unit Four at increased risk for continued small fly infestation. Findings include: Review of the facility policy titled Pest Control, revised 1/2025 included but was not limited the following: -All Employees >report any suspected pest activity to their supervisor immediately. >properly store food in sealed containers. -Facility Management >maintain records of pest control activities and treatment applications. -Integrated Pest Management (IPM) Principles >regularly inspect for pest activity, including signs of infestation like .live insects. >the company (facility) will engage a licensed and reputable pest control provider to conduct regular inspections and treatments. >the provider (pest control service provider) will follow the established IPM plan and provide detailed reports on pest activity and treatment applications. >all employees will receive training on pest identification, prevention, and reporting. 1. On 4/21/26 between 11:15 A.M. and 12:48 P.M., the surveyor observed eight small black flying flies flying over and landing on the food service area during meal tray service for Nursing units two, three, and four (all the nursing units in the facility). During an interview at the time, the Food Service Director (FSD) said that pest treatment had been done a while ago, but the pest activity had continued from the dishwashing area. The FSD said that facility management was aware of the flying insect concern. On 4/22/26 at 12:50 P.M., the surveyor observed the FSD step onto the large, black, porous mat on the dishwasher room floor. The surveyor then observed a large pool of milky white liquid with white solid substances surround the FSD's shoes while she was standing on the black porous mat. During an interview at the time, the FSD said that the floor in the dishwasher room was always wet because the dish room floor was missing tiles around the floor drain and missing grout around most of the tiles on the floor. The FSD said the tiles and tile grout had been missing for as long as she could remember and needed to be fixed. The surveyor and the FSD then observed the flooring under the black mat to be missing six tiles, a large area of missing tile grout, and pooling of a milky colored liquid within the areas of the six missing tiles and white solid substances embedded in the spaces of the missing tile grout. The FSD said that the water on the floor contained liquids and solids from the breakfast tray cleaning. The surveyor and the FSD then observed 15 black flies on the dish room walls, dish room equipment and flying overhead in the dish room area. The FSD said that the pest control company was in the facility on 4/16/26 but she was not sure if the flies had been treated. During an interview on 4/22/26 at 1:00 P.M., The Director of Maintenance said that he was unaware of the broken tiles, missing grout and pooling water in the dishwasher room. The Director of Maintenance said the pest company provided written reports in the portal after each visit, but he was unaware of how to retrieve the reports. The Director of Maintenance said he should probably have asked someone to help him print the reports off the portal. During a follow-up interview on 4/22/26 at 1:30 P.M., the Director of Maintenance said he had requested assistance from the business office to print the most recent pest reports from the portal. The surveyor and the Director of Maintenance reviewed the portal reports as follows: -On 10/23/26: the pest control company had reviewed the initial report from 3/16/23 which indicated floor tiles broken/need grout/water leaking - nearly all the grout in the dishwasher room is missing and there is a gap between the wall and floor that traps organic debris and moisture, allowing small flies to breed. Action needed by the facility to repair/replace grout and tiles, fix wall, clean debris and water. -On 1/15/26: the pest control company had reviewed the initial report from 3/16/23 which indicated floor tiles broken/need grout/water leaking-nearly all the grout in the dishwasher room is missing and there is a gap between the wall and floor that traps organic debris and moisture, allowing small flies to breed. Action needed by the facility to repair/replace grout and tiles, fix wall, clean debris and water. Fly activity noted in the kitchen dishwasher room There are a lot of gaps in the baseboards and tiles that allows for water and debris to collect, making the area an ideal breeding ground and water source for numerous pests. In this case it is allowing a breeding ground for flies. If this area was fixed it would be a great step forward in halting the fly problem. Upgrading to a fly service that happens twice a month is another great option to help. This helps us treat before another life cycle can take hold. Our insect light traps do not capture flies due to them not being attracted to ultraviolet light. Regular maintenance of the area is a must. -On 2/19/26: the pest control company had reviewed the initial report from 3/16/23 and added - Action needed by the facility to repair/replace grout and tiles, fix wall, clean debris and water. Several dozen flies observed in the dishwashing area, standing water between floor tiles and wall. >On 3/17/26: the pest control company had reviewed the initial report from 3/16/23 and which indicated floor tiles broken/need grout/water leaking-nearly all the grout in the dishwasher room is missing and there is a gap between the wall and floor that traps organic debris and moisture, allowing small flies to breed. Action needed by the facility to repair/replace grout and tiles, fix wall, clean debris and water. During a telephone interview with the facilities pest control company on 4/22/26 at 2:36 P.M., the Operation Support Manager (OSM) #1 said the facility was contracted for a monthly rodent and roach program which did not include flying pest treatment. OSM #1 said that flying pests like fruit flies, house flies, blow flies and sewer flies were an add-on service which needed to be requested individually by the facility. OSM #1 said the facility had most recently had flying pest treatment service conducted on 10/23/26 with findings as follows: -inspected and spoke with client (facility) about fly service in the kitchen area, small flies were seen flying around. A treatment of Finito (a multi-pest pesticide) was applied and the pest company had left a card and sent an email to the facility director for the need of ongoing services to treat the flies. OSM #1 said treatment with a Borate (a pest control compound) product would be necessary every two weeks following the application of the Finito product to prevent further fly infestation because the flies were feeding on and laying eggs in the organic matter and standing water on the dishwasher room floor. OSM #1 said the facility director never responded to the pest company's email or contacted the pest company for additional fly treatments. OSM #1 said that the concern for broken/missing tiles in the dish room, missing grout in the dish room, and moisture collection had been initially identified on the service report from 3/16/23 [sic] and re-reviewed on an ongoing basis but most recently in October 2025, January 2026, February 2026, and March 2026 for high severity and action needed by the facility to replace tiles and grout in an effort to halt the fly problem. OSM #1 said the facility is provided with a report through the portal following each service visit with recommendations/actions needed. OSM #1 said that flies will migrate within the facility to wherever other food/liquid sources are. OSM #1 said the risk of fly infestation to the residents of the facility would be flies landing onto foods/beverages, contaminating the foods/beverages and laying eggs on the resident's foods/beverages. During an interview on 4/22/26 at 3:08 P.M., the Administrator said the missing floor tiles, missing grout, and standing water had been present in the dish room for over a year. The Administrator said the repairs should have been made when they were identified as a concern by the pest company. The Administrator said the Director of Maintenance was responsible to review the pest company reports from the portal after each visit and initiate the required action. The Administrator said he was aware that the Director of Maintenance had difficulty getting reports from the portal due to a password issue. The Administrator said he did not have access to the pest company portal. During an interview on 4/22/26 at 4:11 P.M., the Infection Preventionist (IP) said that she had concerns with the flies in the facility because bugs are dirty, could get into a resident's wounds and cause maggots, and could get into the resident's food and be consumed. 2.Resident #95 was admitted to the facility in December 2022 and resided in his/her current room on Unit Four since November 2024. Resident #22 was admitted to the facility in April 2026 and resided in his/her current room on Unit Four since admission to the facility. On 4/21/26 at 2:50 P.M., the surveyor observed Resident #22 exit his/her Unit Four room into the hallway and approach the surveyor and asked the surveyor for a can of fly spray for his/her room. During an interview at the time, Resident #22 said that there were flies in his/her room and that the flies had been in his/her room since he/she came to the facility. The surveyor observed the following in Resident #22's room at this time: -One small fly on the upper netted portion of the privacy curtain hanging on the door-side of the room. -Five small flies on the wall on the door-side of the room. -Four small flies on the wall behind the head of the Resident's bed. -One open, empty banana peel and one spoon and one knife with food debris on the Resident's nightstand. -One covered cup of liquid, with an open hole in the center of the cover, on the floor next to the Resident's bed. During an interview on 4/21/26 at 3:04 P.M., Nurse #3 said she provided care for Resident #22 that day and that she did not notice any small flies in the Resident's room. At the same time, Nurse #3 waved her hand across her face, and said she was swatting at a small fly. Nurse #3 then said, it's that time of year. During an interview on 4/21/26 at 3:06 P.M., Unit Manager (UM) #3 said she would contact the Maintenance Department to alert them that Resident #22 had small flies in his/her room. UM #3 said staff would look in Resident #22's room to see whether the Resident had items in the room that might be attracting small flies and remove the items. On 4/22/26 at 8:00 A.M., the surveyor observed the following in Resident #22's room: -One open, empty, brown banana peel on the nightstand (in the same location as observed on 4/21/26). -Two open small cartons of milk containing a small amount of milk. Both cartons were room temperature to touch. -The Resident's bedside table was positioned between the Resident's bed and the privacy curtain. There were small flies on the privacy curtain, and the privacy curtain was touching the edge of the bedside table. -Eight small flies on the Resident-facing side of the privacy curtain and two small flies on the door-facing side of the privacy curtain hanging on the door-side of the room. -Six small flies on the wall on the door-side of the room. -Four small flies on the wall behind the head of the Resident's bed. During an interview at the time, Resident #22 said no one had offered to help clean up the open food and drink items on the nightstand and that the milk cartons and banana peel were left over from the previous day (4/21/26). Resident #22 said he/she probably should clean up his/her space in the room and throw the open food and drink items away. Resident #22 said he/she waited in his/her room for someone from the facility to come and inspect the small flies after he/she spoke to the surveyor the previous day (4/21/26), but no one came. At the same time, the surveyor observed the admission Coordinator deliver Resident #22's breakfast meal tray to the Resident's room. The admission Coordinator placed the Resident's breakfast tray on the Resident's bedside table and uncovered and opened the Resident's food and drinks. The small flies flew off the privacy curtain over the Resident's food and the admission Coordinator left the room. During an interview on 4/22/26 at 9:15 A.M., the Maintenance Director said the facility's pest control company services the main kitchen routinely and that pest control services for other areas of the facility would require a separate pest control request as an add-on service. The Maintenance Director said there is an issue with small flies on Unit Four, in Resident #95's room. The Maintenance Director said the small flies have always been a problem for Resident #95 and that the flies have migrated into the hallway and into the next room which is Resident #22's room. The Maintenance Director said UM #3 did call him on 4/21/26 to alert him of the small flies in Resident #22's room but he did not inspect Resident #22's room. The Maintenance Director said pest control is the responsibility of all staff in the facility and that all staff should make sure food and drink items are not left in resident rooms. On 4/22/26 at 9:30 A.M., the surveyor observed the following on Unit Four with the Maintenance Director and Housekeeping Supervisor: -Several uncovered plastic cups of water on Resident #95's windowsill, observed from the hallway. -Small flies on both side of the hallway walls outside of Resident #95 and #22's rooms. -Small flies on the railing in the hallway across from Resident #95 and #22's rooms. -Small flies on the privacy curtain and two walls in Resident #22's room. During an interview at the time, the Housekeeping Supervisor said small flies have always been a problem in Resident #95's room and that the small flies are migrating into the hallway and into Resident #22's room. The Housekeeping Supervisor said that Houskeeper #2 had been cleaning Unit Four until approximately two weeks prior when Housekeeper #2 left her position at the facility. The Housekeeping Supervisor said she started working on Unit Four again a couple of weeks prior and she could not believe how bad the flies had gotten in Resident #95's room. The Housekeeping Supervisor said she killed approximately 90 flies in Resident #95's bathroom a couple of weeks ago and that there were also flies in the room. The Housekeeping Supervisor said that she was cleaning Resident #95's room daily and still killing flies daily when she cleaned Resident #95's room. On 4/22/26 at 10:01 A.M., the surveyor placed a phone call to Housekeeper #2. Housekeeper #2's voicemail box was full, and the surveyor could not leave a message. The surveyor then sent a text message to Housekeeper #2 requesting a call back. Housekeeper #2 did not respond to the surveyor's text message prior to or after the survey exit. During an interview on 4/22/26 at 12:15 P.M., the Maintenance Director said the facility did not contact the pest control company when the small flies were identified on Unit Four. The Maintenance Director said when the facility's intervention for cleaning Resident #95's room daily did not rectify the fly problem, the facility should have contacted the pest control company to provide an add on service for small fly activity.

Based on interviews and record review, the facility failed to complete comprehensive assessments in the timeframe specified by the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) manual for six Residents (#5, #133, #82, #98, #122 and #9) out of a total sample of 24 residents.Specifically, the facility failed to ensure that:1.annual Minimum Data Set (MDS) assessments were completed for Residents #5, #133, #82 and #98 no later than 14 days after the MDS assessment reference dates (ARDs).2. significant change in status assessments (SCSAs) were completed for Residents #122 and #9 no later than 14 days after determination that significant change in the Residents' status occurred, resulting in both Residents being admitted to hospice services. Findings Include:Review of CMS' RAI Version 3.0 Manual dated October 2025, indicated the following relative to comprehensive assessment requirements:-The annual comprehensive assessment is required to be completed no later than 14 calendar days after the assessment's ARD (ARD plus 14 calendar days). 1a. Resident #5 was admitted to the facility in March 2024. Review of Resident #5's clinical record indicated:-The Resident had a comprehensive Annual MDS Assessment with an ARD of 3/4/26. -The comprehensive Annual MDS Assessment was not completed until 4/16/26 (the forty-third day following the ARD). 1b. Resident #133 was admitted to the facility in March 2024. Review of Resident #133's clinical record indicated:-The Resident had a comprehensive Annual MDS Assessment with an ARD of 2/25/26.-The comprehensive Annual MDS Assessment was not completed until 4/16/26 (the fiftieth day following the ARD). 1c. Resident #82 was admitted to the facility in February 2025. Review of Resident #82's clinical record indicated:-The Resident had a comprehensive Annual MDS Assessment with an ARD of 2/25/26.-The comprehensive Annual MDS Assessment was not completed until 4/16/26 (the fiftieth day following the ARD). 1d. Resident #98 was admitted to the facility in February 2025. Review of Resident #98's clinical record indicated:-The Resident had a comprehensive Annual MDS Assessment with an ARD of 2/25/26.-The comprehensive Annual MDS Assessment was not completed until 4/16/26 (the fiftieth day following the ARD). 2. Review of CMS' RAI Version 3.0 Manual, dated October 2025, indicated the following relative to comprehensive assessment requirements:-The significant change in status comprehensive assessment is required to be completed no later than the fourteenth calendar day after determination that significant change in resident's status occurred (determination date plus 14 days). 2a. Resident #122 was admitted to the facility in November 2021. Review of Resident # 122's clinical record indicated:-A Nursing Progress Note dated 3/18/26, that the Resident signed on to hospice services that day.-The Resident had a comprehensive SCSA with an ARD of 3/25/26.-The Resident's comprehensive SCSA was in process and had not been completed as of 4/16/26 (the twenty-ninth day after the Resident signed on to hospice services). 2b. Resident #9 was admitted to the facility in February 2026. Review of Resident #9's clinical record indicated:-A Physician Order dated 3/13/26, for the Resident to be admitted to hospice services.-The Resident had a comprehensive SCSA with an ARD of 3/13/26.-The Resident's comprehensive SCSA was in process and had not been completed as of 4/22/26 (the fortieth day after the Resident signed on to hospice services). During an interview on 4/22/26 at 1:31 P.M., the Regional MDS Nurse said the comprehensive MDS Assessments for Residents #5, #133, #82, #98, #122, and #9 were not completed within the required timeframe specified in the RAI manual and they should have been.

Based on interview and record review, the facility failed to complete non-comprehensive quarterly Minimum Data Set (MDS) assessments within the timeframe specified by the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) manual for six Residents (#34, #115, #3, #124, #138, and #105) out of a total sample of 24 residents. Specifically, the facility failed to complete non-comprehensive quarterly MDS Assessments for Residents #34, #115, #3, #124, #138, and #105 no later than 14 days following the assessment reference date (ARD). Findings include: Review of CMS' RAI Manual, dated October 2025, indicated non-comprehensive quarterly assessments are required to be completed no later than 14 calendar days following the ARD (ARD plus 14 calendar days). Resident #34 was admitted to the facility in July 2019. Review of Resident #34's clinical record indicated: -The Resident had a non-comprehensive Quarterly MDS Assessment with an ARD of 2/25/26. -The Resident's non-comprehensive Quarterly MDS Assessment was not completed until 4/16/26 (the 50th day following the ARD). Resident #115 was admitted to the facility in December 2021. Review of Resident #115's clinical record indicated: -The Resident had a non-comprehensive Quarterly MDS Assessment with an ARD of 3/11/26. -The Resident's non-comprehensive Quarterly MDS Assessment was not complete as of 4/21/26 (the 41st day following the ARD). Resident #3 was admitted to the facility in December 2022. Review of Resident #3's clinical record indicated: -The Resident had a non-comprehensive Quarterly MDS Assessment with an ARD of 3/4/26. -The Resident's non-comprehensive Quarterly MDS Assessment was not completed until 4/16/26 (the 43rd day following the ARD). Resident #124 was admitted to the facility in November 2024. Review of Resident #124's clinical record indicated: -The Resident had a non-comprehensive Quarterly MDS Assessment with an ARD of 2/5/26. -The Resident's non-comprehensive Quarterly MDS Assessment was not completed until 4/16/26 (the 70th day following the ARD). Resident #138 was admitted to the facility in November 2025. Review of Resident #138's clinical record indicated: -The Resident had a non-comprehensive Quarterly MDS Assessment with an ARD of 2/25/26. -The Resident's non-comprehensive Quarterly MDS Assessment was not completed until 4/16/26 (the 50th day following the ARD). Resident #105 was admitted to the facility in December 2025. Review of Resident #105's clinical record indicated: -The Resident had a non-comprehensive Quarterly MDS Assessment with an ARD of 3/18/26. -The Resident's non-comprehensive Quarterly MDS Assessment was not complete as of 4/21/26 (the 34th day following the ARD). During an interview on 4/22/26 at 1:31 P.M., the Regional MDS Nurse said the non-comprehensive MDS Assessments for Residents #34, #115, #3, #124, #138, and #105 were not completed within the required timeframe specified by CMS' RAI Manual and they should have been.

Based on observation, interviews, and record review, the facility failed to follow professional standards of practice for food storage and environmental cleaning of the facility's main kitchen, placing the facility residents at risk of contamination and foodborne illnesses.Specifically, the facility failed to ensure that:-food items were properly dated, stored, and/or discarded timely in the main kitchen.-clean and sanitary surfaces were maintained in the food preparation areas. Findings include: Review of the Food Drug Administration (FDA) Food Code 2017 (www.fda.gov), indicated the following: -Food Preparation: >During preparation, unpackaged food shall be protected from environmental sources of contamination. -Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: >the objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. >Microorganisms may be transmitted from food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces. >Food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. >The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. -Cleaning, Frequency and Restrictions: >Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when food is in protected storage and when food is not being served or prepared. Review of the facility policy titled Food Storage, revised 4/10/25, indicated:-it is the policy of this facility that sanitary conditions should be maintained in all storage areas of food.-small, open boxes of food shall be re-wrapped, dated, and used up as soon as possible, before other boxes are opened. -an employee will be assigned to store perishable foods immediately upon delivery. -prepared foods in the refrigerator shall be kept covered, labeled and dated. -store all wrapped foods when cooled or in sanitized containers and cover tightly. Foods will be labelled and dated to ensure adherence to shelf life. -never hold leftover poultry, fish, eggs, or meat products more than 72 hours at refrigeration temperatures. Anything held longer than 72 hours should be discarded. On 4/16/26 at 7:08 A.M., the surveyor observed the following during the initial kitchen walk through: >In the reach-in refrigerator: -ten covered bowls of salad, unlabeled and undated.-twelve small, clear covered plastic containers with an orange-colored substance inside, unlabeled and undated.-four small, clear covered plastic containers with a white-colored substance inside, unlabeled and undated.-two covered plates of wilted salad, undated. >In the walk-in refrigerator: -one plastic container of rice pilaf, use by date of 4/15/26-one wrapped onion, dated 4/12/26-one ten-inch cheesecake, undated-one plastic storage container of noodles, use by date of 4/13/26-one large plastic container of mushrooms, use by date of 4/15/26-two large baking trays with a dried meat product, open to air, unlabeled and undated-five bowls of sliced pears, open to air, unlabeled and undated-one large baking tray of yellow cake, open to air, unlabeled and undated -one opened and unsealed package of 25 hot dogs, undated-one opened large container of sour cream, opened date 4/12/26-one sealed open package of shredded cheese, opened date 4/9/26-one opened box of unsealed sausage patties, undated-one large plastic bag of thawed spinach, unlabeled and undated-one large sealed opened package of ham, undated-one large box of opened tortillas packages, undated-one 16 fluid ounce can of Monster Fruit Punch belonging to staff-19 raw eggs, undated>In the Main Kitchen food preparation area:-multiple shelves of stacked large pots, bowls, sieves, containing multiple dried areas on the shelves of large white powder-like substance and light brown and white colored semicircular water stains on the shelves surfaces.-small flies flying around the main kitchen area.-a used, dirty spatula and three hard plastic cups rolled on their sides on the kitchen floor.-a food preparation table containing plastic tubs with various plastic container lids covered in food debris on the table, inside the plastic tubs and on the lids. -small and large white, brown, pink, and yellow crumbs on the kitchen floor with discarded plastic lid covers, food wrappers and twist ties.-large dried dark brown and white colored splatters and spills on the kitchen floor and large dried brown spills on the side of oven surface.-two dietary trolley carts (used to cart various drinks and foods to each) covered in dried yellow, orange and white stains, dried semi-circular stains, opened used sugar packets and food crumbs on the upper and lower shelves of the carts. During an interview on 4/16/26 at 8:40 A.M., the surveyor and Food Service Director (FSD) reviewed the concerns from the initial kitchen walk through. The FSD said that items with the specific use by dates should have been thrown away by the use by dates listed. The FSD also said that uncovered, unlabeled, and undated items should have been sealed, labeled and dated and they had not been. The FSD said that the kitchen surfaces were not sanitary and should have been because the unsanitary surfaces have the potential to make someone sick if they are not clean. Please refer to F865 and F925

Based on observations, interviews, and record review, the facility failed to maintain an effective QAPI program relative to pest control in the facility, which increased the risk for pest infestation throughout the facility. Specifically, the facility failed to develop and maintain a QAPI project relative to pest control when: -small flies were identified in the facility's main kitchen in October 2025 and repairs and bi-weekly pest control treatment was recommended by the facility's pest control company to treat for small flies. -small flies were still present in the facility's main kitchen and also on Unit Four, in resident areas, migrating from Resident #95's room into the Unit Four hallway and into Resident #22's room, placing residents on Unit Four at increased risk for continued small fly infestation. Findings include: Review of the facility's pest control company reports indicated the following: -10/23/25: -Initial report from 3/16/23 [sic] indicated floor tiles broken/need grout, water leaking. Nearly all the grout in the dishwasher room is missing and there is a gap between the wall and the floor that traps organic debris and moisture, allowing small flies to breed. -Action needed by the facility to repair/replace grout and tiles, fix wall, clean debris and water. -1/15/26: - . floor tiles broken/need grout/water leaking-nearly all the grout in the dishwasher room is missing and there is a gap between the wall and floor that traps organic debris and moisture, allowing small flies to breed. -Action needed by the facility to repair/replace grout and tiles, fix wall, clean debris and water. -Fly activity noted in the kitchen dishwasher room. -There are a lot of gaps in the baseboards and tiles that allows for water and debris to collect, making the area and ideal breeding ground and water source for numerous pests. In this case it is allowing a breeding ground for flies. -If this area was fixed it would be a great step forward in halting the fly problem. -Upgrading to a fly service that happens twice a month is another great option to help. This helps us treat before another life cycle can take hold. -Regular maintenance of the area is a must. -2/19/26: -floor tiles broken/need grout/water leaking-nearly all the grout in the dishwasher room is missing and there is a gap between the wall and floor that traps organic debris and moisture, allowing small flies to breed. -Action needed by the facility to repair/replace grout and tiles, fix wall, clean debris and water. -Several dozen flies observed in the dishwashing area, standing water between floor tiles and wall. -3/17/26: -floor tiles broken/need grout/water leaking-nearly all the grout in the dishwasher room is missing and there is a gap between the wall and floor that traps organic debris and moisture, allowing small flies to breed. -Action needed by the facility to repair/replace grout and tiles, fix wall, clean debris and water. On 4/16/26 at 7:08 A.M., during the initial kitchen visit, the surveyor observed small flies in the food preparation area. On 4/21/26 at 2:50 P.M., the surveyor observed the following on Unit Four: -Resident #22 approached the surveyor and requested a can of fly spray for his/her room. -The surveyor observed the following in the Resident's room at this time: >One small fly on the upper netted portion of the privacy curtain hanging on the door-side of the room. >Five small flies on the wall on the door-side of the room. >Four small flies on the wall behind the head of the Resident's bed. During an interview at the time, Resident #22 said the flies had been in his/her room since he/she was admitted to the facility a few weeks ago. On 4/21/26 at 3:04 P.M., the surveyor observed Nurse #3, seated at the Unit Four nurses' station, wave her hand in the air, in front of her face. During an interview at the time, Nurse #3 said she was swatting at a small fly. On 4/22/26 at 8:00 A.M., the surveyor observed Resident #22's room as follows: -Eight small flies on the Resident-facing side of the privacy curtain and two small flies on the door-facing side of the privacy curtain hanging on the door-side of the room. -Six small flies on the wall on the door-side of the room. -Four small flies on the wall behind the head of the Resident's bed. The surveyor observed the admission Coordinator deliver Resident #22's breakfast meal tray to the Resident's room, placed the Resident's breakfast tray on the Resident's bedside table and uncovered and opened the Resident's food and drinks. The small flies flew off the privacy curtain over the Resident's food, and the admission Coordinator left the Resident's room. During an interview on 4/22/26 at 9:15 A.M., the Maintenance Director said there is an issue with small flies on Unit Four. The Maintenance Director said the small flies have always been a problem for one of the Residents (#95) on the Unit and that the flies have migrated into the hallway and into the next room which is Resident #22's room. On 4/22/26 at 9:30 A.M., the surveyor observed the following on Unit Four with the Maintenance Director and the Housekeeping Supervisor: -Small flies on both side of the hallway walls outside of Resident #95 and #22's rooms. -Small flies on the railing in the hallway across from Resident #95 and #22's rooms. -Small flies on the privacy curtain and two walls in Resident #22's room. During an interview at the time, the Housekeeping Supervisor said small flies have always been a problem in Resident #95's room and that the small flies are migrating into the hallway and into Resident #22's room. The Housekeeping Supervisor said she had not worked on Unit Four for a while and that Houskeeper #2 had been cleaning Unit Four until approximately two weeks prior to today when Housekeeper #2 left her position at the facility. The Housekeeping Supervisor said she started working on Unit Four again a couple of weeks prior and she could not believe how bad the flies had gotten in Resident #95's room. The Housekeeping Supervisor said she killed approximately 90 flies in Resident #95's bathroom a couple of weeks ago and that there were also flies in the room. The Housekeeping Supervisor said that she was cleaning Resident #95's room daily and still killing flies daily when she cleaned the Resident's room. On 4/22/26 at 12:50 P.M., the surveyor observed the following in the facility's main kitchen: -Standing water and missing grout and floor tiles around the floor drain in the dish room. -15 small flies on the dish room walls, dish room equipment and flying overhead in the dish room area. During an interview at the time, the Food Service Director (FSD) said the small flies had been present for a while. During an interview on 4/22/26 at 2:36 P.M., the pest control company's Operation Support Manager (OSM) #1 said the facility's service contract for pests did not include treatment for flying insects. OSM #1 said if the facility needed flying pest treatment, the facility would need to call to add the service. OSM #1 said the most recent add on service for flying pests was in October 2025 and the service was provided for small flies in the main kitchen on 10/23/25. OSM #1 said at the time of the service on 10/23/25, recommendations were made for the facility to repair the grout and tiles, and to get rid of organic matter and standing water in the main kitchen's dish room. OSM #1 said a recommendation was also made for the facility to follow through with treatment for the small flies every two weeks. OSM #1 said if not treated, the small flies will migrate to other areas of the building. OSM #1 said the small flies follow food and liquid sources and may end up being consumed by residents. OSM #1 said the facility did not request any further services relative to small flies in the facility since October 2025. During an interview on 4/22/26 at 3:08 P.M., the Administrator said the repairs for the floor tiles, grout, and standing water in the facility's main kitchen had not been repaired since the pest control company recommendations were made in October 2025. The Administrator said he had not been made aware by facility staff of the small flies on Unit Four until surveyor #2's inquiry during the survey period. During an interview on 4/22/26 at 12:15 P.M., the Maintenance Director said the facility did not contact the pest control company when the small flies were identified on Unit Four. During an interview on 4/22/26 at 4:50 P.M., the Administrator said the facility had not developed a QAPI project relative to pest control in the facility. Please refer to F925.

:Based on observation, interview and review, the facility failed to ensure that a dignified dining experiences was provided for one Resident (#38), out of total sample of 24 residents.Specifically, for Resident #38, the facility failed to ensure that staff were seated while assisting the Resident during a breakfast meal, when Certified Nurse Aide (#1) stood beside Resident #38's wheelchair while assisting him/her with the meal. Findings include: Review of the facility policy titled Dignity, last revised 4/2022 indicated the following:-Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.-When assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience, providing assistance during mealtime while maintaining dignity. Resident #38 was admitted to the facility in November 2024 with diagnoses including Hemiplegia affecting the right dominant side, Major Depressive Disorder, and Diabetes Mellitus Type II. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #38:-was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of nine out of a total possible score of 15.-required substantial/maximal assistance for eating where the helper performs more than half the effort required for the task. Review of the person-centered Nutrition care plan, last revised 2/26/26, included interventions for meal tray set up and indicated that Resident #38 may need additional level of assistance for meals, assess as needed. On 4/17/26 at 8:10 A.M., the surveyor observed Resident #38 sitting in a wheelchair at a table with other residents during the breakfast meal in the third-floor unit dining room. Certified Nurse's Aide (CNA) #1 was observed standing next to Resident #38 stirring a bowl of hot cereal. The surveyor then observed CNA #1 offer a spoonful of hot cereal to Resident #38 and walk away to assist another resident at the table. On 4/17/26 at 8:13 A.M., the surveyor observed CNA #1 return to standing beside Resident #38 and assist him/her to eat the hot cereal. On 4/17/26 at 8:15 A.M., the surveyor and Unit Manager (UM) #1 observed CNA #1 standing beside Resident #38 assisting him/her with the breakfast meal. During an interview at the time, UM #1 said that he did not know if staff were supposed to be seated to assist Residents with meals. UM #1 said that CNA #1 standing next to Resident #38 while assisting him/her with breakfast was probably not dignified. During a follow-up interview on 4/17/26 at 8:20 A.M., UM #1 said that he checked with the Administrator, and he said that staff should not be standing while assisting Residents with meals. During an interview on 4/17/26 at 9:01 A.M., CNA #1 said that she has worked in the facility since last July and had received education pertaining to the facility dining experience upon hire. CNA #1 said Resident #38 needed assistance with eating because he/she could not assist himself/herself very well. CNA #1 said that sometimes she stands while assisting residents with eating so that she can keep an eye out on everyone else in the dining area. CNA #1 also said that she should not have been standing while assisting Resident #38 with the breakfast meal because it wasn't the right way to assist him/her with a meal. During an interview on 4/17/26 at 9:57 A.M., the Director of Nursing (DON) said that all staff should be seated when assisting Residents with a meal. The DON said CNA #1 should not have been standing while assisting Resident #38 with the breakfast meal because standing doesn't provide a dignified experience for the Resident.

Based on observation, interview, and record review, the facility failed to coordinate vision care services as required for one Resident (#79) out of a total sample of 24 residents, diagnosed with Type II Diabetes Mellitus (DM II) and Hypertension. Specifically, for Resident #79, the facility failed to schedule routine vision care appointments and ensure that the Resident received appropriate treatment to maintain vision abilities, when the Resident's Healthcare Proxy (HCP- person chosen as the healthcare decision maker when the individual is unable to do so for themself) requested and consented for Resident #79 to receive vision care services, placing the Resident at risk for further vision deterioration.Findings include:Review of the facility admission Packet, undated, included but was not limited to:*Treatment ordered by the attending physician will be provided for residents in need of optometry . Review of the facility policy titled Ancillary Physician, revised 4/2022, included but was not limited to:*Routine and emergency optometry services are available to meet the resident's health services by the resident's assessment and plan of care. -Routine and emergency optometry services are provided to our residents through:>A contract agreement with a licensed optometrist that comes to the facility routinely.>Referral to the resident's personal optometrist.>Referral to community optometrist; or>Referral to other health care organizations that provide optometrist services.-Residents have the right to select a optometrist of their choice when services are needed.-Selected optometrists will be able to provide follow-up care per resident's request.-Social Services or Nursing representatives will assist residents with appointments, transportation arrangements, and for reimbursement of an optometrist services under the state plan, if eligible. Resident #79 was admitted to the facility in October 2025 with diagnoses including Type 2 Diabetes Mellitus with diabetic chronic kidney disease, Essential Primary Hypertension, long term use of Insulin, and Cerebrovascular Disease. Review of Resident #79's April 2026 Physician's orders indicated:-Ancillary Order: May be seen by optometry as indicated, initiated 10/8/25. Review of the Minimum Data Set (MDS) Assessment, dated 1/14/26, indicated Resident #79:-was able to make him/herself usually understood and understood others. -has moderate cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of nine out of a possible 15 points.-has adequate vision and used corrective lenses. Review of Resident #79's clinical record indicated a Consent Form for Eye Care Services signed by the Resident's HCP and dated 10/8/25. On 4/16/26 at 1:02 P.M., the surveyor observed Resident #79 in his/her bedroom seated in a wheelchair wearing eyeglasses, with his/her HCP seated next to him/her. During an interview at the time, the HCP said that he/she would like Resident #79 to be seen for vision services to ensure the Resident's eyes were not getting worse. The HCP said that Resident #79 had a diagnosis of DM II that was being managed with Insulin. The HCP also said a Consent Form was signed by him/her when the Resident was admitted to the facility and the HCP was not made aware by the facility staff that the Resident had been seen by Optometry. During an interview on 4/22/26 at 9:30 A.M., the Director of Nursing (DON) said Resident #79 had not been seen for vison services and should have been seen. The DON said that upon admission to the facility, a resident or resident representative signs a Consent Form for vision services and the facility schedules vision services for residents. The DON further said Resident #79 was admitted in October 2025 and should have been added to the list and seen by the vision service Provider.

Based on record review and interview, the facility failed to ensure that Behavioral Health Services were provided as required for one Resident (#88) out of a total sample of 24 residents.Specifically, the facility failed to ensure Behavioral Health Services were implemented for Resident #88 when he/she had a change in condition, and the Nurse Practitioner (NP) determined the Resident screened positive for Major Depressive Disorder, referred the Resident for Psychiatry/ Behavioral Health and a Physician order was written for Psychiatry Consult. Findings include: Review of facility policy, titled Behavior Management, revised April 2022, indicated the following:-the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. -the interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. -new onset or changes in behavior will be documented. Resident #88 was admitted to the facility in November 2025 with diagnoses that included Transient Ischemic Attack, Chronic Kidney Disease Stage Three, and Hypertension. Review of Resident #88's medical record indicated a Request for Services Form, signed 11/6/25, indicating that the Resident consented to receive counseling or behavioral health services. Review of Resident #88's Care Plan for Behaviors, revised 12/30/25, indicated the following interventions:-to investigate/monitor the need for psychological/psychiatric support. -provide services if desired and as ordered by the physician. Review of Resident #88's most recent Minimum Data Set (MDS) Assessment, dated 2/4/26, indicated:-a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderate cognitive impairment.-has clear speech and could make him/herself understood. Review of Resident #88's Physician's orders indicated the following:-Psych (Psychiatry) Consult - Depression, start date 3/17/26-May be seen by psych as indicated, start date 11/6/25 Review of the Nurse Practitioner (NP) Progress Note, dated 3/17/26, indicated the following: -Depression: daily depressed mood, hopelessness and worthlessness>Depression Screening Result: Positive-Treatment plan required for POSITIVE screening result-Referral to care (e.g. psychiatry, behavioral health)-Major Depressive Disorder>Plan: Refer to Psychiatry Review of the Behavioral Health schedule provided by the facility for March 2026 and April 2026 failed to indicate that Resident #88 had received any Behavioral Health Services. Review of Resident #88's medical record failed to indicate that the Resident had been evaluated by Behavioral Health Services as ordered and was receiving any Behavioral Health Services. During an interview on 4/16/26 at 10:21 A.M., Resident #88 said that he/she felt very depressed and that he/she does not feel supported by the facility staff. During an interview on 4/21/26 at 11:18 A.M., Social Worker (SW) #1 said that Resident #88 had not been seen by the facility's Behavioral Health team and that the team had been busy servicing the facility's new admission residents. During an interview on 4/21/26 at 1:04 P.M., the Director of Nursing (DON) said that Resident #88 had not been seen timely by the facility's Behavioral Health team and should have been. The DON also said that the Resident not receiving Behavioral Health Services was a result of poor communication between the nursing staff and the administrative team.

Based on observation, interview, and record review, the facility failed to ensure that follow-up dental services were implemented timely for one Resident (#2) out of a total sample of 24 residents, when the facility did not initiate dental recommendations until four months later, placing the Resident at risk for unidentified dental disease and deteriorating oral health.Specifically, Resident #2, the facility failed to ensure that the following Doctor of Medicine in Dentistry (DMD) January 2026 recommendations were implemented:-Fluoride toothpaste Prevident (fluoride toothpaste containing 5,000 ppm [parts per million] fluoride) -Brush teeth with over the counter (OTC) fluoride rinse prior to bed.-Apply Remin Pro dental cream (dental protective cream designed to strengthen tooth enamel, prevent sensitivity and re-mineralize teeth) once daily.-Swap gingiva (rinse used to treat and prevent gum disease) with molecular Iodine oral rinse twice daily, minimum twice daily oral to decrease build up on upper teeth. Findings include:Review of the facility policy titled Dental Services, revised 1/2025, included but was not limited to:*Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.-Routine and 24-hour emergency dental services are provided to our residents through:>A contract agreement with a licensed dentist that comes to the facility monthly.>Referral to the resident's personal dentist.>Referral to community dentist; or.>Referral to other health care organizations that provide dental services.-A list of community dentists available to provide dental services to our residents is posted at each nurse's station and the list is also available from social services.-Residents have the right to select dentists of their choice when dental care or services are needed.-Selected dentists must be available to provide follow-up care. Failure of a dentist to provide follow-up services will result in the facility's right to use its consultant dentist to provide the resident's dental needs.-Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible.-Direct care staff will assist residents with denture care, including cleaning. Review of the facility admission Packet, undated, included but was not limited to:*Treatment ordered by the attending physician will be provided for Residents in need of dental and/or as ordered by the attending physician. Review of the American Dental Association (ADA) guidance titled Fluoride: Topical and Systemic Supplements Key Points dated June 14, 2023, and located at https://www.ada.org/resources/ada-library/oral-health-topics/fluoride-topical-and-systemic-supplements included the following:-The ADA recognizes the use of fluoride and community water fluoridation as safe and effective in preventing tooth decay for both children and adults.-Fluoride can be delivered topically and systemically. Topical fluorides strengthen teeth already present in the mouth, making them more decay resistant, while systemic fluorides are those that are ingested and become incorporated into forming tooth structures. Systemic fluorides also provide topical protection because fluoride is present in saliva, which continually bathes the teeth.-Self-applied topical fluorides include toothpastes, mouth rinses, and gels. Professionally applied topical fluorides include higher-strength rinses, gels, and foams; fluoride varnishes; and silver diamine fluoride.-Fluoride Toothpaste. Fluoride-containing toothpaste is the most commonly used form of self-applied fluoride worldwide. Fluoride in toothpaste is taken up directly by the dental plaque and demineralized enamel and also increases the concentration of fluoride in saliva.-Fluoride supplements can be prescribed for children ages 6 months to 16 years who are at high risk for tooth decay and whose primary drinking water has a low fluoride concentration.-Fluoride toothpastes available over the counter in the U.S. generally contain a fluoride concentration of 1,000 to 1,500 parts per million (ppm).-Prescription-strength fluoride toothpastes contain 5,000 ppm fluoride as sodium fluoride.-In 2013, the ADA Center for Evidence-Based Dentistry and a panel of experts convened by the ADA Council on Scientific Affairs developed clinical recommendations for use of professionally applied or prescription-strength, home-use topical fluorides for caries prevention in patients at high risk of developing caries.Resident #2 was admitted to the facility in December 2025 with diagnoses including Hyperlipidemia, Atrial Fibrillation and Flutter, and Atherosclerotic Heart Disease of native coronary artery without angina pectoris. Review of Resident #2's April 2026 Physician Orders indicated the following:-Ancillary Order: May be seen by Dental as indicated, initiated 12/2/25. -Dental evaluation and treatment as indicated, initiated 12/2/25.-ACT Resorting Fluoride Rinse Mouth/Throat Solution 0.05 percent (%) (Sodium Fluoride (Dental)) give 10 milliliters (ml) by mouth at bedtime for prophylaxis, brush teeth with fluoride rinse prior to bed, initiated 4/22/26. Review of the Minimum Data Set (MDS) Assessment, dated 3/4/26, indicated Resident #2:-was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15 points.-was able to make him/herself understood and understood others. During an interview on 4/16/26 at 11:49 A.M., Resident #2 said he/she had a dental exam in January 2026 and had recommendations made by the Dentist but was unsure what the recommendations were. Resident #2 also said he/she had not heard anything from the facility staff about the dental recommendations. The surveyor observed Resident #2's teeth coated with yellow matter and white particles in between the teeth. During an interview on 4/17/26 at 11:20 A.M., Resident #2 was observed seated on the bed in his/her bedroom said he/she was still waiting for the facility staff to inform him/her about the Dentist's recommendations from January 2026. The surveyor observed that the Resident's teeth remained coated with yellow matter and white particles in between the teeth. Resident #2 also said that he/she had broken teeth in the upper left of his/her mouth. Review of the clinical records indicated Resident #2 was evaluated for dental services dated 1/7/26, with the following notes documented on the Dental Consultant Form:>Teeth condition:-Fair, asymptomatic-Soft plaque/food debris buildup.-Heavy: Hard calculus deposits.-Moderate: Gingival inflammation/swollen, bleeding gums.-Fair: Periodontal condition.-High: Risk for caries.>Recommend fluoride every six months due to high caries risk, exam and prophy [prophylactic] due to plaque and calculus. Patient was made aware of broken teeth. Recommend silver diamine fluoride (SDF) and oral aids to prevent further breakdown. Hygiene-poor with severe build up along maxillary teeth that covers teeth surfaces.>Action required by nursing home staff:-Continue daily oral care.-Fluoride toothpaste Prevident (fluoride toothpaste containing 5,000 ppm fluoride), the facility provided the Resident with a 1,000 ppm (less than the DMD recommended amount) fluoride toothpaste during survey. -Brush teeth with over the counter (OTC) fluoride rinse prior to bed, initiated after the surveyor interviews with facility staff (more than four months after the DMD recommendations).-Apply Remin Pro dental cream once daily.-Swap gingiva with molecular Iodine oral rinse twice daily, minimum twice daily oral to decrease build up on upper teeth. During an interview on 4/21/26 at 9:18 A.M., Unit Manager (UM) #2 said when residents are admitted to the facility, the resident or resident representative signs a consent form for dental services. UM #2 said completed consent forms are given to the Director of Nursing (DON), who then schedules appointments for services. UM #2 said the DON typically follows up on all dental recommendations after the resident had been seen and evaluated. The surveyor and UM #2 reviewed Resident #2's dental recommendations dated 1/7/26 and UM #2 said Resident #2's dental recommendations were missed by the facility staff. The surveyor and UM #2 reviewed Resident #2's April 2026 Physician orders and UM #2 said there had been no new Physician orders to address the recommendations made by the Dentist and there should been. During an interview on 4/21/26 at 10:40 A.M., the DON said that she had been made aware of recommendation for Resident #2 pertaining to Prevident toothpaste and would investigate a list that was created that the Physician would typically say yes and or no to dental recommendations. On 4/21/26 at 12:49 P.M., the facility provided the surveyor with a dental group visit summary. During an interview on 4/21/26 at 1:25 P.M., Resident #2 said UM #2 provided him/her with a fresh mint toothpaste and a new toothbrush which the facility had in stock. The surveyor observed a tube of fresh mint anticavity fluoride toothpaste on Resident #2's bedside table. Review of the anticavity fluoride toothpaste indicated a total fluoride content of 1000 ppm approx. The surveyor observed Resident #2's teeth remained coated with yellow matter and white particles in between the teeth. Resident #2 said that he/she used the toothpaste and brush that was provided by UM #2 one time. During an interview on 4/21/26 at 2:40 P.M., the Nurse Practitioner (NP) said that she was under the impression that the facility stocked toothpaste that contained a similar ppm (5,000) of fluoride to what was recommended by the Dentist. During an interview on 4/22/26 at 9:25 A.M., the DON said the mouth wash was added to Resident #2's medication profile yesterday (4/21/26) by the NP. The DON also said that it was important to follow recommendations made by the Dentist and encourage Resident #2 to use the recommended dental regimen to prevent further dental decay.

Based on observation, interview, and record review, the facility failed to provide assistance with activities of daily living (ADLs) care for four Residents (#41, #84, #9, and #19) out of a total sample of 19 residents, who required staff assistance for personal hygiene and grooming. Specifically, 1. For Residents #41 and #84, the facility failed to ensure the Residents were provided with assistance for nail care. 2. For Residents #9 and #19, the facility failed to ensure the Residents were provided assistance with grooming of unwanted facial hair. Findings include: Review of the facility policy titled Activities of Daily Living, revised 3/22, indicated the following: -Residents will be provided with care, treatment, and services as appropriate to maintain or improve as able, their ability carry out activities of daily living (ADLs). -Residents who are unable to carry out activities of daily living independently will receive the services necessary for activities of daily living. -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care including appropriate support and assistance with: >Hygiene (bathing, dressing, grooming, and oral care) . Review of the facility policy titled Dignity, revised 4/22, indicated the following: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. -When assisting with care, residents are supported in exercising their rights. For example, residents are: >Groomed as they wish to be groomed (hair styles, nails, facial hair, etc.) . 1a. Resident #41 was admitted to the facility in October 2024 with diagnoses including Acute Osteomyelitis of the right lower limb. Review of Resident #41's most recent comprehensive Minimum Data Set (MDS) Assessment, dated 10/27/24, indicated the Resident: -required supervision or touching assistance for personal care which included nail care, -he/she had clear speech, usually understood and usually understands, -scored a 12 out of 15 on the Brief Interview of Mental Status (BIMS) exam indicating he/she was moderately cognitively impaired. Review of Resident #41's Kardex (sheet utilized by Certified Nurses Aide [CNAs] that indicates a resident's level of care) indicated Resident #41 needed limited assistance (the Resident was highly involved in his/her daily care but required physical help at times). Review of Resident #41's Care Plan titled Resident has ADL Self-Care Deficit, initiated 10/22/24, indicated a goal of: -Resident will receive assistance as needed in ADL activities. Review of Resident #41's January 2025 CNA ADL Documentation from 1/1/25 through 1/27/25 indicated: -for 25 of 27 days, Resident #41 needed some form of staff assistance for ADL care. On 1/23/25 at 8:36 A.M., the surveyor observed Resident #41's fingernails to be long and had dark brown debris visible under his/her fingernails. During an interview at the time, Resident #41 said he/she would like to have his/her fingernails trimmed and cleaned. On 1/27/25 at 9:59 A.M., the surveyor observed Resident #41's fingernails to have jagged edges and remained with dark brown debris under the fingernails. During an interview at the time, the Resident said no staff had offered him/her fingernail care since he/she was admitted to the facility. During an interview on 1/27/25 at 10:14 A.M., Activities Assistant (AA) #1 said a hand care activity was provided regularly and this included soaking the fingers and nails, cleaning the fingernails, applying lotion to the hand, and nail polish if wanted. AA #1 said no staff had expressed that Resident #41 would benefit from the hand care activity, so he/she was not on the list for the hand care activity. During an observation and interview on 1/27/25 at 10:18 A.M., with the Infection Preventionist (IP), who was working as a CNA, the IP said CNAs should be checking the Resident's fingernails daily during ADL care and should clean the fingernails as needed. The IP further said if the Resident was not diabetic, the CNAs could clip the Resident's fingernails and if the Resident was diabetic, the Resident's Nurse could clip the fingernails. The surveyor and the IP observed Resident #41's fingernails and the IP said Resident #41's fingernails appeared dirty with dark debris under the fingernails, some fingernails were jagged, and fingernail care should have been provided to the Resident. 1b. Resident #84 was admitted to the facility in December 2024 with diagnoses including breast cancer. Review of Resident #84's most recent comprehensive MDS Assessment, dated 12/18/24, indicated the Resident: -required partial to moderate assistance for personal care which included nail care. -had clear speech, was able to be understood, and understands. -scored a 14 out of 15 on the BIMS exam indicating he/she was cognitively intact. Review of Resident #84's Kardex indicated Resident #84 was an assist of one staff member for personal care. Review of Resident #84's Care Plan titled Resident has ADL Self-Care Deficit, initiated 12/16/24, indicated the Resident was an assist of one staff member for personal care. Review of Resident #84's January 2025 CNA ADL Documentation from 1/1/25 through 1/27/25 indicated: -for 23 of 27 days, Resident #84 needed some sort of staff assistance for ADL care. During an observation and interview on 1/23/25 at 9:50 A.M., the surveyor observed Resident #84's fingernails to be very long extending well past the fingertips. Resident #84 said due to edema in his/her arm he/she was unable to maintain his/her fingernails and they needed to be clipped. During the observation, the IP entered the room and Resident #84 said to the IP that he/she needed his/her fingernails clipped. The IP said she would let the Resident's Nurse know. On 1/23/25 at 3:07 P.M., the surveyor observed Resident #84's fingernails remained unclipped and long. The surveyor relayed to three CNA's who were sitting at the charting area, that Resident #84 would like his/her fingernails trimmed. During an observation and interview on 1/27/25 at 2:07 P.M., the surveyor observed Resident #84's fingernails to be long extending past the fingertips and some nails were jagged. Resident #84 said he/she tried to clip his/her fingernails but due to the edema in his/her hand he/she was not able to clip his/her fingernails and they were now jagged in some areas. During an observation and interview on 1/27/25 at 4:07 P.M., the surveyor and CNA #2 observed Resident #84's fingernails. CNA #2 said Resident #84's fingernails were long and jagged and should have been clipped. CNA #2 further said CNA's should provide daily fingernail care including soaking the fingernails if needed, cleaning the fingernails, and if the Resident was not diabetic, they could be clipped or if the Resident was diabetic the CNA should let the Nurse know the Resident's fingernails needed to be clipped. CNA #2 was observed notifying the Nurse following the observation that Resident #84 needed his/her fingernails clipped. During an interview on 1/28/25 at 10:58 A.M., the Director of Nursing (DON) said hand care including caring for a Resident's fingernails should be done weekly but if the Resident's fingernails were observed to be dirty or jagged the fingernails should be cleaned and clipped that day. 51571 2a. Resident #9 was admitted to the facility in September 2023 with diagnoses including Dementia and Major Depressive Disorder. Review of Resident #9's ADL Care Plan, initiated 10/4/23 and revised 10/6/23, indicated the following: -The Resident requires assist with bathing. -The Resident is dependent for personal hygiene. Review of Resident #9's MDS Assessment, dated 12/25/24, indicated the Resident: -was severely cognitively impaired as evidenced by a BIMS score of six out of 15 total possible points. -required substantial/maximal assist for showering and bathing. -required substantial/maximal assistance for personal hygiene (grooming). -did not exhibit any refusals of care during the observation period for the assessment. Review of Resident #9's January 2025 CNA Documentation Survey Report for Personal Hygiene from 1/1/25 through 1/28/25 indicated: -The Resident required varied levels of assistance from partial/moderate assistance to dependent assistance from staff for personal hygiene, including grooming. -The Resident did not exhibit any refusals of care relative to personal hygiene. On 1/24/25 at 10:23 A.M., the surveyor observed Resident #9 sitting in a wheelchair, dressed for the day and had facial hair underneath his/her chin. On 1/28/25 at 8:57 A.M., Resident #9 was observed in the dining room, sitting in a wheelchair and was dressed for the day. The Resident was observed with facial hair remaining under his/her chin. During an interview on 1/28/25 at 9:40 A.M., CNA #4 said Resident #9 required substantial/maximum assistance from staff with personal care. CNA #4 said Resident #9 was cooperative with care and had never refused care and was currently dressed for the day. During an interview on 1/28/25 at 9:48 A.M., CNA #3 said she did not remove the Resident's facial hair because some residents did not want the facial hair removed. CNA #3 said Resident #9 could ask staff to have his/her facial hair removed if needed. CNA #3 said usually the residents, or their family members would ask staff to remove facial hair then the staff would do it. When the surveyor asked Resident #9 if he/she had any concerns about the facial hair underneath his/her chin, the Resident said that he/she would like to have the facial hair under his/her chin removed. On 1/28/25 at 9:54 A.M., the surveyor observed CNA #3 and CNA #4 assist the Resident #9 to his/her room. On 1/28/25 at 10:08 A.M., the surveyor observed Resident #9 seated in a wheelchair near the nurses station and no longer had facial hair underneath his/her chin. 50563 2b. Resident #19 was admitted to the facility in July 2024 with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia. Review of Resident #19's MDS assessment dated [DATE], indicated the Resident: -was cognitively intact as evidenced by a BIMS score of 13 out of a possible score of 15. -required partial or moderate assistance with personal hygiene activities. Review of Resident #19's ADL Flow Sheet indicated the Resident: -was last showered on 1/22/25. -typically required partial or moderate assistance with personal hygiene. During an observation and interview on 1/23/25 at 9:10 A.M., the surveyor observed Resident #19 had visible facial hair on his/her face. Resident #19 said he/she preferred to have facial hair removed but staff do not always offer to help him/her shave. On 1/24/25 at 10:24 A.M., the surveyor observed Resident #19 lying in bed with visible facial hair on his/her face. During an observation and interview on 1/24/25 at 2:55 P.M., the surveyor observed Resident #19 remained with facial hair. Resident #19 said that he/she would like to be shaved but no-one had offered. During an interview on 1/24/25 at 3:08 P.M., CNA #1 said that they do not typically remove facial hair for residents on the evening (3:00 P.M. through 11:00 P.M.) shift. CNA #1 further said that if a resident had expressed a desire to have facial hair removed on the day (7:00 A.M. through 3:00 P.M.) shift but the staff were unable to assist that resident with facial hair removal that day shift, staff would relay this to the evening shift and they would assist with shaving at that time. CNA #1 said she did not recall the day shift staff ever informing her that Resident #19 desired to be shaved or that day shift staff could not complete this task. During an interview on 1/24/25 at 3:08 P.M., Unit Manager (UM) #1 said that the standard procedure was that resident's facial hair was removed on their shower day and then more frequently based on observation of hair growth between shower days. UM #1 observed Resident #19 and said she could tell he/she needed to have his/her facial hair removed. During an interview on 1/28/25 at 10:53 A.M., the DON said the expectation was that the CNAs should observe residents for facial hair and ask if the resident desires to have their facial hair removed every day if facial hair was present. If a resident refused to have their facial hair removed it would be documented in the CNA charting.

Based on observation, and interview, the facility failed to ensure medications were stored according to professional standards of practice for one unit (4th floor) out of three units. Specifically, for the 4th floor unit, the facility failed to: -store medications in pharmacy approved and pharmacy labeled containers. -accurately label medications for precautions and safe administration. Findings include: Review of the facility policy titled Medication Storage, revised March 2022, indicated the following: -Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. -Only the issuing pharmacy is authorized to transfer medications between containers. On 1/23/25 at 1:35 P.M., the surveyor observed the following during a medication cart observation on the 4th floor unit: -multiple sandwich bags that contained medications, and a piece of paper indicating the medication names. -the sandwich bags were rubber-banded together in the bottom drawer of the medication cart with a resident's name attached to the rubber-band. -no evidence of pharmacy packaging or pharmacy labels. During an interview on 1/23/25 at 1:42 P.M., Nurse #1 said that the medications should not be stored in this manner. Nurse #1 further said the medications should either have been sent home with the resident's family or destroyed upon receipt. During an interview on 1/28/25 at 10:53 A.M., the surveyor reviewed the observation of medications stored in sandwich bags with the Director of Nursing (DON). The DON said the expectation if medications were received in this type of storage, they should be destroyed immediately. The DON further said that medications stored in this manner could not be accurately identified and staff could not verify the medications were prescribed for that resident.

Based on observation, interview, and record review, the facility failed to adhere to infection control standards to prevent the transmission of communicable diseases and infections for one Resident (#19) out of a total sample of 19 Residents. Specifically, for Resident #19, the facility failed to ensure that the Resident's indwelling urinary catheter bag and catheter tubing were maintained off the floor to stop the risk of contamination and spread of infections. Findings include: Review of the AHRQ (Agency for Healthcare Research and Quality) Safety Program for Long-Term Care: HAIs/CAUTI (Healthcare Associated Infections/Catheter Associated Urinary Tract Infections) power point titled Catheter Care and Maintenance (https://www.ahrq.gov), dated March 2017, indicated the following: -The catheter itself can act as a key highway or interstate for microbes [bacterial organisms that can cause infection] to get into that resident. >Probably the most common way microbes get in once an indwelling urinary catheter is in place, is by the outside surface of the catheter. >Bacteria and other pathogens are able to use the outer surface of the catheter to work their way up the urethra, and into the bladder. Review of the facility policy titled Indwelling Catheter Care, revised April 2022, indicated the following: - .always keep the drainage bag below the level of the resident's bladder and off the floor. Resident #19 was admitted to the facility in July 2024 with diagnoses including Obstructive and Reflex Uropathy. Review of Resident #19's Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of a possible score of 15. -had an indwelling urinary catheter. On 1/24/25 at 10:24 A.M., the surveyor observed Resident #19 lying in bed with the urinary catheter bag secured to the bed frame in a manner where the urinary catheter bag and catheter tubing were laying on the floor. On 1/24/25 at 2:55 P.M., the surveyor observed Resident #19 lying in bed and the urinary catheter bag was secured to the bed with the urinary catheter bag and catheter tubing laying on the floor. During an interview on 1/24/25 at 2:56 P.M., the surveyor and Nurse #2 observed Resident #19's urinary catheter bag. Nurse #2 said that the urinary catheter bag should not be positioned on the floor. Nurse #2 performed hand hygiene, donned a gown and gloves and removed and repositioned the urinary catheter bag off the Resident's bedroom floor. During an interview on 1/28/25 at 10:53 A.M., the Director of Nursing (DON) said the expectation for urinary catheter bag and catheter tubing positioning was that the equipment should be positioned off the floor as the floor was dirty and this was an infection control concern relative to the potential for contamination.

Based on record review, and interview, the facility failed to ensure that the facility's Arbitration Agreement contained specific language as required pertaining to communication with federal, state, or local officials, for three Resident's (#13, #81, #237) out of a total sample of three residents. Specifically, the facility failed to ensure that the Arbitration Agreements signed by Resident's #13, #81, #237 and/or their Representative's, explicitly stated that the Resident or anyone else (e.g., Resident's Representative) maintained the right to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and Representative(s) of the Office of the State Long Term Care Ombudsman. Findings include: Review of the facility's Admission Packet, Exhibit C, Arbitration Agreement, undated, did not indicate the resident or anyone else (e.g., resident's representative) maintained the right to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. Review of signed arbitration agreements for Residents #13, #81, and #237 indicated the following: -Resident #13's Resident Representative signed the Arbitration Agreement on 4/10/24 -Resident #81's Resident Representative signed the Arbitration Agreement on 10//31/24 -Resident #237 signed the Arbitration Agreement on 3/18/21. Further review of the Arbitration Agreements indicated the signed Arbitration Agreements were missing information stating the Resident and/or Resident Representative maintained the right to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and Representative(s) of the Office of the State Long Term Care Ombudsman. During an interview on 1/23/25 at 3:26 P.M., the Administrator reviewed the signed Arbitration Agreements and said that the signed Arbitration Agreements did not indicate the Resident and/or the Resident Representative's maintained the right to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and Representative of the Office of the State Long Term Care Ombudsman. During an interview on 1/27/25 at 2:47 P.M., the Administrator said the facility's Arbitration Agreement did not contain all the necessary components and he needed to update the Arbitration Agreement to include that the resident or anyone else (e.g., resident's representative) maintained the right to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and Representative of the Office of the State Long Term Care Ombudsman.

Based on records reviewed and interviews, for one of three sampled residents (Resident #3), whose Physician's Orders included the administration of two different narcotic medications for pain, one was scheduled to be administered two times a day, the other medication could be administered every four hours as needed (PRN), the Facility failed to ensure the resident was free from significant medication errors, when on two separate occasions instead of being administered the PRN narcotic medication, Nurse #4 administered him/her the scheduled narcotic medication, placing Resident #1 at increased risk for adverse effects of a narcotic medication. Findings include: Review of the Facility's policy titled Oral Medication Administration, dated 04/2022, indicated the purpose of this procedure is to provide guidelines for the safe administration of oral medications. Steps in the procedure: -Place the Medication Administration Record (MAR) within easy viewing distance. -Select the medication from the unit dose drawer (medication cart). -Check the label on the medication and confirm the medication's name and dose with the MAR. -Check the medication dose. Re-check to confirm the proper dose. -For narcotics, check the narcotic record for the previous drug count and compare with the supply on hand. -Confirm the identity of the resident. -Allow the resident to swallow oral tablets or capsules at his/her comfortable pace. -Document medication administered on the MAR. Resident #3 was admitted to the Facility in April 2024, diagnosis include right hip osteoarthritis. Review of Resident #3's Medication Administration Record (MAR) for the month of July 2024 indicated his/her physician's orders for narcotic medications was as follows: -Oxycontin (opioid, narcotic)10 milligram (mg) extended-release (slowly released in the body over a period of time, usually 12 to 24 hours) tablet, give 10 mg by mouth two times a day for pain at 0800 (8:00 A.M.) and 1600 (4:00 P.M.). -Oxycodone (opioid, narcotic) 5 mg tablet, give 5 mg by mouth every four hours, as needed, for pain. -Oxycodone 5 mg tablet, give 10 mg [two tablets] by mouth every four hours, as needed, for pain. Review of Resident #3's Medication Variance Report, dated 07/05/24 and signed by Nurse #4, indicated that Resident #3 requested pain medication for pain level 8 out of 10 and that Resident #3 always asked for Oxycodone 10 mg [two 5 mg tablets] and this writer (Nurse #4) unintentionally administered the Oxycontin [two 10 mg tablets, total of 20 mg] instead of the Oxycodone to Resident #3. The Report indicated Resident #3 slept better and was easily aroused when it was time to wake up. Review of the Facility's Controlled Substance Log (book used by nursing to keep an accurate count of all narcotics and to record administration of narcotics) for Resident #3's Oxycontin, indicated that two Oxycontin 10 mg tablets were removed from the count on 07/05/24 at 2:30 A.M., by Nurse #4. Review of Resident #3's Medication Variance Report, dated 07/21/24 and signed by Nurse #4, indicated that the writer (Nurse #4) believed that at 2:00 A.M. after checking twice that she was giving him/her two tablets of the Oxycodone 5 mg, instead accidentally gave Resident #3 two [10 mg] tablets of Oxycontin [total of 20 mg], the error was discovered at change of shift during the narcotic count. The Report indicated Resident #3 stated he/she felt fine. Review of the Facility's Controlled Substance Log for Resident #3's Oxycontin, indicated that two Oxycontin 10 mg tablets for Resident #3 were removed from the count on 07/21/24 at 6:00 A.M., by Nurse #4. During a telephone interview on 12/05/24 at 10:46 A.M., Nurse #4 said she worked the night shift (11:00 P.M.- 7:00 A.M.) at the time of Resident #3's medication incidents [07/05/24 and 07/21/24]. Nurse #4 said that Resident #3's narcotic medications were in blister pack cards next to each other in the narcotic box. Nurse #4 said she thought she had pulled the correct card of medication, but on both occasions she pulled Resident #3's Oxycontin instead of his/her Oxycodone. Nurse #4 said she gave him/her two Oxycontin 10 mg tablets [total 20mg] instead of two Oxycodone 5 mg tablets [total 10mg] both times. Nurse #4 said the medications were the same color which may have contributed to the errors. During an interview on 12/04/24 at 3:35 P.M., the Director of Nurses (DON) said she had been notified of both Resident #3's medication errors. The DON said she expected the nurses to administer the medications as ordered by the physician.

Based on records reviewed and interviews, for one of three sampled residents (Resident #3), whose Physician's orders included the administration of two different narcotic pain medications, one that was scheduled, the other was a PRN (as needed only), the Facility failed to ensure nursing maintained an accurate medical record when although Nursing documentation indicated Resident #3 was administered his/her PRN (as needed) pain medication, on two different occasions, he/she was actually administered his/her scheduled narcotic pain medication in error. Findings include: Review of the Facility's policy titled Charting and Documentation, dated 04/2022, indicated that medications administered shall be documented in the resident's medical record. Resident #3 was admitted to the Facility in April 2024, diagnosis include right hip osteoarthritis. Review of Resident #3's Medication Administration Record (MAR) for the month of July 2024 indicated the following: -Oxycontin (opioid, narcotic)10 milligram (mg) extended-release tablet, give 10 mg by mouth two times a day for pain at 0800 (8:00 A.M.) and 1600 (4:00 P.M.). -Oxycodone (opioid, narcotic) 5 mg tablet, give 5 mg by mouth every four hours, as needed, for pain. -Oxycodone 5 mg tablet, give 10 mg [two tablets] by mouth every four hours, as needed, for pain. Further review of the MAR indicated that on 07/05/24, Nurse #4 signed off that she administered the PRN narcotic, Oxycodone 5 mg by mouth as needed for pain, and on 07/21/24 Nurse #4 signed off that she administered the PRN narcotic Oxycodone 10 mg by mouth as needed for pain, despite having dispensed and administered his/her Oxycontin 10 mg two tablets (which was not a PRN medication), in error, on both occasions. Review of Resident #3's Medication Variance Report, dated 07/05/24 and signed by Nurse #4, indicated that Resident #3 requested pain medication for pain level 8 out of 10 and this writer (Nurse #4) unintentionally administered the Oxycontin instead of the Oxycodone to Resident #3. Review of the Facility's Controlled Substance Log (book used by nursing to keep an accurate count of all narcotics and to record administration of narcotics) for Resident #3 indicated that two Oxycontin 10 mg tablets for Resident #3 were removed from the count on 07/05/24 at 2:30 A.M., by Nurse #4. Review of Resident #3's Medication Variance Report, dated 07/21/24 and signed by Nurse #4, indicated that the writer (Nurse #4) accidentally gave Resident #3 two tablets of Oxycontin [instead of Oxycodone], the error was discovered at change of shift during the narcotic count. Review of the Facility's Controlled Substance Log for Resident #3 indicated that two Oxycontin 10 mg tablets for Resident #3 were removed from the count on 07/21/24 at 6:00 A.M., by Nurse #4. During a telephone interview on 12/05/24 at 10:46 A.M., Nurse #4 said she worked the night shift (11:00 P.M.- 7:00 A.M.) at the time of Resident #3's medication incidents (7/05/24 and 7/21/24). Nurse #4 said that Resident #3's narcotic medications were in blister pack cards next to each other in the narcotic box. Nurse #4 said she thought she had pulled the correct card, but on both occasions she pulled Resident #3's Oxycontin instead of his/her Oxycodone. Nurse #4 said the medications were the same color which may have contributed to the errors. During an interview on 12/04/24 at 3:35 P.M., the Director of Nurses (DON) said she had been notified of both Resident #3's medication errors. The DON said she expected the nurses to administer the medications as ordered by the physician and document medication administration accurately.

Based on observation, interview, and record review, the facility failed to ensure their smoking policy addressed what preventative measures were in place in the event of a fire emergency for one Resident (#8) out of one applicable resident. Specifically, the facility failed to ensure fire prevention equipment was readily available in the smoking area to ensure a safe smoking environment. Finding include: Review of the facility policy titled Smoking, revised 3/2022, indicated the following: -Smoking is only permitted in designated resident smoking areas, which are located outside of the building. -Metal containers, with self-closing cover devices, are available in smoking areas. Further review of the Smoking policy indicated no mention of what fire prevention equipment (fire extinguisher and fire blanket) should be available in the smoking areas in case of a fire emergency. Resident #8 was admitted to the facility in September 2023. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had a Brief Interview of Mental Status (BIMS) score of 13 out of 15, indicating he/she was cognitively intact. During an interview on 11/16/23 at 9:30 A.M., Resident #8 said he/she was a smoker and that one of the facility's staff members would bring him/her out to smoke a couple times a day. Review of the Smoking Safety Screen dated 9/18/23, indicated the Resident required supervision and one to one assistance while smoking. During an observation and interview on 11/17/23 at 9:20 A.M., the surveyor observed Certified Nurses Aide (CNA) #1 take Resident #8 to the outdoor smoking area. The surveyor was unable to locate any emergency fire prevention equipment such as a fire extinguisher or fire blanket in the vicinity of the resident smoking area. When the surveyor asked CNA #1 what she would do if a Resident was accidently on fire, CNA #1 said she would use a fire extinguisher. When the surveyor asked about the fire extinguisher, CNA #1 said there used to be a fire extinguisher outside but she was unsure where it was and where the closest fire extinguisher could be located inside the building. CNA #1 further said she was unaware if there was a fire blanket available in the facility. On 11/17/23 at 9:25 A.M., the surveyor observed the Regional Maintenance Director open the front door of the facility and place a fire extinguisher outside the front door on the ground, and then close the front door. During an interview on 11/17/23 at 9:35 A.M., the Regional Maintenance Director said prior to placing the fire extinguisher on the ground outside the front door, there was no fire prevention equipment readily available in the smoking area. He further said there was also no fire blanket readily available in the smoking area and that both a fire extinguisher and fire blanket should be readily available in the smoking area in the event of a fire emergency. During an interview on 11/21/23 at 10:09 A.M., the Administrator said that all staff were educated on the smoking policy and proper procedure for supervising residents who smoke. She provided the surveyor with the Employee Education Attendance Record, dated 9/18/23 (that included CNA #1) which indicated the following procedures were supposed to take place when a resident was smoking: Fire extinguisher on front patio (did not include mention of a fire blanket). The Administrator further said when staff took a resident outdoors to smoke, they were supposed to take the fire blanket (located at the receptionist desk inside the front door) outside with them and neither taking the fire blanket outside nor having the fire extinguisher in place occurred during the smoking observation on 11/17/23.

Based on observation, interview, and policy review, the facility failed to ensure the replacement of an Emergency Kit (E-Kit) medication in one (Unit Three) out of one Medication Storage rooms where the Emergency Kit (E-kit) was stored. Specifically, the facility failed to replace an Insulin (Insulin-a hormone that lowers the level of sugar in the blood, used to treat diabetes) E-Kit for the medication to be available if/when needed urgently. Findings include: Review of the policy titled Preparation and General Guidelines, dated November 2021 indicated the following: -Replenishment of the medication in the E-kit is scheduled so that no medication supply is exhausted. On 11/17/23 at 12:01 P.M., while inspecting the medication storage room on Unit Three with Nurse #1, the Insulin E-kit was observed to be unlocked and the following items were missing: -Insulin Glargine (long-acting insulin) -Insulin Lispro (fast-acting insulin) -Levimir (long-acting insulin) During an interview on 11/17/23 at 12:01 P.M., Nurse #1 said she was unable to determine when the Insulin E-kit had been opened, how long it had been opened, or if had been re-ordered. Nurse #1 said the Insulin medications that were missing from the E-kit were the ones that were used most often and could have been used for Residents from other units. She said when a medication is removed from the E-kit the Nurse should complete the re-order form that is enclosed in the E-kit, fax it to the Pharmacy, and place the form in the pharmacy bin at the nurses station. Nurse #1 could not provide evidence to the surveyor that the Insulin E-kit had been re-ordered. During an interview on 11/21/23 at 12:24 P.M., the Director of Nurses (DON) said the Insulin E-kit on Unit Three was the only Insulin E-kit in the facility. The DON said she was unable to determine when the E-kit had been opened or if it had been re-ordered.

Based on record review and interview, the facility failed to ensure a Notice of Medicare Non-Coverage form (NOMNC - form given by the facility to all Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay) was issued to one Resident (#191) out of three applicable sampled residents. Findings include: Resident #191 was admitted to the facility in July 2023 under his/her Medicare Part A benefit. Review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form completed by the facility indicated that Resident #191 ended his/her Medicare Part A benefit on 8/9/23. Further review of the form indicated no attached NOMNC form. During an interview on 11/20/23 at 9:37 A.M., the Social Work Consultant said she was unable to confirm if the Resident had been issued a NOMNC form as required, as there was not a copy available in the Resident's medical record or in the binder that was kept by the Social Services Department. She further said the Resident should have been issued a NOMNC form and a copy should have been placed in the medical record.

Based on interviews and records review, the facility failed to accurately code the Minimum Data Set (MDS) Assessment for three Residents (#23, #59, and #88) out of a total sample of 18 residents. Specifically, the facility failed to code: 1. For Resident #23, that the Resident utilized a position change alarm (a Velcro seatbelt with an alarm that sounded if the Resident attempted to stand from his/her wheelchair). 2. For Resident #59, that the Resident was receiving Hospice services. 3. For Resident #88, accurately identify the Resident's discharge status. Findings include: 1. Resident #23 was admitted to the facility in September 2017 with diagnoses including Parkinson's Disease and Dementia. Review of the November 2023 Physician's orders indicated the following: -Velcro alarmed seatbelt to wheelchair for reminder to call for assistance every shift. -Special Instructions: Check placement and functioning every shift for safety, initiated 8/28/22. -Resident to remove Velcro alarmed seatbelt on command weekly on Monday day shift, initiated 8/29/22. Review of the Resident's MDS assessment dated [DATE], did not indicate that the Resident utilized any alarming devices. Review of a Nursing Progress Note dated 9/21/23, indicated: seatbelt on as ordered for safety, Resident tolerating it well. The surveyor observed the Resident utilizing the Velcro alarmed seat belt on the following dates and times: -11/16/23 at 9:33 A.M. -11/17/23 at 8:13 A.M. -11/17/23 at 4:45 P.M. -11/21/23 at 9:00 A.M. During an interview on 11/21/23 at 11:40 A.M., the MDS Nurse said the Resident utilized an alarmed seatbelt, and that the MDS assessment dated [DATE], was not coded correctly and needed to be modified. 45435 2. Resident #59 was admitted to the facility in August 2022 with diagnoses including Alzheimer's Disease. Review of the November 2023 Physician's orders indicated the following: -Signed on to Hospice on 3/17/23 for Alzheimer's Disease. Review of the Resident's MDS Assessments dated 6/17/23, and 9/17/23, did not indicate that the Resident utilized Hospice services. During an interview on 11/21/23 at 11:03 A.M., the MDS Nurse said the Resident utilized Hospice services, and that the MDS Assessments dated 6/17/23, and 9/17/23, were not coded correctly and needed to be modified. 42741 3. Resident #88 was admitted to the facility in August 2023. Review of the Resident's Transfer/Discharge Evaluation dated 10/6/23, indicated the Resident was discharged from the facility to the community. Review of the discharge MDS assessment dated [DATE], indicated the Resident was discharged to the hospital. During an interview on 11/20/23 at 5:10 P.M., the MDS Nurse said the 10/6/23, MDS Assessment was coded inaccurately and needed to be modified to show that the Resident was discharged to the community not the hospital.

Based on observation, interview, policy and manufacturer's guidelines review, the facility failed to label and date an opened multi-dose vial of Tubersol Purified Protein Derivative (PPD- a skin test where solution is injected under the skin and is used to diagnose Tuberculosis infection) stored in one (Unit Two) out of three Medication Storage rooms. Findings include: 1 Review of the facility policy titled, Medication Storage in the Facility, dated November 2021, indicated the following: -When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated, if applicable for medications requiring a shortened expiration date. -The Nurse shall place a date opened sticker on the medication and enter the date opened, and the new date of expiration. Review of the manufacturer Sanofi Pasteur, Tuberculin - Purified Protein Derivative package insert indicated the following: -A vial of Tubersol PPD solution which has been entered (used) and in use for 30 days should be discarded. On 11/17/23 at 12:47 P.M., while inspecting the medication storage room on Unit Two with Nurse #2, the surveyor observed an open vial of Tubersol PPD, that was undated. during an interview at the time, Nurse #2 said she did not know when the vial had been opened, and that it should have been dated when it was opened. Nurse #2 further said the Tubersol PPD should be discarded. During an interview on 11/21/23 at 12:24 P.M., the Director of Nurses (DON) said the Tubersol PPD should have been dated when opened.

Based on record review, interview and observation, the facility failed to provide the necessary supervision and effective devices for one resident (#1) out of 13 applicable residents with falls, in a sample of 22 residents. For Resident #1, nine of ten unwitnessed falls were sustained in a 10 month period of time. These falls resulted in a hip fracture, skin tears, and a laceration closed with staples. Additionally, a black eye was sustained 24 hours after a fall. Findings included: Resident #1 was admitted to the facility in 11/08. This Resident's pertinent [DIAGNOSES REDACTED]. Review of the facility's Fall Prevention Program dated 2000, on page 1, states: "Each year 1 in 10 residents has a serious fall related to injury such as a fracture, laceration or severe head injury. About 65,000 have a hip fracture, one of the most serious fall-related injuries... Poor safety practices also increase fall risk. These include problems with the resident's environment and with personal safety..." On page 6, under Uneven floors, raised thresholds or wet spots, states: "Uneven floors or raised thresholds can cause the resident to trip... Floor surfaces should be even. Raised thresholds should either be removed or grading should be added on either side. When a floor surface changes from one type to another, it should be as smooth as possible." On page 8, under Transfers and Mobility, it states: "The bed (wheels) should always be left locked in the lowest position needed." Review of the quarterly Minimum Data Set (MDS) Assessment of 5/22/11 indicated that this Resident's brief interview for mental status was a 3, severely cognitively impaired, required supervision with ambulation was set up for help with ambulation. Review of the Physical Therapy plan of care of 5/15/11 indicated this Resident was having difficulty walking. This Resident received Physical Therapy for ambulation. Review of the Physical Therapy Evaluation and Discharge Summary of 5/26/11 stated that this Resident was modified independence on level surfaces and needed assistance with ambulation on uneven surfaces. Review of the falls care plan of 6/1/11 indicated the following: This Resident was at risk for falls due to dementia with confusion, an unsteady gait at times, and with a history of falls. He/she often forgets to use his/her walker when ambulating, history of syncope and unaware of safety risks. He/she has impulsive behaviors. As his/her dementia progresses, he/she is at risk for progressive decline. Interventions included: - Monitor for environmental hazard such as clutter, furniture in path... - Resident is supervised with ambulation on the unit and in his/her room with supervision off the unit and in the hall. - Resident uses the walker at times and forgets to use the walker and requires frequent reminders. - Monitor for increased unsteadiness and intervene as indicated. - Gripper pad (gripper strips) in the bathroom in front of the sink and next to the floor. - Bed alarm on at night to alert staff when this Resident is up as he/she does not always remember to use the call bell. - On (5/12/11) referral to Physical Therapy secondary to difficulty with ambulation. Review of the nurse's note and falls investigation of 6/8/11 at 10:30 P.M. (the 3:00 P.M. to 11:00 P.M. shift) indicated this Resident is status [REDACTED].M., and this Resident denies pain. There was no nurse's note on the 7:00 A.M. to 3:00 P.M. shift for the fall on that shift. There was no fall investigation for this fall. There were no injuries. Review of the nurse's note and the fall investigation of 7/15/11 indicated this Resident had an unwitnessed fall in his/her room on 7/15/11. This Resident's roommate alerted the nursing staff that this Resident had fallen. This Resident was found sitting on the floor between the bed and the chair. This Resident was trying to transfer from chair to bed. There were no injuries. The falls care plan was updated on 7/15/11 as follows: gripper strips were added to the right side of this Resident's bed. Review of the nurse's note and the fall investigation of 7/26/11 indicated this Resident had an unwitnessed (by the staff) fall. The fall was witnessed by a visitor for another Resident on 7/26/11 at 6:45 P.M. This Resident was ambulating in the hall unattended. This Resident was walking with a walker out onto the balcony and tripped over a bump and went down onto his/her knees. The Nurse on duty heard a loud noise and the Resident called out. This falls investigation stated, "? mental status decline." There were no injuries. The falls care plan was updated on 7/26/11 and indicated that this Resident fell to his/her knees walking out to the balcony. Regular laboratory work was being drawn secondary to questionable mental status changes. The falls care plan of 8/24/11 was updated to include that this Resident is supervised with ambulation on the unit, in his/her room, off the unit and in the hall. Review of the nurse's note and the fall investigation of 9/12/11 indicated this Resident had an unwitnessed fall on 9/12/11 at 10:30 A.M. The Nurses heard a loud noise, and the Resident called out. This Resident was ambulating unattended in the corridor, although this Resident was care planned to be supervised with ambulation. The Resident was found lying on the floor with his/her head and shoulders against the wall. Under the question, was this Resident's head struck, it was answered, "yes." The Resident was complaining of pain with attempts to move the left leg. This resident sustained [REDACTED]. This Resident was sent to the Community Hospital for evaluation and treatment. Review of the Discharge Summary from the Community Hospital indicated this Resident was admitted from 9/12/11 to 9/17/11 for a left hip fracture and surgical repair. The falls care plan was updated on 9/17/11 to include an alarm in this Resident's wheelchair. Review of the significant change MDS of 9/24/11 indicated that this Resident: was non-ambulatory was an extensive assist of one with transfers, had fallen in the past month, had fallen in the last 2 to 6 months, and had a fracture related to a fall in the past 6 months. The falls care plan was updated on 10/6/11 to include that this Resident requires a one person assist with his/her ambulation and with a walker. He/she requires a one person assist with transfers. Use an alarm when this Resident is in bed or in the wheelchair. Review of the nurse's note and the fall investigation of 10/23/11 indicated this Resident had an unwitnessed fall on 10/23/11 at 12:15 P.M. This Resident was in another Resident's room, and fell while ambulating to the bathroom of this unoccupied resident room. This Resident was yelling out. This Resident was found sitting on his/her coccyx on the floor facing the door with his/her back against the tub. He/she said he/she was trying to use the bathroom. No injury was sustained. Review of the nurse's note and the fall investigation of 11/12/11 indicated this Resident had an unwitnessed fall, on 11/12/11 at 3:20 A.M.; this Resident fell in his/her room from his/her bed. This Resident's alarms sounded and he/she was found kneeling on the floor next to his/her bed. Review of the nurse's note and unusual occurrence investigation of 11/13/11 indicated that this Resident had a bruise above the right eye, and the Resident stated, "They say I have a black eye." This investigation indicated that this bruise could be related to the fall of 11/12/11. The care plan was updated on 11/12/11 to have landing mats at the bedside. Review of the nurse's note and the fall investigation of 11/25/11 indicated this Resident had an unwitnessed fall in the Dining Room, on 11/25/11 at 9:35 A.M. The time of the last meal was 9:00 A.M. This Resident attempted to ambulate from the Dining Room chair to his/her wheelchair. An alarm was sounding, and this Resident was found on the floor with his/her head against the heater with 3 lacerations that were bleeding on the posterior area of the head. The bleeding stopped in 10 minutes. This Resident was transferred to the Community Hospital for evaluation and treatment. This Resident received 2 staples to a 3 centimeter laceration in his/her scalp. The falls care plan was updated on 11/25/11 to include the following: To make sure the Resident is left in his/her wheelchair in the Dining Room, and do not transfer this Resident to a straight back chair. Review of the nurse's note and the fall investigation of 11/28/11 indicated this Resident had an unwitnessed fall in the Resident's bathroom, on 11/28/11 at 4:15 P.M. The Resident's alarm was sounding in the bathroom. This Resident fell while ambulating to the bathroom. This Resident was found on his/her knees in front of his/her wheelchair in the bathroom. The falls care plan was updated on 11/28/11 to include to place an alarm on the bathroom door. Review of the quarterly MDS of 12/18/11 indicated this Resident, was an extensive assist of one for ambulation and transfers; had 2 falls with no injury and one fall with injury (expect major), i.e. skin tears, lacerations, superficial bruises... Review of the nurse's note and the fall investigation of 1/6/12 indicated this Resident had an unwitnessed fall in the Resident's Room, on 1/6/12 at 12:15 A.M. The Resident was found on the floor on top of the floor mat next to his/her bed. The Resident had fallen from his/her bed. The Resident indicated he/she was trying to go to the bathroom. The alarm did not sound because it was not plugged in and the Resident's wheel locks on his/her bed were left unlocked at the time of the fall. There were no updates to the falls care plan. Review of the nurse's note and the fall investigation of 3/6/12 indicated this Resident had an unwitnessed fall in this Resident's Room, on 3/6/12 at 4:45 P.M. The alarm was sounding and this Resident was found sitting on the bathroom floor. He/she had been previously sitting in his/her wheelchair. During an interview with Physical Therapist #1 on 4/4/12 at 8:20 A.M., he stated that upon discharge from physical therapy on 5/26/11, "(this Resident) was moderately independent with a walker on a level surface but not on an uneven surface, and would need assistance with an uneven surface." Physical Therapist #1 stated, for the Physical Therapy discharge on 11/7/11, "This Resident was a minimal assist or contact guard (a one assist) with ambulation. This means the (Resident) is walking with a one person physical assist and contact guard. Contact guard is light touch at one part of the control areas, the shoulders or the hips as needed." During an interview with the Assistant Director of Nurses (ADON, who is also the 3rd floor Unit Manager) on 4/4/12 at 9:10 A.M., she stated, "On 6/8/11, (this Resident) did not fall on the evening shift, he/she fell on the day shift. The evening nurse was told this (referring to the fall on the day shift) in report and wrote a note on the evening shift. The nurse who was involved in the fall (referring to the day shift nurse) did not write a nurse's note, nor was a fall investigation done." When the Surveyor asked if it was the facility's policy to write a nurse's note on the shift the fall occurred and complete a falls investigation, the ADON stated, "It is." When the Surveyor asked if the falls care plan was updated after the fall of 6/8/11, she stated, "It was not updated because we were not aware of the fall." When the Surveyor asked if this was a witnessed or an unwitnessed fall, the ADON said, "I don't know because the fall was not documented on days, nor was an investigation done." During an interview with the ADON on 4/4/12 at 9:15 A.M., indicated the 9 falls from 7/15/11 through 3/6/12 were all unwitnessed. When the ADON was asked regarding the 3rd fall on 7/26/11 (when a visitor witnessed this fall), she indicated it was not Resident #1's visitor but a family member of another Resident. When the Surveyor asked the ADON if the access to the balcony from the hallway to the balcony was a level surface, she said, "No, as the doors (referring to the balcony doors) close, there is a little bit of a track going over it." When the Surveyor asked if the laboratory work done after the fall of 7/26/11 was abnormal, she said, "No, off the top of my head, nothing was abnormal. I wanted to show an intervention after each fall." Interview with the ADON at this time related to the fall of 9/12/11, indicated that it was an unwitnessed fall, and that this Resident was not being supervised when he/she fell . During an interview with the ADON on 4/4/12 at 9:15 A.M., regarding the fall of 10/23/11, when she was asked if the Resident fell in the bathroom in another resident's room, she stated, "This Resident fell in the bathroom of an empty patient room, he/she took a right after walking by the Nurses' Station, instead of a left where his/her room was located, and was found in the bathroom of an empty patient room." When the Surveyor asked why did the alarm in the chair not go off for this fall, she stated, "(He/she) had unclipped (his/her) pull away, and (he/she) had stood at the sink in room 307." When the Surveyor asked if this Resident received assistance with ambulation as care planned, she stated, "No." During an interview with the ADON on 4/4/12 at 9:15 A.M., regarding the fall of 11/12/11, she was asked, since the nurse's note stated that this Resident had a bruise above the right eye, and since the unusual occurrence investigation included the Resident stating, "They say I have a black eye," then did this Resident actually have a black eye, the ADON said, "I do not know, that was awhile ago." During an interview with the ADON on 4/4/12 at 9:15 A.M., regarding the fall of 1/6/12, she was asked, prior to this fall from the Resident's bed, why was the bed alarm not plugged in, and why were the bed wheels not locked, she stated, "The CNA (Certified Nursing Assistant) did not do the alarm checks at the beginning of the shift which they are suppose to do, and the CNA left the bed wheels unlocked. The CNA was counseled." Observation on 4/3/12 at 8:45 A.M., revealed this Resident was sitting up in his/her wheelchair in his/her room with his/her head flexed forward, and his/her body leaning to the right with his/her eyes closed. Observation on 4/3/12 at 1:50 P.M., and at 2:30 P.M., indicated that there were no gripper strips in the bathroom. Observation at 4/3/12 at 3:20 P.M. revealed this Resident was in bed with his/her eyes closed, a pull away alarm was attached to this Resident, the bathroom door had an alarm, and there were anti-tippers on his/her wheelchair. Observation and tour of Unit 3 with the ADON on 4/4/12 at 9:45 A.M., indicated that when the balcony doors were open (as they were when this Resident fell on [DATE]), there is an elevated door frame which is an uneven surface and a potential safety hazard. When the ADON was asked if she was aware of this safety hazard for Residents ambulating out to the balcony, she said, "I was aware of this safety issue." When asked if this Resident was given assistance with the walking over the uneven surface (elevated door frame) leading to the balcony, she said, "No one was assisting this Resident over this uneven surface." During this tour, the location of the fall of 10/23/11 was reviewed and this ADON stated, "(This Resident) fell in the bathroom of an empty resident room." Review of Resident #1's own bathroom with the ADON revealed there were no gripper strips in this bathroom as care planned. When asked if she saw any grip strips, she said, "They (the gripper strips) are not there, and yes, they should be there." During an interview on 4/4/12 at 9:50 A.M., when the Surveyor asked the ADON if she could see the concerns for this Resident who is severely cognitively impaired: the lack of staff supervision and assistance and effective interventions to prevent falls. This resident sustained [REDACTED]. a hip fracture and a laceration with staples. The ADON replied, "I can see your concerns with his/her falls."