Every finding on record at Riverside Village Healthcare Center

Based on observation, interview, and record review, the facility failed to provide a safe and comfortable home-like environment, for two of three residents (Residents 1 and 3), when:1.Resident 1's bathroom had black staining to the tile grout next to the toilet, gray colored dust build up to the overhead bathroom fan vent, a black residue ring to the interior of the toilet water tank, black staining to the posterior sink near faucet handles, black and yellow residue to the exterior toilet bowl and peeling paint to the wall near the toilet was observed inside Resident 1's bathroom; and2. Water was actively leaking and pooling beneath/surrounding the toilet, and peeling paint to the wall near the toilet was observed inside Resident 3's bathroom.These failures had the potential to affect the comfort and psychosocial well-being of the residents.Findings:1.On April 2, 2026, at 9:39 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding physical environment. On April 2, 2026, at 9:58 a.m., during a concurrent observation and interview with Resident 1 in Resident 1's bathroom, the following were observed:- black staining to the bathroom tile grout next to the toilet;- gray colored dust build up to the overhead bathroom fan vent;- a black residue ring to the interior of the toilet water tank;- black staining to the posterior sink near faucet handles;- black and yellow residue to the exterior toilet bowl; and- peeling paint on the wall near the toilet.In a concurrent interview with Resident 1, she stated, this is disgusting and unsanitary, I do not feel safe using this bathroom. On April 2, 2026, at 12:24 p.m., during a concurrent observation and interview in Resident 1's bathroom with Certified Nurse Assistant (CNA) 1. CNA 1 stated the toilet looks dirty and old. CNA 1 further stated that housekeeping should have cleaned the sink, toilet and bathroom fan vent for the resident to feel comfortable during her stay at the facility.On April 2, 2026, at 12:49 p.m., during a concurrent observation and interview in Resident 1's bathroom with Maintenance Director (MD). The MD stated the sink basin had blackened areas and was uncertain if it was mold or dirty only. The MD stated the vent fan above the toilet had dust build up. The MD stated the interior of the toilet tank was dirty with brown stains and the exterior tubing needed to be replaced as it was noisy when flushed. The MD stated the bathroom looked dirty and should have been cleaned and toilet should have been replaced.A review of Resident 1's record indicated the resident was admitted to the facility on [DATE], with diagnoses which included generalized anxiety disorder and difficulty in walking. A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated March 27, 2026, indicated the resident has a BIMS (Brief Interview for Mental Status) score of 15 (cognitively intact). 2.On April 2, 2026, at 1:51 p.m., Resident 3's bathroom was observed to have water pooling under toilet and water dripping from beneath/surrounding toilet. The wall near the toilet was observed to have peeling paint.On April 2, 2026, at 2:05 p.m., during a concurrent observation and interview in Resident 3's bathroom with CNA 2, CNA 2 stated the CNA was expected to report to the charge nurse or housekeeping department if the resident's room required maintenance. CNA 2 stated the water leaking from the toilet should have been reported immediately for resident safety due to risk of falls and injuries. CNA 2 further stated Resident 3's bathroom wall peeling has been like this for a while and should have been reported to maintenance for repair. On April 2, 2026, at 2:22 p.m., during a concurrent observation and interview in Resident 3's bathroom with the MD, the MD confirmed water was actively leaking and pooling beneath/surrounding the toilet. The MD stated this was a safety concern as this could place the residents at risk to slip and fall. The MD further stated it was not acceptable to have the resident's bathroom in this condition and Resident 3's bathroom should have been repaired. A review of Resident 3's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included hemiplegia (weakness in one side).A review of Resident 3's History and Physical, dated February 23, 2025, indicated the resident had the capacity to understand and make decisions.A review of Resident 3s Care Plan, dated March 13, 2025, indicated, .At risk for falls/injury .due to .balance problem .safely promote functional ability to highest practicable level .bathing facility with non-slip surface .keep environment free of hazards .A review of the facility's policy and procedure titled, Homelike Environment, revised February 2021, indicated, .Residents are provided with a safe, clean, comfortable . homelike environment .encouraged to use their personal belongings to the extent as possible .The facility staff and management maximizes .to the extent possible .the characteristics of the facility .that reflect a personalized, homelike setting These characteristics include .clean, sanitary and orderly environment .comfortable .A review of the facility's policy and procedure titled, Policies and Practices-Infection Control, revised October 2018, indicated, .The facility's infection control policies .are intended to facilitate .maintaining a safe, sanitary and comfortable environment .to help prevent and manage transmission of diseases and infections .

Based on interview and record review the facility failed to ensure behavioral health care and services were provided, for one of three residents reviewed (Resident A), when the resident was not provided psychiatric/psychological consult when the resident continues to exhibit behaviors of refusal of care and medications.This failure resulted in Resident A's behavior of continued refusal of meals, medications, and activities of daily living (bathing, toileting, and continence [bladder and bowel function]) care needs, and being sent to the hospital for a further evaluation.Findings:On February 4, 2026, at 11 a.m., an unannounced visit to the facility was conducted for an investigation of complaints regarding quality of care and treatment.On February 4, 2026, at 11:10 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident A was only in the facility for a few weeks and the resident had a history of schizophrenia (severe brain disorder characterized by delusions, hallucinations, disorganized thoughts and speech). The DON stated Resident A was refusing to eat and would tell others that the facility was not feeding her. The DON stated the facility called Resident A's family member to inform them of the resident's behavior and confirmed they were aware of the resident's behaviors and that Resident A had called the police and had come out to evaluate her.On February 4, 2026, a review of Resident A's medical record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder (mental health condition combining schizophrenia symptoms with mood disorder episodes) and depression. A review of Resident A's admission H & P [History and Physical]), documented by the physician, dated December 18, 2025, indicated, .Has decision making capacity. A review of Resident A's Minimum Data Set (MDS - a resident assessment tool), dated December 23, 2025, indicated a BIMS (Brief Interview for Mental Status) score of 14 (cognitively intact). A review of Resident A's Order Summary Report, included physician's orders which included the following psychotropic medications:-Aripiprazole Oral Tablet 10 mg one tablet one time a day for schizoaffective disorder M/B delusional thoughts; date ordered December 19, 2025; and-Lexapro (medication used to treat depression) 10 mg (milligram - unit of measurement), one (1) tablet one time a day for Depression M/B (manifested by) self-report of feeling depressed; date ordered December 22, 2025; A review of Resident A's Medication Administration Record (MAR), for the month of January 2026, indicated Resident A began to refuse her medications on the following dates:- January 1, 2026, Lidocaine Patches (numbing medication for pain).- January 2, 2026, Atorvastatin Calcium (cholesterol medication) and Gabapentin (used to treat nerve pain).- January 4, 2026,; Lexapro, Aripiprazole, Benazepril (also called Lotensin - used to treat high blood pressure, heart failure, and kidney disease), Celebrex (helps reduce pain, swelling, stiffness), Colace (stool softener for constipation), Vitamin C, Multi-vitamin, and Zinc supplement.- January 5, 2026, Protonix (also called pantoprazole-used to treat gastric acid in the stomach).- January 6, 2026, began to refuse having her with blood sugar checked.On January 5, 2026, Resident A began to exhibit episodes of schizoaffective disorder with delusional thoughts, and the frequency of episodes increased and continued until being sent out to the hospital on January 10, 2026.A review of Resident A's Change of Condition, dated January 6, 2026, at 10:48 a.m., .resident noted with refusing medication.behavioral changes.A review of Resident A's Progress Notes, indicated the following episodes of Resident A's behavior:- On January 7, 2026, at 8:05 a.m., .At about 0630 (6:30 a.m.) resident yelling for the nurse.When this writer entered resident room resident was giving this writer her phone, she wanted this writer to give address to person on the phone whom which identified themselves as the (name of county) Sheriff.sheriff stated that resident had reported to them that she had not eaten in five days.Resident on monitoring refusing medication.- On January 7, 2026, at 10:32 a.m., .Resident continues to refuse medications and will refuse meals as well.she called 911, police officers arrived and spoke with resident.- On January 7, 2026, at 4:06 p.m., .Multiple attempts made to provide care, including, but not limited to changing and repositioning.stated leave me alone;- On January 7, 2026, at 5:32 p.m., .She became upset and shouted at CNA (Certified Nursing Assistant) staff.- On January 8, 2026, at 12:39 p.m., .Patient this morning refused her medications and states she does need to explain why she does not want it.-On January 8, 2026, at 11:21 p.m., .Resident refused her dinner, refused all meds (medications) and BS (blood sugar) check, does not want to go back to bed.- On January 9, 2026, at 1:08 p.m., .Patient is non-compliant at times with changes and will deny to go back to her bed after being on her wheelchair as well.- On January 9, 2026, at 5:45 p.m., .Resident refused dinnertime meal tray stating she does not like the food to be delivered, however no food delivery was dropped off.Resident states police officers will bring her Mexican food.- On January 10, 2026, at 1:33 p.m., .refusal to eat or drink.order from physician is to send pt (patient) to hospital.A review of Resident A's Inter Disciplinary Team Notes indicated:- On January 7, 2026, at 9:30 a.m., .resident was noted with behavior of refusing her medications on 1/6/26 [January 6, 2026].noted with impaired cognition and is disorientation to reality.multiple attempts provided to administer medications, however, resident continues to refuse.- On January 9, 2026, 9:30 a.m., .disoriented with impaired cognition.with adverse behavior.refusing meals, meds and care.schizoaffective disorder, adverse behaviors of refusing care.On February 4, 2026, at 1:30 p.m., an interview was conducted with the Certified Nursing Assistant (CNA) 1. CNA 1 stated she took care of Resident A while at the facility. Resident A did not like the food and accused the facility of starving her and not giving her any food. CNA 1 stated Resident A refused several of her meals, would be demanding and confused at times, would refuse to be showered, and would affect her personal hygiene.On February 4, 2026, at 1:50 p.m., an interview was conducted with CNA 2. CNA 2 stated Resident A would refuse her showers, and she would ask her several times throughout the day. CNA 2 stated on the morning of January 10, 2026, she gave the Resident A her breakfast, opened all the items on her meal tray and she ate the sausage and drank the coffee but refused to eat anything else, she refused her lunch tray completely, and there were orders in place, if the resident continued to refuse her meals they were to send Resident A to the hospital. CNA 2 stated a few days before transferring Resident A to the hospital, the resident had refused to have her diaper changed or be put to bed on the evening shift, she sat in her wheelchair in front of the nurse's station and refused to move. CNA 2 stated we would offer Resident A bed bath, she would refuse, at one point she smelled, and we begged her to shower and she still refused. On February 4, 2026, at 4 p.m., conducted an interview with the DON. The DON stated there was a psychiatric consult ordered for Resident A on January 6, 2026, and it was to be completed the following day, but the psychiatrist needed to postpone his visit until January 15, 2026, and this delayed her needed evaluation and was she sent to the hospital on January 10, 2026 for refusing food, medications, and basic care. The DON stated referral for psychiatry should have been initiated immediately and if not able to be coordinated due to availability, the primary MD should have been informed for further orders to manage her behavior.A review of the facility's policy titled Change in a Resident's Condition or Status, dated May 2017, indicated, .significant change in the resident's physical/emotional/mental condition.refusal of treatment or medications.impacts more than one area of the resident's health status.a comprehensive assessment of the resident's condition will be conducted as required.A review of the facility's policy titled Behavioral Health Services, dated February 2019, indicated, .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, person-centered approach to care.residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs.staff training.includes.recognizing changes in behavior that indicate psychological distress.implementing care plan interventions that are relevant to the resident's diagnosis and appropriate to his or her needs.monitoring care plan interventions and reporting changes in condition.protocols and guidelines related to the treatment of mental disorders.

Based on interview and record review, the facility failed to monitor emotional distress after an abuse and neglect allegation, for one of three residents reviewed (Resident 1), when the resident alleged abuse and neglect by the nursing staff at the General Acute Hospital (GACH). This failure could result in staff not recognizing Resident 1's emotional distress and being unable to provide necessary psychosocial support. Findings:On September 9, 2025, at 11:14 a.m., an unannounced visit was conducted at the facility to investigateOn September 9, 2025, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included postlaminectomy syndrome (a condition characterized by persistent or recurrent pain and other symptoms after a laminectomy surgery [a surgical procedure that involves removing part or all of the lamina, which are the bony arches that cover the spinal cord]), diabetes mellitus (abnormal blood sugar), and fibromyalga (a chronic condition characterized by widespread pain, fatigue, and other symptoms). A review of Resident 1's Progress Notes, dated July 29, 2025, at 10:28 a.m., indicated, .admission H&P (History and Physical).Patient has capacity to make medical decisions.A review of Resident 1's Progress Notes, dated August 18, 2025, indicated, .spoke to resident TX (Treatment) Nurse regarding her report to Tx Nurse about feeling neglected in the emergency room at the hospital over the weekend. Resident stated she felt the nurse in the emergency room at (name of hospital) was very dismissive towards her and did not give her the care that she needed while she was there.Further review of Resident 1's record, indicated there was not follow up monitoring of resident's psychosocial condition after the resident reported the allegation against the GACH.On September 9, 2025, at 2:48 p.m., during an interview conducted with Licensed Vocational Nurse (LVN) 1, LVN 1 stated residents were to be monitored for 72 hours after a change of condition (COC).On September 9, 2025, at 5:14 p.m., during an interview conducted with the Administrator (ADM), the ADM stated Resident 1 reported an allegation of neglect while at the emergency room of the GACH. The ADM stated 72-hour monitoring should have been implemented and documented when Resident 1 reported an allegation of neglect.A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, dated May 2017, indicated, .The nurse will notify the resident's Attending Physician or physician on call when there has been a(an).significant change in the resident's physical/emotional/mental condition.The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on interview and record review, the facility failed to ensure meal substitutes were offered to the residents when the food intake was below 50% (percent), for one of three residents reviewed (Resident 2).This failure had the potential for Resident 2 to have weight loss and affect the resident's overall health condition.Findings:On September 9, 2025, at 11:14 a.m., an unannounced visit was conducted at the facility to investigateOn September 9, 2025, Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included gastroenteritis (an inflammation of the stomach and intestines that causes an upset stomach ) and protein-calorie malnutrition (a condition resulting from insufficient intake of protein and calories to meet the body's needs).A review of Resident 2's Weight and Vitals Summary, indicated the following weights:-August 16, 2025; 114.8 lbs. (pounds - unit of measurement);-August 19, 205; 111 lbs.;-August 27, 2025; 104 lbs.; 7 lbs. weight loss in a week; 6.3% in a week;-September 3, 2025; 106 lbs.; 2 lbs. weight gain in a week.A review of Resident 2's Document Survey Report, for the month of August and September 2025, indicated Resident 2 had food intake below 50% (percent) and was not offered substitute/alternative menu on the following dates:-August 17, 2025; Lunch (L)-August 19, 2025; breakfast (BF), lunch (L), dinner (D);-August 20, 2025; BF, D;-August 22, 2025; BF, L;-August 23, 2025; L;-August 24, 2025; L, D;-August 25, 2025; BF, L, D;-August 26, 2025; L;-August 27, 2025; BF, L;-August 28, 2025; BF, L;-August 29, 205; L;-August 30, 2025, BF-August 31, 2025; BF, L, D;-September 1, 2025; L;-September 3, 2025; L;-September 4, 2025; BF, L, D;-September 5, 2025; BF, L, D; and-September 6, 2025; BF, L, D.On September 16, 2025, at 10:22 a.m., during an interview with the Director of Nursing (DON), the DON stated that the facility offers an alternative menu for residents who do not like the served food or have poor intake.On September 16, 2025, at 1:32 p.m., during a concurrent interview and record review with the Food and Nutritional Services Director (FNSD), the FNSD stated the CNA should offer a meal substitute if a resident refused or disliked their meal or if the resident consumed less than 50% of the meal. Resident 2's meal intake for the month of August and September 2025 was reviewed with the FNSD. The FNSD stated the CNA should have offered a meal substitute when Resident 2 had food intake below 50%.A review of the facility's undated policy and procedure titled, Resident Food Preferences, indicated, .If the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with.The Food Service Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night.

Based on interview and record review, the facility failed to ensure accurate reconciliation of medications on admission was conducted for one of three sampled residents (Resident 1), when continuous use of oxygen therapy was not reflected in the physician order for a resident admitted on oxygen. This failure has the potential to result in lack of physician oversight, which could negatively affect the resident's current health condition.Findings: On August 12, 2025, at 9 a.m., an unannounced visit to the facility was conducted to investigate quality care issues. A review of Resident 1's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included Encephalopathy (a declining ability to reason, concentrate and memory loss), chronic systolic cardiac failure (the heart weakens and cannot pump adequate blood through the body), ischemic cardiomyopathy (due to damage from lack of oxygen to the heart muscle), atherosclerotic heart disease (a buildup of plaque that causes the heart blood vessels to narrow), non-rheumatic aortic valve stenosis (heart valve does not open fully and heart must work harder) and difficulty walking. A review of Resident 1's admission Assessment Summary, dated July 10, 2025, at 17:47 (5:47 p.m.), indicated, .admitted to the facility with oxygen 2 lpm (liters per minute) via nasal canula in place.A review of the physician's orders dated July 10, 2025, through July 15, 2025, did not indicate that the resident was oxygen therapy. On August 12, 2025, at 12 p.m., during an interview and record review, the Director of Nursing (DON) confirmed that Resident 1's record lacked any physician order for oxygen upon admission or subsequently. The DON stated the resident used oxygen continuously during her stay, as indicated in the admission summary, and acknowledged that the order should have been included in the admission orders. She stated the licensed nurse should have verified the orders for accuracy and contacted the physician for the oxygen order at that time.A review of the facility's policy and procedure titled, Reconciliation of Medications on Admission, dated July 2017, indicated, .to ensure medication safety by accurately accounting for resident's medication, routes and dosages upon admission or readmission to the facility. Preparation 1. Gather the information needed to reconcile the medication list .c. admission order sheet .Medications reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process .if a there is a discrepancy.contact the physician to resolve the discrepancy.

Based on observation, interview, and record review, the facility failed to ensure the necessary care and treatment was provided, for one of five sampled residents (Resident 4), when: 1. Resident 4 ' s left forehead laceration was not evaluated and referred to a physician for suture removal. This failure had the potential for the delay in necessary care and treatment of possible complications related to skin injuries/problems; 2. Resident 4 ' s blood sugar level was not monitored after the insulin medication was discontinued on March 13, 2025. This failure had potential for Resident 4 ' s blood sugar level to be inadequately control which could alter the resident's mental status and affect the resident's overall health condition. 3. Resident 4 ' s baseline weight was not obtained timely after admission on [DATE]. This failure had the potential for the delay in necessary care and further complications of malnourishment; 4. Resident 4 ' s change of condition (COC) of low blood pressure was not relayed to a physician for appropriate management. This failure has the potential to result in deterioration of Resident ' s 4 health condition; and 5. Resident 4 ' s oral care after meals was not provided on March 27, 2025. This failure had the potential to cause serious health issues and could affect Resident ' s psychosocial well-being. Findings: On May 29, 2025, at 8 a.m., an unannounced visit was conducted to the facility for the investigation of a complaint regarding quality of care and treatment. 1. On May 29, 2025, Resident 4 ' s record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included encephalopathy (brain disorder) and sepsis (blood infection). A review of Resident 4 ' s History and Physical, dated March 2, 2025, indicated Resident 4 was mentally incapable of understanding. A review of Resident 4's BODY CHECK, dated March 13, 2025, indicated, .Pt (patient) returned to facility with laceration to L (left) forehead measuring 4.5 x (by)1.0 cm. (centimeter-unit of measurement) with 6 sutures . A review of Resident 4's Order Summary, dated March 13, 2025, indicated, .L (left) forehead laceration-clean with ns (normal saline), pat dry, apply betadine, leave OTA (open to air) every day shift for 14 days . A review of Resident 4's Care Plan Report, dated March 14, 2025, indicated, .Surgical Wound .Lt (left) forehead laceration, 6 sutures .Provide skin care .Treatment as ordered, notify MD . A review of Resident 4's WEEKLY SKIN ALTERATION REPORT, dated March 18, 2025, indicated the following: - Resident 4 ' s left forehead with six (6) surgical sutures has no drainage, peri wound was dry with quality 90% epithelial tissue (wound's progression towards healing and restoration) and 10% scab, and; - Resident 4 ' s current treatment orders indicated, . weekly assessment of Lt forehead wound .Sites Healing . A review of Resident 4's acute hospital records titled, Daily Focus Assessment Report, dated March 27, 2025, indicated, .Removed stiches from patients forehead that were placed by (name of hospital) on March 12, 2025 . On May 29, 2025, at 11:25 a.m., during a concurrent interview and record review with the Treatment Nurse (TN), the TN stated there was no wound and suture evaluation conducted on the fourth week stay of Resident 4 and was not relayed to a physician. The TN stated the healing surgical wound with suture should have been reported to the physician. The TN stated the suture should have been removed to prevent complications such as overgrowth or the skin and could lead to skin irritation and infection. The TN further stated if the surgical wound would not be evaluated and reported, the skin condition would fall through the cracks. On June 2, 2025, at 2:45 p.m., during an interview with the Director of Nursing (DON), the DON stated she expected to the nurses follow the procedure guidelines for wound care. The DON stated the surgical wound with sutures should have been monitored and relayed to a physician. The DON further stated the healed wound with sutures should have been evaluated and should have been removed to prevent complications such as skin irritation and infections. A review of the facility's policy and procedure titled, Staple and Suture Removal, dated September 2013, indicated, .The purpose of this procedure is to provide guidelines for the removal of staples or sutures from a healing wound .Review the resident ' s care plan, current orders, and diagnoses to determine if there are special residents needs .Report other information in accordance with facility policy and professional standards of practice . 2. On May 29, 2025, Resident 4 ' s record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus II (DM II-abnormal blood sugar). A review of Resident 4 ' s Order Summary, dated March 1, 2025, indicated, .glipiZIDe Oral Tablet 10 MG (Milligram-unit of measurement) .Give 1 tablet by mouth two times a day for DM II; Give with meals . A review of Resident 4's Care Plan Report, dated March 2, 2025, indicated, .Risk for hypo/hyperglycemia (low/high blood sugar level) secondary to: Diabetes Mellitus .Test the resident ' s blood glucose (sugar) .Blood sugar check as ordered .Monitor for s/s (signs and symptoms) low blood sugar .Monitor for s/s of high blood sugar . A review of Resident 4 ' s Lab Results Report, indicated the following: - March 18, 2025, glucose 176, high, and: - March 23, 2025, glucose 154, high. A review of Resident 4 ' s Blood Sugar Summary, dated March 2025, indicated, Resident 4 ' s last blood sugar level was 107 mg/dL (milligrams per deciliter) was documented on March 13, 2025, and no documentation of Resident 4's blood sugar continued after March 13, 2025. On May 29, 2025, at 11:30 a.m., during a concurrent interview and record review with the Registered Nurse (RN), the RN stated Resident 4 ' s insulin was discontinued on March 4, 2025, and she did not clarify to a physician if the blood sugar check would be continued. The RN stated Resident 4 ' s blood sugar level should have been checked and should have been monitored to prevent complications of diabetes. The RN further stated if Resident 4 ' s blood sugar level would not be monitored, it could alter mental status and potentially lead to hospitalization. On June 2, 2025, at 2:45 p.m., during an interview with the DON, the DON stated she expected for the nurses to follow the facility ' s policy and procedure for diabetes management. The DON stated Resident 4 ' s blood sugar level should have been monitored and checked to prevent complications. The DON further stated if blood sugar would not be monitored it would lead to serious condition such as diabetic coma or shock. A review of the facility's policy and procedure titled, Diabetes-Clinical Protocol, dated November 2020, indicated, .As indicated, the Physician will order appropriate lab tests .and adjust treatments based on results and other parameters .Examples of blood glucose monitoring for various situations might include the following: (1) For the resident on oral medication(s) who is well controlled: monitor blood glucose level at least twice a weekly .(3) For resident receiving insulin who is well controlled: monitor blood glucose levels twice a day . 3. On May 29, 2025, Resident 4 ' s record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included muscle waiting and atrophy (loss of muscle mass). A review of Resident 4 ' s Order Summary, dated March 1, 2025, indicated, .Fortified diet .for Nutrition . A review of Resident 4 ' s 12 MINI NUTRITIONAL ASSESSMENT, dated March 1, 2025, indicated, Resident 4 has a score of 5 with a category of malnourished. A review of Resident 4 ' s Care Plan Report, dated March 1, 2025, indicated, .NUTRITIONAL RISK .Monitor weight and notify MD for any undesirable weight changes .Refer for dietary/RN (Registered Dietician) consult . A review of Resident 4 ' s Weight Summary, dated March 2025, indicated the following: - March 3, 2025, 109 lbs. (pounds - unit of measurement); - March 11, 2025, 107 lbs; - March 19, 2025, 105 lbs; and - March 25, 2025, 101 lbs. On May 29, 2025, at 11:30 a.m., during a concurrent interview and record review with the Restorative Nursing Assistant (RNA), the RNA stated Resident 4 was admitted on [DATE], and she took the weight on March 3, 2025. The RNA stated Resident 4 ' s weight should have been taken upon admission or the next day so it would be reported to the nurse the accurate weight of resident upon admission. The RNA further stated it was two days delayed. On May 29, 2025, at 11:30 a.m., during a concurrent interview and record review with the RN, the RN stated Resident 4 ' s weight should have been taken upon admission or the next day so the nurses could identify if there was a need to notify a dietician regarding nutritional management. The RN stated if there was a delay of obtaining weight, it would potentially result to a further weight loss. On June 2, 2025, at 2:45 p.m., during a follow up phone interview with the DON, the DON stated she expected the staff follow policy and procedure of weight loss management. The DON stated Resident 4 should have been weighed upon admission or the next day of admission. The DON further stated if weight would not be obtained timely, there was a potential delay of care to Resident 4. A review of the facility's policy and procedure titled, Weight Assessment and Intervention, dated September 2008, indicated, .The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter . 4. On May 29, 2025, Resident 4 ' s record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included hypertension (HTN - elevated blood pressure). A review of Resident 4 ' s Order Summary, dated March 1, 2025, indicated, Carvedilol (medication to treat hypertension) Oral Tablet 3.125 MG .Give 1 tablet by mouth one time a day for HTN . A review of Resident 4's Care Plan Report, dated March 2, 2025, indicated, .Hypertension .Resident will maintain clinically acceptable range of blood pressure .Monitor BP and refer to MD for changes . A review of Resident 4 ' s Blood Pressure Summary, dated March 2025, indicated the following: - March 26, 2025, at 21:59 p.m., 64/47 mmHG (unit of measurement), BP-low; - March 27, 2025, at 00:11 a.m., 94/56 mmHg, BP (low_; and - March 27, 2025, at 00:42 a.m., 106/59 mmHg, BP (low.) A review of Resident 4 ' s Nurse ' s Note, dated March 27, 2025, indicated, Vital signs for resent (sic) rechecked due to CNA advising this writer that resident had a low blood pressure. Using an arm cuff blood pressure rechecked at 0042 with BP reading 106/59 . On May 29, 2025, at 11:30 a.m., during a concurrent interview and record review with the RN, the RN stated Resident 4 ' s blood pressure of 106/59 on March 27, 2025, was low and there was no evidence of documentation of change of condition and the physician was not notified. The RN further stated if a physician would not be notified of the change of condition of a resident, it could result to conditions such as alteration of mental state, shock (life threatening condition where the body experiences insufficient blood flow) and could passed out. On June 2, 2025, at 2:45 p.m., during an interview with the DON, the DON stated she expected all the nurses to follow the facility ' s policy and procedure for a resident ' s change of condition and blood pressure management. The DON stated a physician should have been notified of Resident 4 ' s change of condition. The DON further stated if physician was not notified and no COC, Resident 4 ' s could potentially increase her health deterioration. On June 3, 2025, at 8:56 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 4 ' s blood pressure was low when he manually rechecked it with blood pressure cuff on March 27, 2025, at 00:42 in the morning. LVN 1 stated Resident 4 ' s change of condition was not relayed to the attending physician. LVN 1 stated Resident 4 ' s low blood pressure should have been identified as COC and should have been reported to a physician. LVN 1 further stated if COC not reported to a physician, resident could deteriorate and declined health condition. A review of the facility's policy and procedure titled, Blood Pressure, Measuring, dated September 2010, indicated, .The purpose of this procedure is to measure the pressure exerted by the circulating volume of blood .Hypotension is defined as blood pressure less than 100/60 mm/Hg .Hypotension should be reported to the physician . A review of the facility's policy and procedure titled, Change in a Resident ' s Condition or Status, dated May 2017, indicated, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident ' s medical/mental condition and/or status .Prior to notifying the Physician .the nurse will make detailed observations and gather relevant and pertinent information .including (for example) information prompted by the Interact SBAR Communication Form . 5. On May 29, 2025, Resident 4 ' s record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), encephalopathy (condition where brain function is impaired), gastro-esophageal reflux disease (stomach acid flows back and cause heartburn) and muscle wasting. A review of Resident 3's Minimum Data Set (MDS - an resident assessment tool), dated March 7, 2025, indicated the following: - Resident 3 had a Brief Interview for Mental Status (BIMS - a cognitive assessment) score of 06 (severe cognitive impairment); - Resident 3 required totally dependent with oral hygiene; and - Resident 3 would hold food in her cheeks after a meal, and had difficulty swallowing food. A review of Resident 3's Physician Orders, dated March 1, 2025, indicated Resident 3 had an appointment to a pain clinic on March 27, 2025, at 9:30 a.m. A review of Resident 3's care plan, dated March 6, 2025, indicated, .ADL (Activities of Daily Living) functioning with self-care deficit .requires total assistance in personal hygiene .dental/oral care PRN (as needed) .: On May 29, 2025, at 10:20 a.m., an interview was conducted with the RNA. The RNA stated the staffs should be watchful while feeding residents, residents should be fed very slowly, check and feel residents ' cheeks and ensure the residents were able to tolerate the food. The RNA stated oral care must be provided to the residents after each meal and before bed. The RNA stated they used clean cloth dip in warm water to clean all surrounding cheeks, upper and lower lips, and teeth to remove anything that could have been stuck. On May 29, 2025, at 11:30 a.m., during an interview with the RN, the RN stated the CNAs (Certified Nursing Assistants) do oral care on residents with feeding issues, immediately after meals and before bed. On May 29, 2025, at 12:57 p.m., an interview and concurrent document review conducted with the Food and Nutritional Service Director (FNSD), the FNSD reviewed menu from March 26 and 27, 2025 and the Cook's spreadsheet. The FNSD stated Resident 4 received dinner March 26, 2025, which included a soft diet with green beans soft, cheese ravioli garlic bread soft, soft ripe and no skin. The FNSD stated for breakfast on March 27, 2025, included egg soft fried, oats softened in milk, and soft hash browns. The FNSD stated Resident 4 was assigned with a 1:1 feeding assistant. The FNSD further stated Resident 4 did have holding of food in mouth and cheeks noted in MDS admission notes. On May 30, 2025, at 10:06 a.m., during an interview conducted with the CNA, the CNA stated she fed Resident 4 with scrambled eggs and milk for breakfast on March 27, 2025. The CNA stated she was informed Resident 4 was about to get picked up for a scheduled physician appointment that day, so she did not complete the oral care. On June 2, 2025, at 2:45 p.m., during an interview conducted with the DON, the DON stated Resident 4's family member had called her to informed Resident 4 was transferred to the acute care facility, as green beans and egg had been found in her mouth at the physician ' s office during the appointment. The DON stated the resident should have had oral care after each meal to assure no food residue remained. A review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), Supporting, dated March 2018, indicated, .Residents will be provided with care .residents who are unable to carry out the activities of daily living independently will receive the service .to maintain good .oral hygiene .oral care .appropriate care and services will be provided for residents who are unable to carry out ADL ' s independently .including .oral hygiene .

Based on interview and record review, the facility failed to ensure scheduled hemodialysis (a treatment using a machine and special filter to clean the blood of a kidney failure person) treatments were provided timely, for one of three residents reviewed (Resident 5), when the transportation to the dialysis center was not arranged. This failure resulted in Resident 5 to missed dialysis treatments while at the facility. In addition, this failure had the potential for Resident 5 to increased risk of medical complications including fluid overload (excess fluid in the blood), edema (swelling), shortness of breath, and high blood pressure. Findings: On May 29, 2025, at 8 a.m., an unannounced visit was made to the facility for the investigation of a complaint regarding quality of care and treatment. On May 29, 2025, Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (a severe condition where the kidneys have permanently lost most of their ability to function). Resident 5 was readmitted back to the facility on May 17, 2025. A review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated May 6, 2025, indicated as follows: - Resident 5 had a BIMS (Brief Interview of Mental Status) score of 10 (moderate cognitive impairment), and; - Resident was on hemodialysis. A review of Resident 5's Order Summary, included a physician's order, dated April 2, 2025, which indicated, .Dialysis: Dialysis Center: (Name of Center) .On T-Th-S (Tuesday-Thursday-Saturday) Chair Time:12PM (p.m.) Transportation: (Name of Company) .Pick up at 11:00AM (a.m.) . A review of Resident 5's Nurse ' s Note, dated May 20, 2025, indicated, .pt (patient) missed HD (hemodialysis) today d/t (due to) transportation not arriving . On May 29, 2025, at 1 p.m, an interview was conducted with the Social Service Director (SSD). The SSD stated the transportation for the dialysis schedule should be pre-arranged prior to admission to the facility. The SSD stated if there would be an issue with transportation to the dialysis clinic on the scheduled dialysis, the licensed nurse should call the transport company, notify the dialysis center, physician, and the resident or resident representative. The SSD stated the facility should have followed up with the transport company about Resident 5's dialysis schedule and pick up when the resident was readmitted back to the facility. On May 29, 2025, at 1:45 p.m., during a concurrent interview and record review with Licensed Vocational Nurse (LVN) 2. LVN 2 stated Resident 5 did not receive her dialysis treatment on May 20, 2025, due to transportation did not show up. LVN 2 stated the transportation should have been followed up and arranged prior to dialysis to avoid missed dialysis treatments. LVN 2 further stated, if a resident would not receive dialysis, Resident 5 could have complications such as shortness of breath and edema that could lead to hospitalization. On June 2, 2025, at 2:45 p.m., during an interview with the Director of Nursing (DON), the DON stated she expected for all licensed nurses to follow the facility's policy and procedure of dialysis care. The DON stated the transportation should have been followed up or arranged prior dialysis treatment and should have been communicated to avoid miss treatment. The DON further stated if the resident would not receive a dialysis treatment, resident would increase the risks for medical condition such as fluid overload, respiratory problems and high blood pressure. A review of the facility ' s policy and procedure titled, End-Stage Renal Disease, Care of a Resident with, dated September 2010, indicated, .Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care . A review of the facility ' s transfer agreement titled, NURSING HOME DIALYSIS TRANSFER AGREEMENT, dated, April 2024, indicated, .Facility shall have the responsibility for arranging suitable transportation of the Designated Resident to and from Center, including the selection of the mode of transportation, qualified personnel to accompany the Designated Resident and transportation equipment usually associated with this type of transfer including the use of appropriate life support measures in accordance with the applicable federal and state laws and regulations .

Based on observation, interview, and record review, the facility failed to treat residents with respect and dignity when: 1. For Resident 19, Certified Nursing Assistant (CNA) did not fully close the privacy curtain to cover resident's body while providing care; 2. For Resident 47, the staff did not answer call lights in a timely manner, and; 3. For Resident 55, the staff did not respond to resident's requests to provide care. These failures resulted in not ensuring residents' rights to be treated with dignity and respect and could potentially result in negative physical or psychosocial outcomes, such as embarrassment, or changes in mood and/or behavior. Findings: 1. On April 29, 2025, at 10:21 a.m., during a concurrent observation and interview with CNA 1, CNA 1 was observed providing care to Resident 19 in her room. CNA 1 was changing Resident 19's clothes and the privacy curtain was observed half drawn and Resident 19's body was exposed. CNA 1 stated she was in a hurry because the therapy told her Resident 19 would be next for treatment. CNA 1 further stated, I forgot to fully close the curtain. On May 1, 2025, Resident 19's record was reviewed. Resident 19 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss). A review of Resident 19's Minimum Data Set (MDS - a tool for assessment), dated February 10, 2025, indicated Resident 19 had a BIMS (Brief Interview for Mental Status - a tool used to assess cognition) score of 02 which indicated severe cognitive impairment. On May 1, 2025, at 10:32 a.m., during interview with Registered Nurse (RN) 1, RN 1 stated privacy was important and CNA1 should have fully closed the curtain and should not expose Resident 19's body while providing care. RN 1 stated she would feel embarrassed if someone would saw her body. RN 1 further stated, It's a dignity issue. On May 1, 2025, at 3:32 p.m., an interview with the Director of Nursing (DON) was conducted. The DON stated she expected all staff to always treat residents with respect and dignity. The DON stated the CNA 1 should have drawn the privacy curtains while providing care to residents. A review of the facility's policy and procedure titled, Dignity, dated February 2021, indicated, .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 .Residents are treated with dignity and respect at all times .Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures . 47374 2. On May 1, 2025, at 2:35 p.m., an observation of the call lights and nurse response during change of day shift (7 a.m. to 3 p.m.) to evening shift (3 p.m. to 11 p.m.) was conducted. The CNAs were observed standing near the central nurse station talking to each other while the call lights in two rooms were observed on. The call lights were were answered with an average time of 5 -10 minutes. On May 1, 2025, at 3:40 p.m., an interview with Resident 47 was conducted. Resident 47 stated the call lights were not being answered timely especially during the day and evening shift. Resident 47 stated he could not do many things for himself after his stroke and several times his roommate had to go into the hallway to find a nurse to help him. Resident 47 further stated he felt disrespected and unimportant when he had to wait for the nurse for a prolonged time. A review of Resident 47's medical record indicated Resident 47 was admitted to the facility on [DATE], with the diagnoses which included cerebral infarction (when blood flow to the brain is blocked causing brain tissue to die) and hemiplegia (paralysis or severe weakness on one side of the body). Resident 47's Minimum Data Set (MDS - an assessment tool), dated April 1, 2025, indicated Resident 47 had a BIMS (Brief Interview for Mental Status) score of 15 (cognitively intact). On May 2, 2025, at 3:40 p.m., an interview was conducted with Director of Nursing (DON). The DON stated her expectation was for the nurses to answer lights as soon as possible, and if unable to assist immediately inform the residents of their return time. The DON stated the resident's sense of well-being or self-worth were not being promoted when call lights are not being answered as soon as possible. 49113 3. On April 29, 2025, at 10:14 a.m., during an interview with Resident 55, Resident 55 stated he turned on the call light to request for assistance to transfer from wheelchair to bed, on the night of April 24, 2025. Resident 55 stated he waited for at least 15- 20 minutes and no staff came, then his roommate (Resident 48) went to get help. On April 29, 2025, at 10:34 a.m., during an interview with Resident 48, Resident 48 confirmed the incident alleged by Resident 55 on April 24, 2025. Resident 48 stated he used his call light for staff assistance and they never came. Resident 48 stated he got out of his bed and went to get help for Resident 55 after 20 minutes had passed and no staff responded to their call light. On May 2, 2025, at 3:40 p.m., during an interview with the DON, the DON stated the call lights should be answered timely. The DON stated it was every staffs responsibility to answer the lights. The DON stated the concern was resident's needs would not be met timely and there was a potential for resident falls. A review of the facility's policy and procedure titled, Dignity, dated February 2021, indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being .and feelings of self-worth and self-esteem .Residents are treated with dignity and respect at all times .Demeaning practices and standards of care that compromise dignity are prohibited .Staff are expected to promote dignity and assist residents; for example; promptly responding to a resident's request for toileting assistance . A review of the facility's policy and procedure titled, Answering The Call Light, dated September 2022, indicated, .to ensure timely responses to resident's requests and needs .answer the resident call system immediately .answering an auditory request for assistance .if resident needs assistance indicate approximate time it will take for you to respond .if you can not fulfill the resident's request .ask the nurse supervisor for help .

Based on interview and record review, for seven of 16 residents reviewed for Advanced Directive (AD - a written statement of an individual's wishes regarding his/her medical treatment) the facility failed to ensure a copy of the AD was readily available in the resident's records when: 1. For Resident 9, the facility did not follow up with resident representative (RR) to obtain a copy of the resident's AD. This failure had the potential for Resident 9's wishes regarding his medical treatment would not be honored; 2. For Residents 29, 30, 39, 55, 160 and 209, a written information regarding formulating an AD was not provided to the resident or RR. This failure had the potential for Residents 29, 30, 39, 55, 160 and 209 to not be aware of how to formulate an AD. Findings: 1. On May 1, 2025, Resident 9's record was reviewed . Resident 9 was admitted on [DATE], with diagnoses which included acute kidney failure (a condition in which kidneys suddenly can not filter waste from the blood). A review of Resident 9's Advance Directive Acknowledgement dated February 5, 2024, indicated Resident 9 had executed an AD. A review of Resident 9's Minimum Data Set (MDS - an assessment tool), indicated Resident 9 had BIMS (Brief Interview for Mental Status) score of 12 (moderate cognitive impairment). Further review of Resident 9's record indicated there was no AD readily available for review in Resident 9's chart. On May 1, 2025, at 9:56 a.m., an interview was conducted with the Social Service Director (SSD). The SSD stated the residents were inquired regarding information if they have an AD or not. The SSD stated if the resident have an AD, it should be in the resident's electronic file or a hard copy in the resident's chart. The SSD stated it was important for a physical copy of the AD to be readily available in the resident's chart so that the facility staff and the physician would be aware of the wishes of the resident and to honor their wishes. The SSD stated a copy of Resident 9's AD was not uploaded in the resident's electronic record as well as in the paper chart, and was not readily available for the facility when needed. The SSD stated Resident 9's AD should have been followed up from the resident's family member. 2. On May 1, 2025, Resident 29 's record was reviewed. Resident 29 was admitted to the facility on [DATE], with diagnoses that which included cerebral vascular accident (CVA - a condition where blood flow to the brain is interrupted, causing brain tissue damage). Further review of Resident 29's record indicated there was no documented evidence written information regarding formulating an AD being given to Resident 29. 3. On May 1, 2025, a review Resident 39's record indicated Resident 39 was admitted on [DATE], with diagnoses which included fracture (break) of the right and left tibia (the shinbone) and mandible (the lower jawbone). A further review of Resident 39's record indicated there was no documented evidence written information regarding formulating an AD was provided to Resident 39. 4. On May 1, 2025, Resident 209's record was reviewed. Resident 209 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection, inflammatory polyarthropathy (joint swelling and pain affecting five or more joints). A review of Resident 209's Advance Directive Acknowledgement, dated April 24, 2025, indicated Resident 209 did not have an AD, and there was no documentation the resident was provided written information regarding formulating an AD. 49113 5. On April 30, 2025, Resident 30's record was reviewed. Resident 30 was admitted on [DATE], with diagnoses which included hemiplegia/hemiparesis (partial paralysis on one side of the body), slurred speech, facial weakness, difficulty walking, dysphagia (difficulty swallowing), and hypertension. A review of Resident 30's History and Physical, dated March 24, 2025, indicated Resident 30 had the capacity to make decisions. A review of Resident 30's Advance Directive Acknowledgement, dated _____, indicated Resident 30's did not have an AD, and there was no documentation the resident was provided written information regarding formulating an AD. 6. On April 29, 2025, Resident 55's record was reviewed. Resident 55 was admitted to the facility on [DATE], with diagnoses which included fusion of the spine (procedure joining two or more vertebrae of the spine), cauda equina syndrome (damaged to bundle of nerves at the end of the spinal cord), and difficulty walking. A review of Resident 55's History and Physical, dated April 15, 2025, indicated Resident 55 had the capacity to make medical decisions. A review of Resident 55's Minimum Data Set (MDS - a resident assessment tool), dated April 18, 2025, indicated Resident 55 had a BIMS score of 13 (cognitively intact). A review of Resident 55's Advance Directive Acknowledgement, dated _____, indicated Resident 30's did not have an AD, and there was no documentation the resident was provided written information regarding formulating an AD. 7. On April 30, 2025, Resident 160's record was reviewed. Resident 160 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (blood flow to the brain is blocked), hemiplegia (weakness on one side of the body), difficulty walking, dysphagia (difficulty swallowing), and diabetes mellitus (too much sugar in the blood). A review of Resident 160's History and Physical, dated February 27, 2025, indicated Resident 160 did not have the capacity to understand and make decisions. A review of Resident 160's MDS, dated [DATE], indicated Resident 160 had a BIMS score of 6 (severe cognitive impairment). A review of Resident 30's Advance Directive Acknowledgement, dated _____, indicated Resident 160's did not have an AD, and there was no documentation the resident's representative was provided written information regarding formulating an AD. On May 1, 2025, at 9:56 a.m., during an interview with the SSD, the SSD stated she was not providing written information to the resident or RR regarding formulating an AD. The SSD stated there was no documentation a written information regarding formulating an AD was provided to the resident or RR. The SSD stated Residents 9, 29, 30, 39, 55, 160, and 209 should have been provided written information regarding formulating an AD. A review of the facility's policy and procedure titled, Advance Directives, dated December 2016, indicated, .Advance Directives will be respected in accordance with state law and facility policy .Upon admission, the resident will be provided with written information concerning the right .to formulate an advance directive if he or she chooses to do so .Written information will include a description of the facility's policies to implement advance directives .If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative .Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his legal representative, about the existence of any written advance directives .Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record .If a resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives .

Based on observation, interview, and record review, the facility failed to provide a comfortable homelike environment, for two of four residents reviewed for environment (Residents 37 and 14), when the peeled painted walls were observed damaged behind the resident's headboard. In addition, peeled painted walls were observed in rooms [ROOM NUMBER]. This failure had the potential for residents not to experience comfortable and pleasant stay in the facility. Findings: 1. On April 29, 2025, at 9:30 a.m., Resident 37 was observed sleeping in her bed. Multiple peeled painted walls were observed damaged behind the headboard of Resident 37's bed. On April 30, 2025 at 9:20 a.m., the walls behind Resident 14's headboard was observed to have peeled paint. In addition, on April 30, 2025 at 1:29 p.m., multiple peeled painted wall was observed behind residents headboard in rooms 9B and 22. On May 2, 2025, at 10:10 a.m., an interview was conducted with the Maintenance Supervisor (MS). The MS stated he was aware of the condition of the painted walls. The MS further stated the damaged painted walls should have been fix and repainted. On May 2, 2025, at 10:20 a.m., an interview was conducted with the Administrator (ADM). The ADM stated he expected maintenance to check and fix any damaged wall or surfaces in the rooms. The ADM further stated the walls should have been fixed and the facility should have a homelike environment feeling for all the residents. A review of the facility's policy and procedure titled, Homelike Environment, dated February 2021, indicated, .Residents are provided with a safe, clean, comfortable and homelike environment .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .clean sanitary and orderly environment . 49113 2. On May 2, 2025, at 10:10 a.m., an interview was conducted with the MS. The MS stated he was aware of the condition of the painted walls. The MS further stated the damaged painted walls should have been fix and repainted. On May 2, 2025, at 10:20 a.m., an interview was conducted with the Administrator ADM. The FA stated he expected maintenance to check and fix any damaged wall or surfaces in the rooms. The FA further stated the walls should have been fix and the facility should have a homelike environment feeling for all residents. A review of the facility's policy and procedure titled, Homelike Environment, dated February 2021, indicated, .Residents are provided with a safe, clean, comfortable and homelike environment .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .clean sanitary and orderly environment .

Based on observation, interview and record review, the facility failed to ensure professional standards of practice during medication administration and the facility's policy and procedure were implemented, for three of 10 residents observed during medication administration (Residents 48, 55, 31, and 161), when: 1. Resident 48's medication was placed on a shelf next to Resident 55, readily available for use. This failure had the potential for Resident 48's medication be administered to Resident 55; 2. The identification of Resident 31 was not verified prior to administering the medications. This failure had the potential for the medications to be administered to the wrong resident; and 3. Resident 161 was not provided privacy while administering the medications. This failure had the potential to affect Resident 161's psychosocial and mental status. Findings: 1. May 1, 2024, at 7:44 a.m., during a medication pass observation with Licensed Vocational Nurse (LVN) LVN 3, LVN 3 was observed to have 1 open packet of Lidocaine Patch 5% (topical medication for pain relief) labeled for Resident 48 sitting on a shelf next to Resident 55. Resident 55's record was reviewed. Resident 55's Admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included fusion of the spine (procedure joining two or more vertebrae of the spine), cauda equina syndrome (damaged to bundle of nerves at the end of the spinal cord), and difficulty walking. Resident 55's Minimum Data Set (MDS- an assessment tool), indicated Resident 55 had a BIMS (Brief Interview for Mental Status) score of 13 (cognitively intact). A review of Resident 55's physician's orders, dated April 16, 2025, indicated, .Lidocaine Patch 4% Lidocaine, Apply to bilateral knee pain topically one time a day for bilateral knee pain and remover per schedule . On May 1, 2025, at 2:33 p.m., during an interview with LVN 3 , LVN 3 confirmed she left 1 Lidocaine Packet 5% belonging to Resident 48 open and readily available for use on the shelf by Resident 55. LVN 3 stated the medication belonged to Resident 48. LVN 3 stated she did not put the medication back into the cart nor discarded it and she should have. LVN 3 stated she should not have had another resident's medication out while administering to a different resident. LVN 3 stated the resident could have used the medication and could have adverse effect from the medication. On May 1, 2025, at 3:48 p.m., during an interview with the Director of Nursing (DON), the DON stated open medication should not be open and left unattended in the presence of another resident. The DON stated the expectation was staff should handle one resident medication at a time to decrease the risk for any medication errors. The DON stated potential concerns was if the resident was confused and used the medicine, there was a possibility of adverse side effects. A review of the facility's policy and procedure titled, Administering Medications, revised April 2019, indicated .Medications are administered in a safe and timely manner, and as prescribed .Medications ordered for a particular resident may not be administered to another resident . 2. On May 1, 2025, at 8 a.m., during a medication pass observation with LVN 3, LVN 3 was observed administering medication to Resident 31 without verifying the resident's identity. Resident 31's record was reviewed. Resident 31's Admission Record, indicated the resident was initially admitted to the facility on [DATE], with diagnoses which included fracture (break) of right wrist and hand, bradycardia (slow heart rate), and difficulty walking. Resident 31's History and Physical, dated April 13, 2025, indicated Resident 31 had the capacity to understand and make decisions. Resident 31's Minimum Data Set (MDS - a resident assessment tool), indicated Resident 31 had a BIMS score of 15 (cognitively intact). A review of Resident 31's Medication Administration Record, indicated a physician's order which indicated, Sodium Chloride Oral Tablet (Sodium Chloride) Give 0.5 tablet by mouth three times a day for hyponatremia (low sodium levels) by mouth three times a day. On May 1, 2025, at 2:33 p.m., during a concurrent interview and record review with LVN 3. LVN 3 acknowledged she did not verify the resident before administering the medication to Resident 31. LVN 3 stated the facility's process was for the licensed nurse to check every single resident identification by confirming the name and date of birth of the resident before she administers the medication to make sure she did not give the medication to the wrong resident. On May 1, 2025, at 3:39 p.m., during an interview with the DON, the DON stated her expectation was licensed staff nurses was to identify resident typically with their identification wrist band to verify they have the right resident. The DON stated licensed nurses was expected to follow the medication administration guidelines and verify all residents prior to administration. The DON further stated some consequences was the possibility of adverse reactions, abnormal vitals signs, hospitalization depending on reactions or even death. On May 1, 2025, at 4:20 p.m., during an interview with LVN 4, LVN 4 stated the facility's process during medication administration was the licensed nurse introduced themselves and verify the resident by their wrist band and/or ask the resident their name and date of birth. LVN 4 stated residents change rooms all the time and the outside name plaque on the door may not be updated. LVN 4 stated the licensed nurse need to verify the resident to prevent administering the wrong medicine to the wrong patient. LVN 4 further stated if you do not verify the resident and give the wrong medicine to a resident there was a possibility of an allergic reaction or possible death. A review of the facility's policy and procedure titled, Administering Medications, revised April 2019, indicated .Medications are administered in a safe and timely manner, and as prescribed .The individual administering medications verifies the resident's identity before giving the resident his/her medications .Methods of identifying .include .a. Checking identification band .The individual administering the medication check the label THREE (3) times to verify the right resident .before giving the medication . 3. During a medication pass observation on May 1, 2025, 08:06 a.m., with LVN 3, LVN 3 was observed not providing privacy during medication administration to Resident 161. Resident 161's record was reviewed. Resident 161's Admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included fracture (break) of left femur (thigh bone), difficulty walking, diabetes (too much sugar in the blood), and hypertension (high blood pressure). Resident 161's MDS, dated [DATE], indicated Resident 161 had a BIMS score of 13 (cognitively intact). On May 1, 2025, at 2:43 p.m., during a concurrent interview and record review with LVN 3. LVN 3 acknowledged she did not provide privacy while administering medications to Resident 161. LVN 3 stated she should always provide privacy and dignity when administering medication because it was their right. LVN 3 stated she should have pulled the curtain or closed the door when administering Resident 161 medications. On May 1, 2025, at 3:52 p.m., during an interview with the DON, the DON stated resident the licensed nurse should have provided privacy when administering medications to the resident. The DON stated staff should have pulled the curtain or closed the door. On May 1, 2025, at 5:51 p.m., during a follow-up interview with the DON, the DON stated residents needed privacy during medication administration. The DON also stated the resident could feel embarrassed or exposed. The DON further stated the expectation was licensed staff should provide privacy for the resident during medication administration. A review of the facility's policy and procedure titled, Dignity, revised February 2021, indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being .Residents are treated with dignity and respect at all times Staff promote, maintain and protect resident privacy, including bodily privacy .during treatment procedures

Based on observation, interview, and record review, the facility failed to ensure sufficient staff were provided to meet the needs of the residents when: 1. For five of 55 residents (Residents 55, 48, 31, 163, and ) complained that staff failed to assist with activities of daily living (ADL- daily care activities) in a timely manner; and 2. The facility did not meet the required minimum of Actual Total CNA Direct Care Service Hours the actual CNA DHPPD of 2.4 hours for the month of March 2025, for 16 out of 31 days reviewed, and for the month of April 2025, for 11 out 30 days reviewed. These deficient practices caused feelings of frustrations and anger, among the residents, and negatively affected the quality of care for the residents. Findings: 1a. On April 29, 2025, at 11:09 a.m., during an interview with Resident 55, Resident 55 stated he was sliding off his bed and used his call light and yelled out for the nurse aound late night of April 24, 2025. Resident 55 stated he yelled out for over 15 to 20 minutes, and no staff came. Resident 55 stated his roommate got up and pulled his call light and the staff still did not come. Resident 55's record was reviewed. Resident 55's Admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included fusion of the spine (procedure joining two or more vertebrae of the spine), cauda equina syndrome (damaged to bundle of nerves at the end of the spinal cord), and difficulty walking. Resident 55's Minimum Data Set, (MDS - a resident assessment tool), dated April 18, 2025, indicated Resident 55 had a BIMS (Brief Interview for Mental Status) score of 13 (cognitively intact). 1b. On April 29, 2025, at 10:34 a.m. during an interview with Resident 48, he acknowledged and confirmed that Resident 55 waited for his call light too long. Resident 48 stated he used his call light and staff never came. Resident 48 stated he had to go to the nurse station to get help. Resident 48 stated his light was on for at least 20 minutes. Resident 48 also stated staff would take forever to answer the call light and it happened more than once and sometimes the wait was over 30 minutes. Resident 48's record was reviewed. Resident 48's Admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included disorders of kidney and ureter (problems filtering urine), pulmonary nodule (mass in the lungs), muscle wasting and difficulty walking. Resident 48's MDS, dated [DATE], indicated Resident 48 had a BIMS score of 15 (cognitively intact) and uses a wheelchair as primary mode of locomotion. 1c. On April 30, 2025, at 1:37 p.m., during an interview with Resident 31, Resident 31 stated staff would take a long time to answer the call light about over 30 minutes. Resident 31 stated it was mostly in the evening that the staff would respond to the call light. Resident 31's record was reviewed. Resident 31's Admission Record indicated the resident was initially admitted to the facility on [DATE], with diagnoses which included a fracture (break) of right wrist and hand, bradycardia (slow heart rate), and difficulty walking. Resident 31's History and Physical, dated April 13, 2025, indicated Resident 31 had the capacity to understand and make decisions. Resident 31's MDS, dated [DATE], indicated Resident 31 had a BIMS score of 15 (cognitively intact). 1d. On May 2, 2025, at 3:43 p.m. during an interview with Resident 163, Resident 163 stated the staff does not look at the call light. Resident 163 stated she waited up to an hour at night waiting for pain medicine. Resident 163 stated she was wet and waited for over 30 minutes. Resident 163's record was reviewed. Resident 163's Admission Record, indicated the resident was initially admitted to the facility on [DATE], with diagnoses which included saddle embolus of pulmonary artery (condition where large blood clot lodges in main lung artery), muscle wasting, and difficulty walking, Resident 163's History and Physical, dated April 13, 2025, indicated Resident 163 had the capacity to make medical decisions. Resident 163's MDS, dated [DATE], indicated Resident 163 had a BIMS score of 15 (cognitively intact). 1e. On May 2, 2025, at 3:51 p.m., during an interview with Resident 162, Resident 162 stated it would take staff over an hour to answer the call light. Resident 162 stated she was left soiled and wet. Resident 162's record was reviewed. Resident 162's Admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included respiratory failure with hypoxia (lungs not able to deliver enough oxygen), congestive heart failure (heart does not pump blood well), difficulty walking, obesity (too much body fat), and muscle wasting. Resident 162's MDS, dated [DATE], indicated Resident 162 had a BIMS score of 13 (cognitively intact) and required assistance with bathing, dressing, and using the toilet. 2. On May 2, 2025, at 11:22 a.m., a concurrent interview and record review of the facility's Census and Direct Care Service Hours Per Patient Day, (DHPPD - measures the number of hours of direct care given to patients in skilled nursing facilities) with the Director of Staff Development (DSD) was conducted. The DSD acknowledged and confirmed records for multiple days in March 2025, and April 2025, indicated the Actual Total CNA Direct Care Service Hours were below the required minimum of 2.4 hours for 16 of the 31 days reviewed for March 2025, and eleven (11) of 30 days reviewed for April 2025. The Actual Total DCSH hours were below 2.4 hours (hrs,) on the following dates: - March 1, 2025 (Saturday): 2.3 hrs. (CNA DCSH); - March 3, 2025 (Monday): 2.31 hrs. (CNA DCSH); - March 9, 2025 (Sunday): 2.29 hrs. (CNA DCSH); - March 10, 2025 (Monday): 2.39 hrs. (CNA DCSH); - March 15, 2025, (Saturday): 2.38 hrs. (CNA DCSH); - March 16, 2025 (Sunday): 2.10 hrs. (CNA DCSH); - March 17, 2025 (Monday): 2.34 hrs. (CNA DCSH); - March 18, 2025 (Tuesday): 2.38 hrs. (CNA DCSH); - March 19, 2025 (Wednesday): 2.39 hrs. (CNA DCSH); - March 21, 2025 (Friday): 2.30 hrs. (CNA DCSH); - March 22, 2025 (Saturday): 2.34 hrs. (CNA DCSH); - March 23, 2025 (Sunday): 2.28 hrs. (CNA DCSH); - March 24, 2025 (Monday): 2.24 hrs. (CNA DCSH); - March 29, 2025 (Saturday): 1.96 hrs. (CNA DCSH) - March 30, 2025 (Sunday): 2.30 hrs. (CNA DCSH); - March 31, 2025 (Monday): 2.21 hrs. (CNA DCSH). - April 5, 2025 (Saturday): 2.33 hrs. (CNA DCSH); - April 6, 2025 (Sunday): 2.11 hrs. (CNA DCSH); - April 7, 2025 (Monday): 2.34 hrs. (CNA DCSH); - April 9, 2025 (Wednesday): 2.32 hrs. (CNA DCSH); - April 11, 2025, (Friday): 2.37 hrs. (CNA DCSH); - April 12, 2025 (Saturday): 2.28 hrs. (CNA DCSH); - April 13, 2025 (Sunday): 2.30 hrs. (CNA DCSH); - April 15, 2025 (Tuesday): 2.39 hrs. (CNA DCSH); - April 19, 2025 (Saturday): 2.18 hrs. (CNA DCSH); - April 20, 2025 (Sunday): 2.24 hrs. (CNA DCSH) and - April 28, 2025 (Monday): 2.36 hrs. (CNA DCSH). On May 5, 2025, at 2:27 p.m., during an interview with the DSD, the DSD stated normally there should be seven CNAs and one Restorative Nurse Assistant (RNA) on the day (AM - 6:30 a.m. to 2:30 p.m.) shift, six CNAs on the PM (2:30 p.m. to 10:30 p.m.) shift and four CNAs on the Night (NOC - 10:30 p.m. to 6:30 a.m.). A concurrent record review and interview with the DSD of the Nursing Staffing Assignment and Sign-In Sheet, for the mentioned dates indicated CNA staffing was not met according to Facility Assessment Projections. Facility CNA staffing was less than projected number per shift on the following dates: - March 1, 2025 (Saturday): AM shift - 6 CNAs (9 residents each); PM shift 5 CNAs (11 residents each); - March 3, 2025 (Monday): AM shift - PM shift 5 CNAs (11 residents each); - March 5, 2025 (Wednesday): AM shift - 6 CNAs (9 residents each); - March 10, 2025 (Monday): PM shift 5 CNA's (11 residents each); - March 16, 2025 (Sunday): PM shift 4 CNAs (14 residents each); - March 17, 2025 (Monday): AM shift 6 CNAs (9 residents each); PM shift 5 CNAs (11 residents each); - March 18, 2025 (Sunday): AM shift 6 CNAs (9 residents each); NOC shift 3 CNAs (18 residents each); - March 21, 2025 (Friday): AM shift 6 CNAs (10 residents each); - March 22, 2025 (Saturday): PM shift 5 CNAs (11 residents each); - March 24, 2025 (Monday): AM shift 6 CNAs (10 residents each); PM shift 4 CNAs (14 residents each); - March 29, 2025 (Saturday): AM shift 5 CNAs (11 residents each); PM shift 5 CNAs- 11 residents each; - March 30, 2025 (Sunday): AM shift 7 CNAs -8 residents each; PM shift 5 CNAs- 11 residents each; NOC shift 4 CNAs -14 residents each and - March 31, 2025 (Sunday): AM shift 6 CNAs (9 residents each); PM shift 5 CNAs (11 residents each); - April 5, 2025 (Saturday): AM shift 5 CNAs (11 residents each); PM shift 5 CNAs (11 residents each); NOC shift 3 CNAs (18 residents each); - April 6, 2025 (Sunday): AM shift 5 CNAs (11 residents each); - April 7, 2025 (Monday): AM shift 6 CNAs (9 residents each); PM shift 5 CNAs (11residents each); - April 9, 2025 (Wednesday): PM shift 5 CNAs (11 residents each); - April 11, 2025 (Friday): AM shift 6 CNAs (9 residents each); PM shift 5 CNAs (11 residents each); - April 12, 2025 (Saturday): AM shift 6 CNAs (9 residents each); PM shift 5 CNAs (11 residents each); - April 13, 2025 (Sunday): AM shift 6 CNAs (9 residents each); - April 15, 2025 (Tuesday): AM shift 6 CNAs (9 residents each; PM shift 5 CNAs (11 residents each); - April 19, 2025 (Saturday): AM shift 6 CNAs (9 residents each); PM shift 4 CNAs (13 residents each); NOC shift 3 CNAs (17 residents each). - April 20, 2025 (Sunday): PM shift 5 CNAs (10 residents each); NOC shift 3 CNAs (17 residents each); and - April 28, 2025 (Monday): AM shift 6 CNAs (9 residents each); PM shift 5 CNAs (10 residents each); NOC shift 3 CNAs (13 residents each). The facility did not meet the expected assigned number of staffing ratio for CNA's as indicated in the Facility Assessment Projections, for staff ratio on the following dates: - March 18, 2025 (Sunday): NOC shift 3 CNAs -18 residents - April 5, 2025 (Saturday): NOC shift 3 CNAs -18 residents each. - April 19, 2025 (Saturday): NOC shift 3 CNAs -17 residents each. - April 20, 2025 (Sunday): NOC shift 3 CNAs -17 residents each and - April 28, 2025 (Monday): NOC shift 3 CNAs -13 residents each. On May 2, 2025, at 3:01 p.m. during an interview with the DSD, the DSD stated it was hard for 3 CNAs to cover 17 residents on a shift where indicated. The DSD stated the Actual Total CNA Direct Care Service Hours were not met on documented dates reviewed. The DSD also stated it was not enough CNAs to provide residents safe, efficient, and adequate care. The DSD stated it was a higher risk for resident falls and residents not getting help to the restrooms. The DSD also stated low staffing affects resident falls and she was working on staffing for the NOC shift. The DSD stated her expectation was to meet the correct number of staffing to provide adequate care for residents to meet their needs. The DSD further stated based on the numbers outlined staffing care was not adequate and she addressed the concern with administration. On May 2, 2025, at 6:22 p.m. during a concurrent interview and record review with the Director of Nursing (DON), the DON stated call lights should be answered. The DON stated all staff were responsible for answering the call lights. The DON stated the concern was a potential for falls and her expectation was that staff answer call lights timely. The DON further stated the Actual Total CNA Direct Are Service Hours were not met on documented dates reviewed and should be 2.4 hours and above. The DON also stated not having the required hours met, meant less staff available to provide care. The DON stated with delays care could be affected. The DON further stated some possible concerns were impaired skin integrity if residents were left soiled in urine and a potential for falls. The DON stated her expectation was staff provide adequate care. The DON stated based on the dates reviewed the facility was not able to meet the required DHPPD hours for the CNAs. A review of the facility's policy and procedure titled, Certified Nursing Assistant, indicated, .The primary purpose of this position is to provide residents with routine daily nursing care and services in accordance with the resident's assessment and care plan and as directed by supervisor .Assist residents in accordance to their needs ranging from minimal assistance to total dependent care on activities of daily living (ADLs). A review of the facility's policy and procedure titled, Staffing, dated October 2017, indicated, .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all resident in accordance with resident care plans and the facility assessment . A review of the facility's policy and procedure titled, Answering the Call Light, dated September 2022, indicated, .The purpose of this procedure is to ensure timely responses to the resident's requests ans needs .Answer the resident call system immediately .If the resident needs assistance, indicate the approcimate time it will take for you to respond .

Based on observation, interview, and record review, the facility failed to store, prepare, and serve foods under safe and sanitary conditions when the staff placed a four-ounce (unit of measurement) soup ladle directly on the table instead of the clean container in between serving of the soup for the residents, for . This failure had the potential to put the vulnerable residents at risk for foodborne illnesses. Findings: On April 29, 2025, at 12:15 p.m., during the dining room observation, the Certified Restorative Nurse Assistant (CRNA) was observed to use the four-ounce ladle to serve soup into a bowl and then placed the ladle on the tablecloth instead of the clean container. On April 29, 2025, at 12:25 p.m., an interview with the CRNA was conducted. The CRNA stated she placed the ladle on the tablecloth in between serving of the soup to the residents. The CRNA stated she had been trained to place the used soup ladle on the clean tray. The CRNA further stated she should not have placed the ladle on the tablecloth as it might cause cross-contamination and illness in the residents. On April 29, 2025, at 12:55 p.m., an interview with the Director of Food and Dietary (DND) was conducted. The DND stated the CRNA had been trained in how to serve the crockpot soup of the day by the DND and the ladle should not have been placed on the table in between serving residents. The DND further stated the concern of illness for residents from the risk of cross-contamination was possible.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Two used diapers were found on top of resident cabinet drawer in room [ROOM NUMBER]; 2. One direct care staff was observed wearing long artificial finger nails while providing care to the residents; 3. The Certified Restorative Nursing Assistant (CRNA) did not wear personal protective equipment (PPE- equipment used to protect against infection or illness) when providing care to a resident with an active of Methicillin-Resistant Staphylococcus Aureus (MRSA - a bacteria resistant to many antibiotics [medication used to treat infections]) wound infection; 4. The CRNA did not clean and disinfect (use of chemicals to reduce the number of germs or virus particles on surfaces) the Hoyer lift (mechanical device use for lifting) after resident use; 5. The CRNA did not conduct proper handwashing after providing care to a resident with active infections of MRSA of the wound; and 6. The Certified Nursing Assistant (CNA) was observed not wearing a mask during resident care while exhibiting cold symptoms. These failures had the potential to increase the spread of pathogens (germs) and infections from staff to residents which could lead to serious illness. Findings: 1. On April 29, 2025, at 9:38 a.m., during a concurrent observation and interview with Licensed Vocational Nurse (LVN) 3, two used white diapers were found on top of the resident cabinet drawer in room [ROOM NUMBER]. LVN 3 stated used diapers should have been tossed into the trash bin and should have not been placed on top of the resident's cabinet drawer. LVN 3 further stated soiled diapers would contaminate the surface of the cabinet and would cause spread of germs and infection. On May 1, 2025, at 2:58 p.m., an interview was conducted with the Infection Preventionist (IP). The IP stated all soiled materials such as diapers should have been placed in the trash bins. The IP stated soiled diapers would contaminate the surface and would spread infections. On May 1, 2025, at 4:53 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated she expected all nurses to follow the facility's policy and procedure for infection control program. The DON stated soiled materials such as diapers should have been discarded to prevent contamination and spread of infections. A review of the facility's policy and procedure titled, Infection Prevention and Control Program, dated October 2018, indicated, .An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . 2. On April 29, 2025, at 10:57 a.m., an observation was conducted with the Director of Staff Development (DSD). The DSD was observed to have long artificial nails when providing care to the residents. On April 29, 2025, at 11:35 a.m., an interview was conducted with the DSD. The DSD stated she was involved in the care of residents and I am considered as direct care staff handling residents. The DSD stated she was capable of helping residents in their care, passing food trays in residents' rooms, oral care, and helping to feed residents. The DSD stated that she had artificial nails made of acrylic, that were attached and extended to her natural fingernails (DSD's finger nails were measured to be approximately 1.8 centimeter in length from the tip of the fingers). The DSD further stated long artificial nails should have not been worn because it could harbor germs underneath the artificial nails and would spread germs and infection. On May 1, 2025, at 2:58 p.m., an interview was conducted with the IP. The IP stated the facility's policy indicated nails must have appropriate length, and the nails should not be too long specially for direct care staff. The IP further stated if staff had long nails, these could potentially scratch the skin of the residents, which could lead to skin breakdown and cause infection. According to the web article titled, Guideline for Hand Hygiene in Health-care Settings published by the Centers for Disease Control and Prevention (CDC - a leading national public health institute in the United States), dated 2002, iindicated, .even after careful handwashing, HCWs (health care workers) often harbor substantial numbers of potential pathogens (disease causing viruses, fungi, and bacteria) in the subungual (under the nails) spaces .HCWs who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than those who have natural nails, both before and after handwashing . According to the web article titled, WHO (World Health Organization) Guidelines on Hand Hygiene in Health Care, published by the World Health Organization in 2009, indicated .Long, sharp fingernails, either natural or artificial, can puncture gloves easily .Each health-care facility should develop policies on the wearing of .artificial fingernails or nail polish by HCWs. These policies should take into account the risks of transmission of infection to patients .recommendations are that HCWs do not wear artificial fingernails or extenders when having direct contact with patients . A review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, dated August 2019, indicated, .Wearing artificial fingernails is strongly discouraged among staff members with direct resident-care responsibilities, and is prohibited among those caring for severely ill or immunocompromised residents .The Infection Preventionist maintains the right to request the removal of artificial fingernails at any time if he or she determines that they present an unusual infection control risk . 3. On April 30, 2025, at 9:20 a.m., Resident 33's room was observed to have a sign by the door indicating instructions to wear appropriate PPE (gown and gloves) before entering the room. The CRNA was observed entering Resident 33's room and provided care to the resident who was in the bathroom without wearing a gown. In a concurrent interview with the CRNA, she stated she forgot to wear PPE. The CRNA further stated she should have worn PPE when she provided care to Resident 33 to prevent the spread of germs and protect the other residents from infection. A review of Resident 33's Order Summary, indicated the following: - .Isolation with .CONTACT precautions related to MRSA/WOUND . date ordered April 28, 2025; and - .EBP .Enhanced Barrier Precautions due to (High contact resident care activities with colonized or infected MDRO (multidrug-resistant organisms), increased risk of MDRO acquisition due to presence of wounds or indwelling medical devices ., date ordered April 29, 2025. On May 1, 2025, at 3:06 p.m., during an interview with the IP, the IP stated Resident 33 had a history of MDRO and had active infection of the wound and was placed on enhanced barrier precaution. The IP further stated the CRNA should have worn PPE before providing care to Resident 33 to prevent the spread of infection to other residents. A review of the facility's policy and procedure titled, Personal Protective Equipment, dated October 2018, indicated, .Personal protective equipment appropriate to specific task requirements is available at all times .The type of PPE required for a task is based on .The type of transmission-based precaution . A review of the facility's policy and procedure titled, Enhanced Barrier Precautions, dated June 2024, indicated, .To provide guidance and recommendations for implementing Enhanced Barrier Precautions (EBP) to include the use of glove and gown during high-contact care activities for residents .High-Contact Resident Care Activities include activities such as .Changing briefs or assisting with toileting . 4. On April 30, 2025, at 9:27 a.m., during a concurrent observation and interview with the CRNA, the CRNA was observed coming out of Resident 33's room with the Hoyer lift. The CRNA used the Hoyer lift to transfer Resident 33 to her bed. The CRNA transported the Hoyer lift into the facility hallway then parked the Hoyer lift to the corner of the facility's dining room and did not clean or disinfect the Hoyer lift. The CRNA further stated, I forgot to disinfect the Hoyer lift, and she should have cleaned and disinfected the Hoyer lift to prevent the spread of infection to other residents who will use it. On May 1, 2025, at 3:06 p.m., during an interview with the IP, the IP stated Resident 33 was on enhanced barrier precaution for MRSA of the wound. The IP stated the CRNA should have disinfected or sanitized all medical equipment such as the Hoyer lift before and after use between residents. A review of the facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated October 2018, indicated, .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA (occupational safety and health administration) Bloodborne Pathogens Standard . 5. On April 30, 2025, at 9:35 a.m., during concurrent observation and interview with the CRNA, the CRNA was observed providing care in the bathroom to Resident 33 and did not perform hand hygiene after care. The CRNA stated, I forgot to wash my hands. The CRNA further stated she should wash her hands after providing care to the residents to prevent the spread of infection. On May 1, 2025, at 3:06 p.m., the IP was interviewed. The IP stated, staff should wash their hands before and after providing care procedure. The IP further stated infection could spread if staff did not wash hands. A review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, dated August 2019, indicated, .This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 49113 6. On April 29, 2025, at 3:23 p.m., during an observation, Resident 5 was observed lying in a geri-chair (geriatric chair - a specialized cushioned and reclineable chair) being assisted to her room by CNA 5 . CNA 5 was observed sniffling (drawing air through nose to keep mucus from running) with a runny nose and was not wearing a mask. A review of Resident 5's record indicated, Resident 5 was admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (lung diseases that block airflow makes it difficult to breathe) and diabetes mellitus (too much sugar in the blood). A review of Resident 5's History and Physical, dated November 25, 2024, indicated Resident 5 was dependent on supplemental oxygen. A review of Resident 5's Minimum Data Set (MDS- assessment tool), indicated Resident 5 had a BIMS (Brief Interview for Mental Status) score of 10 (moderate cognitive impairment). On April 29, 2025, at 3:29 p.m., during a concurrent observation and interview with CNA 5, CNA 5 was observed to be sniffling with a runny nose. CNA 5 stated she started feeling sick about 1 1/2 hours ago. CNA 5 stated she did not report to her supervisor she was ill. CNA 5 stated she should have put on a mask while providing care to the residents. CNA 5 further stated she could possibly get the residents sick and that was critical for the vulnerable residents. On April 30, 2025, at 4:01 p.m., during an interview with the Director of Staff Development (DSD), the DSD stated if staff become sick while on duty, they should notify DSD, their direct Charge Nurse (CN) or the Infection Preventionist (IP) so symptoms could be verified. The DSD stated staff would be sent home if they are sick. The DSD stated staff should not have worked sick without using a mask. The DSD also stated the risk of staff working while sick was the possibility to expose and spread infection to residents and other staff. The DSD further stated there was a high risk of vulnerable residents to further decline. On April 30, 2025, at 4:17 p.m., during an interview with the DON, the DON stated the facility process was staff should let the IP and immediate supervisor know they were sick. The DON stated if staff was exhibiting symptoms of a runny nose and sniffling staff should have worn a mask. The DON stated if staff report they are ill with a runny nose and still worked they should wear a mask. The DON also stated symptoms should be contained to protect others. The DON further stated the concerns of staff not wearing a mask was the possibility of spreading infection or worse to others. A review of the facility's policy and procedure titled, Employee Infection and Vaccination Status, revised August 2013, indicated, .Reportable Conditions .Employees must report the following conditions to the Infection Preventionist (or designee) .Acute Respiratory Infection (URI) or influenza .The Medical Director and Infection Preventionist will collaborate to determine the significance of any employee health condition in relation to job responsibility and the employees' restrictions regarding direct resident contact .

Based on observation, interview, and record review, the facility failed to provide a safe, functional and comfortable environment, when the lint trap of dryer 3 was observed damaged and the lint trap was not cleaned. This failure to maintain a functional environment had the potential to compromise resident safety. Findings: On May 2, 2025, at 9:24 a.m., during a concurrent observation and interview with the Laundry Staff (LS). The lint trap located at the bottom of dryer 3 was observed damaged with an opening at the corner towards the middle of the edge of the screen and filled with thick, soft lint that was collected from the clothes. The LS stated lint trap in dryer 3 was damaged and laundry staff still used it. The LS stated the lint trap was not collected since yesterday and was not cleaned by the laundry staff. The LS further stated the lint trap should have been cleaned and the damaged lint trap of dryer number 3 should have not been used because it could result to fire. A review of record titled, DRYER'S LINT TRAP CLEANING LOG, indicated the lint trap was not cleaned at 12 noon of May 1, 2025 to May 2, 2025 at 8 a.m. In addition, a review of document titled, DAILY STAND UP/CLINICAL MEETING, dated April 28, 2025, indicated the dryer 3 was identified with safety concerns. On May 2, 2025, at 9:45 a.m., an interview was conducted with the Maintenance Supervisor (MS). The MS stated the lint trap of dryer 3 was torn with the screen was ripped off. The MS stated the lint trap 3 should have been fixed, replaced and should have been cleaned per facility policy to prevent hazards such as fire. The MS further stated, It should have been repaired or replaced as soon as possible. On May 2, 2025, at 9:49 a.m., an interview was conducted with the Administrator (ADM). The ADM stated he expected the maintenance staff to repair any damaged equipment and make sure they worked properly. The ADM further stated the damaged equipment should have been replaced or repaired to provide a safe and functional environment for the residents. A review of the facility's policy and procedure titled, Maintenance Service, dated December 2009, indicated, .Maintenance service shall be provided to all areas of the building, grounds, and equipment .The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .Functions of maintenance personnel include .Maintaining the building in a compliance with current federal, state, and local laws, regulations, and guidelines .Maintaining the building in good repair and free from hazards .

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan to address the contractures (shortening and hardening of muscles) of the feet, for one of two residents, (Resident 10). This failure had the potential for Resident 10 not to receive the appropriate interventions tailored to her needs and further worsening of the contractures of the feet. Findings: On April 29, 2025, at 9:37 a.m., during the initial tour of the facility, Resident 10 was observed laying on her bed in her room with both ankles extended in a downward position with no adaptive devices on her feet. Resident 10 was not able to flex both ankles upward. On April 30, 2025, at 9:41 a.m., during an interview with Certified Nursing Assistant (CNA) 2, she stated Resident 10 had the foot drop for a long time already. CNA 2 stated they only put heel pads to protect her from skin breakdown. On May 1, 2025, Resident 10's record was reviewed. Resident 10 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (disrupted blood flow to the brain). A review of Resident 10's History and Physical, dated December 17, 2023, indicated Resident 10 can make needs known but could not make medical decisions. A review of Resident 10's Progress Notes, from a physician's follow up appointment, dated August 26, 2024, indicated Resident 10 had a contractures of the feet. A review of Resident 10's Minimum Data Set (MDS - a tool for assessment), dated February 10, 2025, indicated Resident 10 had impairment on both sides of lower extremities (part of the body that includes hip, knee, ankle, foot). A review of Resident 10's REHAB: JOINT MOBILITY ASSESSMENT (assessment tool evaluating the range and quality of movement at a joint), dated February 11, 2025, indicated Resident 10 had severe joint immobility condition for both ankles. There was no documented evidence a care plan was initiated to address Resident 10's contractures of both feet. On April 30, 2025, at 3:47 p.m., during a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 10 had history of stroke and had contractures on both feet. LVN 1 stated Resident 10 had no care plan to address contractures. LVN 1 further stated care plan should have been initiated to prevent worsening of the contractures. On April 30, 2025, at 4:33 p.m., during a concurrent interview and record review with the Director of Nursing (DON). The DON stated there was no care plan initiated or in placed to manage the contractures of the feet for Resident 10. The DON stated a care plan should have been initiated or in placed to manage the contractures of Resident 10's feet. The DON further stated without a care plan, Resident 10 would not receive functional needs and services that maintain physical well-being. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person- Centered, dated December 2026, indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan will .Described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being .Aid in preventing or reducing decline in the resident's functional status and/or functional levels .Enhance the optimal functioning of the resident by focusing on a rehabilitative program . A review of the facility's policy and procedure titled, Resident Mobility and Range of Motion, dated July 2017, indicated, .The care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed .The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion .

Based on observation, interview, and record review, the facility failed to provide appropriate care and treatment to manage contractures, for one of one resident reviewed for range of motion (ROM-the full movement potential of a joint) (Resident 10). This failure had the potential for Resident 10 to have further worsening of the feet contractures and contribute to pain and discomfort. Findings: On April 30, 2025, at 9:47 a.m., Resident 10 was observed laying on her bed with both feet extended in a downward position. Resident 10 was wearing soft blue foam heel pads to cover the ankles. On April 30, 2025, at 9:41 a.m., during an interview with Certified Nursing Assistant (CNA) 2, she stated Resident 10 had the foot drop for a long time already. CNA 2 stated they only put heel pads to protect her from skin breakdown. On April 30, 2025, at 10:35 a.m., during an interview with Certified Restorative Nursing Assistant (CRNA) 1, CRNA 1 stated she would provide ROM exercises to the residents after she received the order from the licensed nurse or rehab staff. CRNA 1 stated there was no order for ROM exercises for Resident 10, so she did not provide any ROM treatment/exercises to the resident. CRNA 1 stated Resident 10 had contractures on her feet and should have been included in the list for RNA exercises. On April 30, 2025, Resident 10's record was reviewed. Resident 10 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (disrupted blood flow to the brain). A review of Resident 10's History and Physical, dated December 17, 2023, indicated Resident 10 can make needs known but cannot make medical decisions. A review of Resident 10's REHAB: JOINT MOBILITY ASSESSMENT (assessment tool evaluating the range and quality of movement at a joint), dated August 2, 2023, and February 11, 2025, indicated Resident 10 had severe joint immobility on both ankles. A review of Resident 10's Physical Therapy PT Discharge Summary, dated January 9, 2024, indicated, .Discharge Instructions .RNA program (program to restore care, helps patient to regain or maintain functional abilities) for ROM . A review of Resident 10's Progress Notes, from a physician's follow up appointment dated August 26, 2024, indicated Resident 10 had contracture on both feet. A review of Resident 10's Minimum Data Set (MDS - a tool for assessment), dated February 10, 2025, indicated Resident 10 had impairment on both sides of lower extremities (part of the body that includes hip, knee, ankle, foot). On April 30, 2025, at 3:47 p.m., during a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 10 had both feet contracted and were using a heel pad to protect the heels from skin breakdown. LVN 1 stated there was no indicated physician order that would maintain or prevent further contractures of Resident 10's feet. LVN 1 further stated Resident 10 should have been referred to the physical therapist for a device and a therapy program to prevent further contractures and to prevent foot drop. On April 30, 2025, at 4:33 p.m., during an interview with the Director of Nursing (DON), the DON stated she expected the nurses and the rehabilitation therapists to follow the facility's policy and procedure to address residents contractures. The DON further stated Resident 10 should have been placed in the contracture management program and should have received device that prevent further worsening of the contractures. On May 1, 2025, at 3:20 p.m., during an interview with the Physical Therapist (PT), the PT stated Resident 10 condition was called ankle dorsiflex contracture (joint was limited in its ability to bend upward) and the resident was not wearing a proper device to manage or maintain the structure of the joints. The PT stated Resident 10 should have been recommended to wear a device to maintain the proper alignment of the joints. The PT stated Resident 10 should have received the proper contracture management and should have been picked up for rehab therapy and continue RNA maintenance program to avoid further decline of joint contractures and possible foot drop. The PT further stated, She would be a good candidate. A review of the facility's policy and procedure titled, Resident Mobility and Range of Motion, dated July 2017, indicated, .Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM .Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility . A review of the facility's policy and procedure titled, Restorative Nursing Program, dated May 2023, indicated, .It is the policy to assist each and every resident to achieve the highest level of self-care possible. The concept of self-care is an integral part of the daily nursing care and includes at least the following .Proper positioning and body alignment .passive range of motion exercises .

Based on observation, interview, and record review, the facility failed to ensure a resident was free from unnecessary medications for one of five residents reviewed for unnecessary medications (Resident 19) when: 1.Quetiapine (medication used to treat mental illness characterized by disordered thinking, hallucination) was administered without implementing resident-centered non pharmacological interventions prior to administration of the medication; and 2. There was no attempt for gradual dose reduction (GDR - process of slowly and systematically decreasing the dosage of a medication, particularly psychotic medication) with the use of quetiapine. These failures had the potential to result in ineffective behavior management for Resident 19 which increased the potential for unidentified risks associated with the use of medication such as sedation, respiratory depression, and memory loss. Findings: On May 1, 2025, at 12:40 a.m., during a concurrent observation and interview with a Certified Nursing Assistant (CNA) 4, Resident 19 was observed to be sleepy and slow to respond while CNA 4 was feeding the resident. CNA 4 stated Resident 9 did not exhibit any disruptive behaviors while care was being provided to the resident. On May 1, 2025, Resident 19's record was reviewed. Resident 19 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) and psychosis (a mental disorder characterized by a disconnection from reality). A review of Resident 19's History and Physical, dated April 3, 2024, indicated Resident 19 was mentally incapable of understanding. A review of Resident 19's Nurses Note, dated April 2, 2024, indicated, .Resident noted with saying I go repeatedly, tearful at times . A review of Resident 19's IDT NOTES, dated April 17, 2024, indicated, .Continued episodes of saying/raising her voice saying, I go, I go home continued . A review of Resident 19's, Order Summary Report, dated April 25, 2024, indicated, .Quetiapine Fumarate Tablet 25 MG (milligram - unit of measurement) Give 1 tablet by mouth two times a day for PSYCHOSIS MANIFESTED BY VISUAL HALLUCINATION (a perception of having seen, heard, touched, tasted, or smelled something that was not actually there) . A review of Resident 19's Minimum Data Set (MDS - a tool for assessment), dated February 10, 2025, indicated Resident 19 had a BIMS (Brief Interview for Mental Status - a tool used to assess cognition) score of 02 which indicated severe cognitive impairment. Further review of Resident 19's record indicated there was no documented evidence in Resident 19's medical record non-pharmacological interventions were implemented prior to initiating quetiapine. A review of Resident 19's MDS Section E- Behavior-indicators for psychosis, indicated the following: - September 3, 2024, no indications of hallucinations; - November 22, 2024, no indications of hallucinations; and - February 10, 2025, no indications of hallucinations. A review of Resident 19's Medication Administration Record (MAR), indicated episodes of visual hallucination as follows: - January 2025; no behavior of visual hallucination; - February 2025; no behavior of visual hallucination; - March 2025; 14 episodes of visual hallucination; and - April 2025; three episodes of visual hallucination. A review of Resident 19's Medication Regimen Review, dated January 7, 2025, indicated, .This resident continues on Seroquel 25 mg BID (twice a day) from 4/25/2024 (April 25, 2024). The Federal nursing facility require that a gradual dose reduction (GDR) be attempted in two separate quarters . Further review of Resident 19's record indicated there was no gradual dose reduction attempted after the pharmacy consultant recommended GDR related to the use of quetiapine. On May 1, 2025, at 12:50 p.m., during a concurrent interview and record review with the MDS Nurse (MDSN), the MDSN stated, MDS behavior assessment indicated there were no hallucinations on September 3, 2024, November 22, 2024, and February 10, 2025. The MDSN stated the behavior monitoring in Resident 19's MAR indicated there were no manifestations of visual hallucination for the months of January 2025 and February 2025. The MDSN further stated, The GDR should have been attempted. On May 1, 2025, at 1 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 5. LVN 5 stated she had taken cared of Resident 19 and had not observed Resident 19 to have disruptive behavior. LVN 5 stated, .she is quiet lady and sleeps most of the time . On May 1, 2025, at 1:10 p.m., an interview was conducted with LVN 2. LVN 2 stated Resident 19 was receiving quetiapine since she was admitted for psychosis manifested by visual hallucination, and she did not had a behavior of visual hallucination. On May 1, 2025, at 1:20 p.m., during a concurrent interview and record review with Registered Nurse (RN) 1, RN 1 stated Resident 19 had no disruptive behavior such as visual hallucination that could affect herself and other residents. RN 1 stated there was no evidence of non-pharmacological intervention implemented prior to quetiapine medication administration. RN 1 stated non-pharmacologic intervention should have been implemented prior to administration of any psychotropic medications. RN 1 further stated if non-pharmacologic intervention was not attempted, medication would be inappropriate and could place Resident 19 at risks of sedation and respiratory depression. On May 1, 2025, at 4:16 p.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON stated she expected all nursing staff would follow the facility's policy and procedure of antipsychotic (medication to treat mental illness) medication use. The DON confirmed there was no documentation in Resident 19's medical record of non-pharmacological interventions implemented prior to the initiation or during the use of quetiapine and acknowledged there should have been. The DON stated that the visual hallucination was identified during admission and confirmed that there was no documentation in Resident 19's medical record of harm resulted from visual hallucination. The DON stated it was important to use antipsychotic medications as indicated to ensure residents were medicated properly and had clinical reasons to have continued the medication. The DON further stated, GDR should have been implemented. A review of the facility's policy and procedure titled, Medication Regimen Review (Monthly Report) Unnecessary Medications, dated August 2019, indicated, .Each resident must receive and the Facility must provide the necessary care and services to attain or maintain the highest practicable physical , mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care .Each resident's medication regimen must be free from unnecessary drugs .An unnecessary drug is any used .Without adequate indications for its use .The consultant pharmacist will identify medications that may be considered unnecessary .Residents who use anti-psychotic drugs receive gradual dose reductions, and behavioral interventions .in an effort to discontinue these drugs . A review of the facility's policy and procedure titled, Antipsychotic Medication Use, dated December 2016, indicated, .Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed .Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review .Diagnoses alone do not warrant the use of antipsychotic medication .antipsychotic medications will generally only be considered if the following conditions are also met .The behavioral symptoms present a danger to the resident or others .Behavioral interventions have been attempted and included in the plan of care .medications will not be used unless behavioral symptoms are .Not sufficiently relieved by non-pharmacological interventions .

Based on observation, interview, and record review, the facility failed to ensure resident's information was protected from unauthorized use, for one of five residents observed during medication administration (Resident 161), when the electronic health record of Resident 161 was left open and unattended by the licensed nurse. This failure had the potential for Resident 161's record to be disclosed to other people not authorized in the provision of care and treatment. Findings: On May 1, 2025, 08:06 a.m., during a medication pass observation with Licensed Vocational Nurse (LVN) 3, LVN 3 was observed to leave the computer open and unattended with Resident 161's resident information viewable to persons not directly related to the resident's care. Resident 161's record was reviewed. Resident 161's Admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included fracture (break) of left femur (thigh bone), difficulty walking, diabetes (too much sugar in the blood), and hypertension (high blood pressure). Resident 161's Minimum Data Set (MDS - a resident assessment tool), dated May 3, 2025, indicated Resident 161 had a BIMS (Brief Interview of Mental Status) score of 13 (cognitively intact). On May 1, 2025, at 2:35 p.m., during a concurrent interview and record review with LVN 3, LVN 3 acknowledged she left the computer open and unattended which was a Health Insurance Portability and Accountability Act (HIPPA - law to protect patient sensitive health information) violation. LVN 3 stated the facility's policy was for the staff to close or lock the computer monitor when leaving the medication cart. LVN 3 stated she should have closed her laptop. LVN 3 further stated there was a possibility resident information could get stolen, which violates the resident's privacy. On May 1, 2025, at 3:44 p.m., during an interview with the Director of Nursing (DON), the DON stated her expectation staff should lock their screen before going into a patient room. Stated the concern was a violation of HIPPA. The DON also stated resident information was risk and available to person who was not involved with Resident 161's care. The DON further stated the expectation was for the resident's personal information and health information to be maintained. A review of the facility's undated policy and procedure titled, HIPPA COMPLIANCE, indicated, .It is the intent of the facility to adhere to the Omnibus Health Insurance Portability and Accountability Act (HIPPA) Privacy, Security, Enforcement and Breach Notification Rules .It is our intent to assure that policies, procedures and practices are developed, implemented, staff trained breaches avoided and compliance monitored . A review of the facility's policy and procedure titled, Dignity, revised February 2021, indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being .and feelings of self-worth and self-esteem .Staff protect confidential clinical information .Staff promote, maintain and protect resident privacy, including bodily privacy .during treatment procedures .

Based on observation, interview, and record review, the facility failed to ensure, for one of one resident reviewed for dental (Resident 22), a dental consultation was provided for the resident. This failure had the potential to result in Resident 23 not receiving the dental services needed to maintain her highest practicable level of well-being. Findings: On April 29, 2025, at 4:07 p.m., Resident 22 was observed missing some upper and lower teeth. In a concurrent interview with Resident 22, he stated he could chew well, I don't have postiza (denture- artificial teeth), and had not seen the dentist. On May 1, 2025, Resident 22's record was reviewed. Resident 22 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty in swallowing). A review of Resident 22's Order Summary, included the following physician's order: - Dental Health Services as needed, date ordered July 3, 2021; and - .Dysphagia Mechanical Soft Texture (texture of food to make them easier to chew and swallow) ., date ordered February 5, 2025. A review of Resident 22's Dental Hygiene Progress notes, dated November 18, 2024, indicated Resident 22 had no dentures and was edentulous (no teeth). A review of Resident 22's Minimum Data Set (MDS - a resident assessment tool), dated May January 23, 2025, indicated Resident 22 had a BIMS (Brief Interview for Mental Status - a tool used to assess cognition) score of 05 which indicated severe cognitive impairment. On May 1, 2025, at 10:25 a.m., during a concurrent interview and record review with the Social Service Director (SSD), the SSD stated there was no documentation Resident 22 was seen by the dentist since last year. The SSD stated Resident 22 should have been seen by the dentist. The SSD further stated Resident 22 would not be able to eat properly and could lead to weight loss if Resident 22 would not provide dental services. On May 1, 2025, at 3:35 p.m., the Director of Nursing (DON) was interviewed. The DON stated she expected the nurses and SSD to follow facility's policy and procedure for dental services. The DON stated the resident should have been seen by the dentist. The DON further stated Resident 22 had the potential not to eat the food and could lead to weight loss if dental issues would not be addressed. A review of the facility's policy and procedure titled, Dental Services, dated December 2016, indicated, .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 .Social services representatives will assists residents with appointments, transportation arrangements .

Based on interview and record review, the facility failed to ensure Resident A was free from an act of verbal and physical abuse by a facility staff. Findings: On April 24, 2013, at 2:20 p.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding an alleged act of abuse involving Resident A. During an interview with the Administrator on April 24, 2013, at 2:25 p.m., he stated "On April 18, 2013, I was notified by ...(the DON- Director of Nurses) that a Certified Nursing Assistant J... (CNA 1) was witnessed slapping the resident on the butt and saying to the resident "Nice butt baby". The Administrator stated the incident was witnessed by two "...college students and CNA 2." A review of Resident A's record indicated the resident was a [AGE] year old female admitted on [DATE], with [DIAGNOSES REDACTED]. The facility document titled "history and physical examination [REDACTED]." An interview was conducted with the Director of Staff Development (DSD) on April 24, 2013, at 2:50 p.m., he stated that on April 17, 2013, at approximately 4 p.m., the instructor of the college students informed him that two students had witnessed CNA 1 "Spank the patient's (Resident A) buttock and made a comment "Nice a.. (actual word used) baby." The facility's investigative report indicated there was a written statement from Student 1. The undated statement indicated the following, "As I was holding the patient (Resident A) who was facing me and was on her side. ...(Student 2) was cleaning the patient who had her brief off and I had one hand on the patients back. The other hand was on her hip. ...(CNA 1) then stated " She has a nice butt" and then slapped the patients buttox. That made a loud slap sound and made the patient jerk, tense up , and tighten her hands... Then ...(CNA 1) upon slapping her buttock grabbed her buttock and squeezed it saying "Don't you baby". I noticed the patient getting tense, grinding her teeth ...(I) asked her are you ok?" On April 24, 2013, at 4:40 p.m., an interview was conducted with CNA 2. CNA 2 stated that she was "Partnered" with CNA 1 (to care for residents) "Cause I am new", on April 17, 2013. CNA 2 stated that around 2 p.m., she went into Resident A's room with two students and CNA 1. CNA 2 stated "We had the resident's diaper off and she was turned on her side. ...(CNA 1) came by and slapped the resident on her bare butt. The resident said "Ouch" so I knew that he hurt her. ....The next day I went and spoke to the DSD around 6 a.m. and told him what happened." During a review of CNA 1's personnel file on April 24, 2013, the document titled "Disciplinary Action Form" dated December 17, 2010, indicated "On December 15, 2010,...School Instructor (stated) 1 of her female students was not comfortable around (CNA 1) due to touching her on the hip..." CNA 1 was witnessed by two students and one CNA (CNA 2) slapping Resident A on the buttock. CNA 1 was heard by two students and one CNA (CNA 2) making the derogatory statements "Nice butt baby", and "Don't you baby" when referring to the resident's buttocks.