Every finding on record at Rock Point Nursing Center

Based on observation and interview, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 71.The facility did not provide a policy regarding dietary. 1. Observation on 03/17/26 at 9:50 A.M., 03/18/26 at 10:23 A.M., and 03/19/26 at 6:16 P.M., of the kitchen showed: - One compartment and three compartment sinks with the hot side water temperature at 106 degrees Fahrenheit after one minute;- One large metal cookie sheet with dark brown carbon build-up in the corners and one small cookie sheet with carbon build-up in the corners; - The commercial gas range oven with excessive black grime build-up on all interior surfaces and on the floor beneath; - One dented 3-quart can of spinach, dated received on 03/03/26;- One dented 50-ounce can of cream of mushroom condensed soup, dated received on 03/03/26;- The commercial dishwasher interior and exterior with flaky white grime (dirt ingrained on the surface of something) build-up and scattered debris on the floor beneath;- An approximate 2-inch (in.) x 4 in. uncovered hole in the wall near the dishwasher plumbing accessories;- An approximate 4 in. x 6 in. hole in the wall near the disposal area with a pink substance;- The floor, the plumbing pipes, and the electrical switch box below the corner dishwashing area counters with scattered debris, oily film, and brown grime build-up;- An approximate 2 in. x 6 in. non-intact wall section without a vinyl cove base near the dining room entrance;- An approximate 2 in. diameter non-intact wall section above the vinyl cove base near the closet door;- An approximate 8-foot (ft.) x 8 ft. section of the ceiling tiles and four plastic light fixture covers over the food preparation area counter and one-compartment sink with dust build up and a dark brown substance;- An approximate 3 ft. x 6 ft. and a 24 in. diameter ceiling diffuser (one of the few visible parts of an air conditioning system) with dust buildup and a brown substance on the front exterior surface and in between the ventilation louvers over the food preparation area counter and one-compartment sink;- A 6 in. diameter ceiling diffuser in the dry storage area with dust buildup and a brown substance on the front exterior surface and in between the ventilation louvers. During an interview on 03/19/26 at 6:16 P.M., the Dietary Manager said he/she expected there not to be dented cans left on the racks and normally she kept them from going on the metal storage rack. The kitchen should be clean and without food debris under appliances, shelves, and food counters. The ceiling tiles and vents should be clean; some of the staff attempted to clean the ceiling, but the tiles started to come apart. The water temperatures should be higher on the three-compartment sink and the middle sink, but they might be connected to a separate water heater. The dishwasher should be clean inside and out, the plumbing pipes below each counter should be clean, and the walls should be intact and easy to wipe with cleaner. During an interview on 03/19/26 at 7:18 P.M., the Administrator said the kitchen walls should be intact and easy to clean, the ceiling and vents should be clean, but there was an issue with the large vent. The oven and dishwasher should be clean. The floor should not have food crumbs or debris and there should not be grime or build up on the tiles or the plumbing pipes. She said the door had been replaced to the dining area and a baseboard was left off. There should not be dented cans in storage.

Based on interview and record review, the facility failed to refund resident funds within 30 days of when a resident expired for three residents (Residents #80, #81 and #82) out of three sampled residents. The facility census was 71.Review of the facility's policy titled, Accounting and Records of Resident Funds, revised [DATE], showed:- The facility maintains accounting records of resident funds on deposit with the facility;- Individual accounting ledgers are maintained in accordance with generally accepted accounting principles;- Inquiries concerning a resident's personal funds account record are referred to the Administrator or to the business office. 1. Review of Resident #80's closed medical record showed:- The resident expired on [DATE]. Review of the facility maintained Resident Trust Fund Ledger, dated [DATE], showed:- Resident #80 had $93.13 held in the resident trust fund account as of [DATE] (121 days late). 2. Review of Resident #81's closed medical record showed:- The resident expired on [DATE]. Review of the facility maintained Resident Trust Fund Ledger, dated [DATE], showed:- Resident #81 had $1,683.73 held in the resident trust fund account as of [DATE] (168 days late). 3. Review of Resident #82's closed medical record showed:- The resident expired on [DATE]. Review of the facility maintained Resident Trust Fund Ledger, dated [DATE], showed:- Resident #82 had $483.52 held in the resident trust fund account as of [DATE] (142 days late). During an interview on [DATE] at 3:32 P.M., the Business Office Manager (BOM) said he/she reviewed the resident trust ledger individual balances to make sure they were within the limit. If a resident expired, he/she was normally sent a notice from the funeral home about the expenses. Residents should have a final accounting of their personal funds. During an interview on [DATE] at 5:12 P.M., the Administrator said the resident trust ledger should be audited regularly to make sure no funds were left in the account for residents that expired in the facility. She said the facility should have submitted a Third-Party Liability (TPL - a form which is sent to Missouri (MO) Health Net which gives an accounting of the remaining balance of a resident's funds in the resident trust account for the expired residents.

Based on observation and interview, the facility failed to ensure a homelike environment was provided for the residents residing on the Men's Locked Behavior Unit which affected 12 residents with the potential to affect all 15 residents on the unit. The facility also failed to provide a safe, clean, and comfortable homelike environment which could have the potential to affect all residents in the facility. The facility census was 71. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed:- Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible;- Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences;- The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting including a clean, sanitary and orderly environment. 1. Observation on 03/17/26 at 12:05 P.M., of the Men's Locked Behavior Unit showed:- Staff wheeled a metal cart with the resident lunch trays into the dining area;- Staff removed the individual plastic food trays from the cart, placed the plastic food tray on the table in front of the 12 residents seated family style around the dining room table. 2. Observation on 03/18/26 at 7:21 A.M., of the Men's Locked Behavior Unit showed:- 10 residents were seated family style around the dining room table;- Each resident had a food tray with a plate, bowl, drinks, and silverware that sat on a plastic food tray in front of them;- Staff supervised while the residents fed themselves. During an interview on 03/19/26 at 2:43 P.M., Licensed Practical Nurse (LPN) A said he/she did not know for sure why the residents' food dishes were not removed from the plastic trays when the meals were served. He/She said this is just how things were done at the facility. During an interview on 03/19/26 at 2:05 PM, Certified Medication Technician (CMT) B said it was easier for the staff to serve food on the trays than to take the dishes off the trays. It helped keep the residents from trying to get someone else's food. During an interview on 03/19/26 at 2:07 P.M., LPN C said staff had always served food on the trays to the residents on the unit. The residents were territorial, and it helped define their boundaries. During an interview on 03/19/26 at 5:43 P.M., the Administrator said meals were served on trays on the Men's Locked Behavior Unit because it had been done like that for a while. She did believe that it minimized other residents from trying to take someone else's food that was on the table and some residents liked to use the tray to serve or remove their trays themselves. She said serving meals on trays did not create a homelike environment in the general population but would have to work with the unit since it was part of their structure. 3. Observations on 03/19/26 at 9:00 A.M., and 7:18 P.M., showed:- The A Hall assisted bathroom with a 4-foot (ft.) x 4 ft. ceiling diffuser (one of the few visible parts of an air conditioning system) hung unevenly with a 1-inch (in.) diameter corner section with a brown substance. 4. Observations on 03/19/26 at 9:00 A.M., and 7:18 P.M., showed:- The E Hall assisted bathroom toilet with a non-intact caulking seal near the base and floor joint;- A portable shower chair with an approximate 2 in. smeared brown substance. 5. Observations on 03/19/26 at 9:00 A.M., and 7:18 P.M., of Room A1 showed:- A 1 ft. x 2 ft. section of floor tiles with a dark grime build up;- Two pieces of approximately 2 ft. x 4 ft. ceiling tiles with a 1 ft. diameter brown substance above the resident bed and near the hall door;- The utility closet door with a non-intact surface near the floor gap approximately 3 ft. x 6 in. 6. Observations on 03/19/26 at 9:05 A.M., and 7:23 P.M., of Room A3 showed:- An unlocked utility closet with non-draining yellow water pooled about 6 in. deep above a 4 in. floor drain with miscellaneous facility supplies stored upon the shelving. During an interview on 03/19/26 at 7:18 P.M., the Administrator said there was a leak in the roof above Rooms A1 and A3 and the roofer would have to be called. Maintenance tried to fix the leak with a sealant, but it did not work. A dehumidifier was used to help dry out the closet in Room A1. She said the ceiling tiles should not be stained, and the door would be replaced. There should not be water standing in the closet of Room A3. The caulk should be around the toilet in the shower rooms, and the shower chairs should be cleaned. The tiles should be clean and not stained.

Based on interview and record review, the failed to provide an appropriate diagnosis for the use of an antipsychotic (medication to treat psychosis, a mental health condition characterized by delusions, hallucinations, and disorganized thinking) medication for two residents (Residents #9 and #16) and failed to attempt a gradual dose reduction (GDR) for an antipsychotic medication for one resident (Resident #16) out of five sampled residents. The facility census was 71. Review of the facility's policy Psychotropic Medication Use, revised 02/2025, showed:- An adequate indication for use refers to the identified, documented clinical rationale for administering medication that is based on: a. an assessment of the resident's condition and therapeutic goals;b. a determination that non-pharmacological interventions are clinically contraindicated;- Psychotropic (any medication that affects brain activity associated with mental processes and behavior) medication may be considered appropriate when: a. a resident's behavioral symptoms present a danger to the resident or others; b. a resident is exhibiting indications of distress that are significant to the resident;c. non-pharmacological approaches (if not clinically contraindicated) have been attempted, but did not relieve the medical symptoms which are presenting a danger or significant distress; and/ord. gradual dose reduction was attempted, but clinical symptoms returned;- The clinical rationale for the use of psychotropic medication, or a change from one type of psychotropic to another, is documented in the medical record;- Diagnosis alone does not necessarily warrant the use of psychotropic medication;- Residents on psychotropic medication receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated to determine whether the continued use of the medication is benefitting the resident, to find an optimal dose, or in an effort to discontinue the medication. 1. Review of Resident #9's medical record showed:- An admission date of 04/11/19;- Diagnoses of major depressive disorder (persistent sadness, loss of interest and low energy lasting at least two weeks) without psychotic features, unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with unspecified severity with other behavioral disturbance, unspecified dementia moderate with other behavioral disturbance;- An order for Zyprexa (an antipsychotic medication) 5 milligrams (mg) by mouth at bedtime for unspecified dementia unspecified severity with other behavioral disturbance, dated 12/01/25;- No documentation the consultant pharmacist or physician addressed the need for appropriate diagnoses for the Zyprexa. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/11/25, showed:- Severe cognitive impairment;- No hallucinations, delusions, behaviors, and rejection of care;- Received antipsychotic medication on a routine basis. Review of resident's comprehensive care plan, dated 03/13/26, showed:- Did not address specific problems, interventions, or goals for dementia care. Observations of the resident showed:- On 03/17/26 at 11:50 A.M., and 1:55 P.M., the resident lay in bed with his/her eyes closed; - On 03/18/26 at 3:00 P.M., the resident sat in his/her wheelchair in the common area near the nurse's station and leaned to the right side with his/her eyes closed. 2. Review of Resident #16's medical record showed:- An admission date of 07/23/25;- Diagnoses of unspecified dementia with unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; anxiety disorder; and sleep disorder;- An order for quetiapine (an antipsychotic medication) 25 mg by mouth at bedtime related to anxiety disorder and unspecified sleep disorder, dated 07/23/25;- No documentation the consultant pharmacist or physician addressed the need for appropriate diagnoses for the quetiapine;- No documentation of an attempted GDR. Review of the resident's quarterly MDS, dated [DATE], showed:- Severe cognitive impairment;- No hallucinations, delusions, behaviors, and rejection of care;- Received antipsychotic medication on a routine basis;- GDR not attempted and not documented as contraindicated. Review of the resident's comprehensive care plan, dated 02/03/26, showed:- Use of medication quetiapine related to anxiety and sleep disorder. Observations of the resident showed:- On 03/17/26 at 11:50 A.M., and 1:55 P.M., the resident lay in bed, with his/her eyes closed. During an interview on 03/19/26 at 6:10 P.M., the Director of Nursing (DON) and the Administrator said they would expect residents to have the correct diagnosis and attempted GDRs when appropriate for antipsychotic medications.

Based on interview and record review, the facility failed to provide the amount a bed would be held for on the bed hold policy upon transfer to the hospital and failed to include the statement of appeal rights or the name, address, or the telephone number of the Office of the State Long Term Care Ombudsmen (advocate for the resident in nursing facilities), the mailing and email address for the agency for protection and advocacy for residents with intellectual disabilities, and the mailing, email address, and telephone number for the agency for protection and advocacy for residents with mental illness, within the transfer and discharge notices for four residents (Residents #1,#3, #24, and #41) out of four sampled residents. The facility census was 71.Review of the facility's policy titled, Bed-Holds and Returns, revised October 2022, showed:- All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave);- Residents, regardless of payer source, are provided written notice about these policies at least twice, notice 1: well in advance of any transfer (e.g., in the admission packet); and notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours);- The written bed-hold notices provided to the residents/representatives explain in detail the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the facility; the reserve bed payment policy as indicated by the state plan (for Medicaid residents), the facility policy regarding bed-hold periods; the facility per-diem rate required to hold a bed (for non-Medicaid residents), or to hold a bed beyond the state bed-hold period (for Medicaid residents); and the facility return policy. Review of the facility's policy titled, Transfer or Discharge, revised March 2025, showed:- Once admitted to the facility, residents have the right to remain in the facility, transfers and discharges must meet specific criteria and require resident/representative notification, orientation, and documentation in the medical record;- When the facility transfers or discharges a resident, the following information is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider, the basis for the transfer or discharge, that an appropriate notice was provided to the resident and/or legal representative, the date and time of the transfer or discharge, the new location of the resident, the mode of transportation, a summary of the resident's overall medical, physical, and mental condition, disposition of personal effects, disposition of medications, others as appropriate or as necessary, and the signature of the person recording the data in the medical record;- If the basis for the transfer or discharge is that the transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility, the resident's physician (or provider) documents the specific resident needs that cannot be met, the facility's attempt to meet those needs, and the receiving facility's service(s) that are available to meet those needs;- Residents have the right to appeal a transfer or discharge through the state agency that handles appeals;- Upon notice of transfer or discharge, the resident is provided with a statement of his/her right to appeal the transfer or discharge, including the name, address, email, and telephone number of the entity which receives such requests, information about how to obtain, complete, and submit an appeal form, how to get assistance completing the appeal process; and the facility bed-hold policy. 1. Review of Resident #1's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE] and returned on 11/06/25;- Transferred to the hospital on [DATE] and returned on 11/26/25;- Transferred to the hospital on [DATE] and returned on 12/17/25;- Transferred to the hospital on [DATE] and returned on 12/28/25. Review of the resident's Notice of Resident Transfer/Discharge and Bed Hold and Return Notification forms, dated 11/03/25 and 12/08/25, showed:- No documentation of the daily bed-hold rate;- No documentation of the appeal agency contact information, the Ombudsmen contact information, the agency contact information responsible for protection and advocacy of individuals with developmental disabilities, and the contact information for the agency for protection and advocacy of individuals with a mental disorder. Review of the resident's Notice of Resident Transfer/Discharge and Bed Hold and Return Notification forms, dated 11/16/25 and 12/28/25, showed:- No selected bed-hold preference;- No documentation of the daily bed-hold rate;- No documentation of the appeal agency contact information, the Ombudsmen contact information, the agency contact information responsible for protection and advocacy of individuals with developmental disabilities, and the contact information for the agency for protection and advocacy of individuals with a mental disorder. 2. Review of Resident #3's medical record showed:- admitted on [DATE];- Transferred to the hospital on 1/22/26 and returned to the facility on [DATE]. Review of the resident's Transfer/Discharge and Bed Hold forms, dated 01/22/26, showed:- No selected bed-hold preference;- No documentation of the daily bed-hold rate;- No documentation of the appeal information, the Ombudsmen contact information, the agency contact information responsible for protection and advocacy of individuals with developmental disabilities, and the contact information for the agency for protection and advocacy of individuals with a mental disorder. 3. Review of Resident #24's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of the resident's Transfer/Discharge and Bed Hold forms, dated 12/22/26, showed:- No documentation of the daily bed-hold rate;- No documentation of the appeal information, the Ombudsmen contact information, the agency contact information responsible for protection and advocacy of individuals with developmental disabilities, and the contact information for the agency for protection and advocacy of individuals with a mental disorder. 4. Review of Resident #41's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE] and returned to the facility on [DATE];- Transferred to the hospital on [DATE] and returned to the facility on [DATE];- Transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of the resident's Transfer/Discharge and Bed Hold forms, dated 01/10/26, 03/05/26, and 03/11/26, showed:- No documentation of the daily bed-hold rate;- No documentation of appeal information, the Ombudsmen contact information, the agency contact information responsible for protection and advocacy of individuals with developmental disabilities, and the contact information for the agency for protection and advocacy of individuals with a mental disorder. During an interview on 03/19/26 at 2:43 P.M., Licensed Practical Nurse (LPN) A said they did the bed hold and transfer/discharge paperwork when a resident left the facility. The nurse sending out the resident was responsible to complete it. If it couldn't go out for some reason, then the Social Service Designee or the Administrator should be notified and they would assist. During an interview on 03/19/26 at 5:50 P.M., the Administrator said the facility staff should fill out all blanks on the bed hold and transfer/discharge paperwork to include the bed hold amount, the appeal information, the Ombudsmen contact information, the agency contact information responsible for protection and advocacy of individuals with developmental disability, and the contact information for the agency for protection and advocacy of individuals with a mental disorder.

Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for one resident (Resident #43) out of one sampled resident that included the instructions needed to provide effective and person-centered care to meet professional standards of quality care. The facility census was 73.Review of the facility's policy titled, Care Plans - Baseline, revised March 2022, showed:- A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission;- The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meets professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to initial goals based on admission orders, discussion with the resident/representative, and physician orders;- The baseline care plan is updated as needed to meet the resident's needs until the comprehensive care plan is developed;- Provision of the summary to the resident and/or resident representative is documented in the medical record. 1. Review of Resident #43's medical record showed:- admission date of 03/02/26:- No documentation of a baseline care plan;- The facility did not complete the resident's baseline care plan within 48 hours after admission to the facility and did not provide a summary to the resident and/or the resident representative. During an interview on 03/18/26 at 9:05 A.M., Licensed Practical Nurse (LPN) A said the nurse was responsible for completing the baseline care plan for new admissions. He/She did not complete a baseline care plan for Resident #43 upon his/her admission. During an interview on 03/18/26 at 12:15 P.M., the Minimum Data Set (MDS - part of a federally mandated process for clinical assessment of all residents in certified nursing homes) Coordinator said the charge nurse was responsible for completing the baseline care plan on admission and for Resident #43 it would have been LPN A. The baseline care plan should be in the front of the resident's hard chart; if it's not there, it should be under assessments in the electronic medical record. During an interview on 03/19/26 at 7:25 P.M., the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) said they would expect a resident to have a baseline care plan completed upon admission and within 48 hours with care areas addressed. The admitting nurse should complete the baseline care plan when the resident comes in as part of the admission packet and then the baseline care plan should be placed in the resident's hard chart upon completion.

Based on observation, interview, and record review, the facility failed to ensure placement of the urinary indwelling catheter (a tube inserted into the bladder to drain urine) drainage bag and tubing was maintained for two residents (Residents #1and #5) out of two sampled residents. The facility census was 71. Review of the facility's policy titled, Urinary Catheter Care, dated August 2022, showed:- The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections;- Be sure the catheter tubing and drainage bag are kept off the floor;- Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. 1. Review of Resident #1's medical record showed:- admitted on [DATE];- Diagnoses of neurogenic bladder (the bladder does not empty properly due to a neurological condition) and urinary tract infection. Review of the resident's Physician Order Sheet (POS), dated March 2026, showed:- An order to flush the suprapubic catheter (a sterile tube inserted into the bladder through the abdominal wall to drain urine) with 60 milliliters (ml) normal saline (salt water) as needed to prevent clots and for patency (open), dated 03/09/26;- An order to change the 16 French (Fr. - size of the catheter) with 10 ml balloon suprapubic catheter and bedside drainage bag every day shift starting on the 28th and ending on the 28th every month related to pressure ulcer (injury to the skin and/or the underlying tissue usually over a bony prominence, as a result of pressure or friction) of the right buttock, unstageable and pressure ulcer of sacral (triangular bone located above the tail bone) region, stage 4 (full thickness tissue loss with exposed bone, tendon or muscle; slough or eschar may be present on some parts of the wound bed. Often includes undermining or tunneling), dated 03/28/26;- An order for suprapubic catheter care every shift for prevention, dated 02/07/26. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/24/25, showed:- Used an indwelling catheter. Review of the resident's Care Plan, dated 03/17/26, showed:- Resident with an indwelling catheter;- Position the catheter bag and tubing below the level of the bladder, in a dignity bag;- Catheter care every shift. Observations of the resident showed:- On 03/18/26 at 6:33 A.M., and 12:35 P.M., and 03/19/26 at 7:40 A.M., the resident lay in a low bed and the catheter drainage bag hung on the bed frame where the bottom of the catheter drainage bag rested on the floor;- On 03/18/26 at 10:30 A.M., during wound care, the Assistant Director of Nursing (ADON) placed the catheter drainage bag on top of the mattress near the resident's right leg, turned the resident to the side, hung the catheter drainage bag on the bed frame, retrieved the catheter drainage bag, placed on top of the mattress and the urine flowed up towards the resident's bladder in the tubing, repositioned the resident, and returned the catheter drainage bag to the bed frame. 2.Review of Resident #5's medical record showed:- admitted on [DATE];- Diagnosis of neuromuscular dysfunction of the bladder (nerve damage from diseases or injuries that interrupts signals between the brain, spinal cord, and the bladder). Review of resident's POS, dated March 2026, showed:- An order to change the urinary catheter 18 Fr. 10 ml balloon and bag monthly on the 15th using sterile technique, dated 12/15/25;- An order to irrigate the urinary catheter with 30 ml normal saline as needed, dated 10/24/25;- An order for urinary catheter care every shift, dated 10/24/25. Review of the resident's quarterly MDS, dated [DATE], showed:- Used an indwelling catheter. Review of the resident's care plan, revised on 01/06/26, showed:- Resident with an indwelling catheter;- Position the catheter bag and tubing below the level of the bladder and away from the entrance room door. Observation of the resident showed:- On 03/18/26 at 9:30 A.M., the resident lay in bed with the catheter drainage bag covered with a dignity drape hung on the bed frame and the bottom of the catheter drainage bag rested on the floor;- On 03/18/26 at 9:40 A.M., the resident lay in bed. Certified Nursing Assistant (CNA) D and Nursing Assistant (NA) E picked up the catheter drainage bag covered with a dignity drape, raised it waist high above the resident's bladder, urine drained toward the insertion site, placed the catheter drainage bag on the foot of the bed, and rolled the resident side to side to put a Hoyer (a mechanical lift used to transfer residents from one position to another) sling under him/her. CNA D raised the resident up with the Hoyer lift and placed the catheter drainage bag into the resident's lap above the level of the bladder. NA E lowered the resident into his/her wheelchair. CNA D removed the catheter bag from the resident's lap and hooked it to the wheelchair below the resident's bladder. During an interview on 03/19/26 at 2:43 P.M., Licensed Practical Nurse (LPN) A said the catheter placement should be below a resident's bladder. The catheter drainage bag should be secured under the wheelchair or on the bed frame. The catheter drainage bag and tubing should not touch the floor and should never be above the waist or the bladder. The catheter drainage bag should not be placed directly on top of the mattress. During an interview 03/19/26 at 3:07 P.M., CNA B said catheter drainage bags should not be raised above the bladder because the urine would backflow towards the bladder. The catheter drainage bags shouldn't touch the floor although it was hard sometimes when the beds were in a low position. Cather drainage bags shouldn't be placed on the bed, but it was done with some because otherwise it would tug the catheter while moving the resident. During an interview on 03/19/26 at 3:15 P.M., Nursing Assistant (NA) C said catheter drainage bags shouldn't touch the floor or go above the resident's bladder. Catheter drainage bags shouldn't be placed on the beds but sometimes it had to be done. During an interview on 03/19/26 at 3:24 P.M., CNA D said catheter drainage bags shouldn't touch the floor or go above the resident's bladder. The catheter drainage bags should always be at a downward angle and hung in a dignity bag. During an interview on 03/19/26 at 3:32 P.M., CNA E said catheter bags shouldn't touch the floor and should always be below the bladder so the urine could flow away from the bladder. During an interview on 03/19/26 at 5:09 P.M., the Director of Nursing (DON) and the ADON said catheter drainage bag placement should be below the bladder and not touch the floor. The catheter bag should also be in a dignity bag. The DON said the catheter drainage bag shouldn't be placed in bed with the resident. The ADON said the bag should be moved from one side to another as the resident was being turned. During an interview on 03/19/26 at 5:43 P.M., the Administrator said she would expect staff to follow policy and procedure for catheter placement ensuring it didn't touch the floor or was above the resident's bladder.

Based on observation, interview, and record review, the facility failed to ensure training was provided, competence was assessed, and a physician's order was received for laryngectomy tube ([NAME] tube - a flexible silicone tube inserted into the stoma (neck opening) to maintain the airway opening) care to be completed independently, and the type and size of the [NAME] tube supplies, and to have all of the needed [NAME] tube supplies easily accessible for one resident (Resident #5) out of one sampled resident with a [NAME] tube. The facility also failed to follow the physician's order for supplemental oxygen therapy and to change, date, and store the oxygen tubing (flexible tubing that delivers supplemental oxygen through the nostrils) and the nebulizer (a medical device that converts liquid medication into a mist to be inhaled directly into the lungs) tubing for one resident (Resident #43) out of two sampled residents. The facility census was 71.The facility did not provide a policy regarding oxygen tubing and humidification. Review of the facility's procedure titled, Laryngectomy Tube Care, dated 09/2013, showed:- Good hand washing habits are important;- Clean the stoma before changing the straps;- You may use water soluble lubricant around the stoma to moisten the crusting. If there are crusted areas inside the stoma, you may spray two squirts of normal saline (salt water) into the stoma to moisten, cough and expel the plugs. Always wash hands before and after doing stoma and [NAME] tube care;- To clean the [NAME] tube, do it regularly and is usually done two or three times a day. Do not use hydrogen peroxide, rubbing alcohol, or chemical to clean the tube;- Changing the strap should be done when it becomes dirty. Remove the tube to replace the straps;- Suctioning (the use of a catheter attached to a machine to suction airway) the trachea: Before suctioning, check to make sure the airway isn't blocked with mucus. Wash hands, and fill a bowl with water, turn the machine on (setting no higher than 120 millimeters of mercury (mm Hg), remove the suction catheter from the wrapper and attach to the suction catheter, dip loose tip into the water, put a thumb on the port and suck up some water, release the thumb from the port, put saline mist in stoma, take a few deep breaths and gently insert moist catheter five to eight inches into trachea until resistance, cover and uncover catheter suction port with thumb and slowly take catheter out of trachea, no longer than 10 seconds, put catheter tip in water to clean suction, turn off machine and disconnect tubing, throw disposable catheter away, if using reusable sterilize;- Did not address the facility would ensure a resident providing self-[NAME] tube care, including suctioning, was trained and competent according to professional standards of practice. 1. Review of Resident #5's medical record showed:- admission date of 10/16/25;- Diagnoses of tracheostomy (trach - an incision in the windpipe to relieve an obstruction for breathing) status, malignant neoplasm (cancer) of the supraglottis (the upper portion of the larynx (voice box) located above the true vocal cords), and paraplegia (impairment or loss of motor and/or sensory function in the lower half of the body, usually caused by damage to the spinal cord below the neck). Review of the resident's Physician Order Sheet (POS), dated March 2026, showed:- An order for [NAME] tube site care: clean with normal saline, change the dressing every day shift, dated 10/27/25;- An order to remove the [NAME] tube, rinse with water, clean with soap, rinse with water, disinfect with 70% rubbing alcohol, allow to dry completely before replacing every day shift, dated 10/28/25;- An order for oxygen tubing, mask, and humidifier to be changed weekly every night shift on Sunday, dated 11/02/25;- An order for oxygen at 4 liters per minute (LPM) via a trach mask every shift, dated 10/24/26;- An order to change the collar for the [NAME] tube weekly on Wednesday every day shift for prevention, dated 10/29/25;- No order for the suctioning and the size and type of the airway tube used by the resident;- No physician order for the resident to perform the [NAME] tube care and suctioning independently. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/16/26, showed:- Resident with a tracheostomy;- Received oxygen. Review of the resident's care plan, dated 11/13/25, showed:- Difficulty breathing and the need for monitoring related to the [NAME] tube. Administer oxygen as ordered at 4 LPM via a trach mask, clean or change the filter at least weekly and as needed, and change the tubing weekly and as needed;- Resident with a [NAME] tube and the resident to change the collar for the [NAME] tube weekly on Wednesday. Give oxygen at 4 LPM via a trach mask. Change the oxygen tubing, mask, and humidifier weekly on Sunday evening. Monitor for restlessness, agitation, confusion, increased heart rate, bradycardia (a below normal heart rate), level of consciousness, mental status, lethargy, and the respiratory rate, depth, and quality check every shift. Provide good oral care daily. Provide means of communication and procedural information. Reassure that help is available immediately. Suction as necessary. The resident will suction him/herself and does not want staff to do it. The resident will remove the [NAME] tube, rinse with water, clean with soap, rinse with water, disinfect with 70% rubbing alcohol, and allow to dry completely before replacing every day shift; - Did not address the type and size of the [NAME] tube airway. Review of the resident's medical record showed:- No documentation the resident was provided [NAME] tube care education;- No documentation the resident's competency for the [NAME] tube care was assessed and the resident was competent to provide his/her own [NAME] tube care. During an interview on 03/17/26 at 11:00 A.M., Resident #5 said he/she did his/her own airway care. He/She preferred to do it him/herself to ensure it was done correctly. Staff would help if he/she needed it, but the resident didn't want help. 2. Review of Resident #43's medical record showed:- admission date of 03/02/26;- Diagnoses of dependence on supplemental oxygen, dyspnea (shortness of breath), chronic obstructive pulmonary disease (COPD - lung disease). Review of the resident's POS, dated March 2026, showed:- An order for oxygen tubing to be changed every Sunday night shift for prevention, dated 03/08/26;- May have oxygen at 2 LPM per nasal cannula as needed, dated 03/02/26. Review of the resident's care plan, dated 03/02/26, showed:- Difficulty breathing/short of breath related to COPD and uses oxygen at night as needed;- Administer oxygen as per the physician order. Observation of the resident showed:- On 03/17/26 at 10:01 A.M., the resident was taken to the shower by staff. The oxygen concentrator was not in use, the resident's undated nasal cannula (oxygen tubing inserted into the nostrils to deliver supplemental oxygen) lay on the floor at the bedside, the humidifier was undated, and no storage container for the nasal cannula when not in use. The undated nebulizer mask lay on the recliner seat with no storage container for it;- On 03/18/26 at 5:40 A.M., the resident lay in bed with oxygen on at 3 LPM. The nasal cannula and humidifier were undated. The undated nebulizer mask sat on the recliner seat in a plastic resealable bag;- On 03/18/26 at 10:30 A.M., and 03/19/26 at 9:05 A.M., the resident lay in bed with oxygen via a nasal cannula, dated 03/18/26, on at 3 LPM. During an interview on 03/18/26 at 10:30 A.M., Resident #43 said he/she wore oxygen at night but wasn't sure what the setting was supposed to be. During an interview on 03/19/26 at 3:07 P.M., Certified Nursing Assistant (CNA) B said usually there was a plastic bag that had the date on it to store the oxygen tubing in while not in use. The nurses usually dated the oxygen tubing and humidifier when they changed them. If the nasal cannula was on the floor, he/she would replace it. During an interview on 03/19/26 at 2:43 P.M., Licensed Practical Nurse (LPN) A said oxygen tubing and the humidifiers on the oxygen concentrators should be dated. There should be a plastic bag on the concentrator for storing the oxygen tubing, and the nebulizer mask should be rinsed and sprayed with disinfectant spray and left to air dry. If the nasal cannula was on the floor, then it should be replaced with a new one and it should not be placed on the resident. The oxygen setting should be set at what was ordered. Resident #43's oxygen order was for 2 LPM as needed, so that was what he/she should receive. Resident #5 did his/her own airway care. The extra [NAME] tube was stored in the Assistant Director of Nursing (ADON)'s office. During an interview on 03/19/26 at 5:09 P.M., the ADON and Director of Nursing (DON) said there should be an order for oxygen and if it had a set rate, they would expect the order to be followed. The nurse who changed the oxygen tubing and humidifier water was responsible for dating them. The oxygen tubing and mask should be stored in a plastic resealable bag and attached to the concentrator or the nebulizer machine. The nasal cannula should be thrown away and staff should get a new one if it was found on the floor. The ADON and DON said the extra [NAME] tube was kept in their office. The DON said she lived just a few minutes away and could run up to get it if needed. Resident #5 was able to keep his/her airway open without the [NAME] tube in place. The care plan showed Resident #5 would do his/her own care but no assessment to show the resident was competent in the care had been completed and there was not a policy regarding that. During an interview on 03/19/26 at 5:43 P.M., the Administrator said oxygen tubing should be dated and in a bag for storage. If a nasal cannula was on the floor, it should be thrown away, replaced with a new one, dated, and put in a bag. She would expect staff to follow the regulations.

Based on observation, interview, and record review, the facility failed to ensure residents diagnosed with dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) had a personalized plan of care to ensure appropriate services to promote the resident's highest level of functioning and psychosocial needs were provided for three residents (Residents #9, #13, and #16) out of three sampled residents. The facility census was 71.Review of the facility's policy titled Dementia - Clinical Protocol, dated November 2018, showed:- The interdisciplinary team (IDT) will evaluate individuals with new or progressive cognitive impairment and help identify symptoms and findings that differentiate dementia from other causes;- For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life;- Direct care staff will support the resident in initiating and completing activities and tasks of daily living. Bathing, dressing, mealtimes, and therapeutic and recreational activities will be supervised and supported throughout the day as needed. 1. Review of Resident #9's medical record showed:- admission date of 04/11/19; - Diagnoses of unspecified dementia with unspecified severity and behavioral disturbance, and unspecified dementia, moderate, with other behavioral disturbance. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/11/25, showed:- Severe cognitive impairment;- Diagnosis of non-Alzheimer's dementia;- Able to understand others and to be understood. Review of the resident's Care Plan, dated 03/13/26, showed:- Did not address specific problems, interventions, or goals for dementia care;- Did not address specific problems, interventions, or goals for activities for a resident diagnosed with dementia. Observations of the resident showed:- On 03/17/26 at 11:50 A.M., and 1:55 P.M., the resident lay in bed with his/her eyes closed; - On 03/18/26 at 3:00 P.M., the resident sat in his/her wheelchair in the common area near the nurse's station and leaned to the right side with his/her eyes closed. 2. Review of Resident #13's medical record showed:- admission date of 11/13/25;- Diagnosis of dementia in other diseases classified elsewhere, mild, with anxiety (persistent worry and fear about everyday situations), and Alzheimer's disease (progressive mental deterioration) with late onset. Review of the resident's quarterly MDS, dated [DATE], showed:- Cognition intact;- Diagnoses of Alzheimer's with late onset, Alzheimer's disease, and non-Alzheimer's dementia;- Able to understand others and to be understood. Review of the resident's Care Plan, dated 02/16/26, showed:- Did not address specific problems, interventions, or goals for dementia care;- Did not address specific problems, interventions, or goals for activities for a resident diagnosed with dementia. Observation of the resident showed:- On 03/17/26 at 9:45 A.M., the resident lay in bed with his/her eyes closed;- On 03/17/26 at 10:30 A.M., the resident lay in bed with his/her eyes open;- On 03/18/26 at 2:30 P.M., the resident sat in the chair next to the bed with his/her eyes open, the television off, and the door to the room closed. 3. Review of Resident #16's medical record showed:- admission date of 07/23/25;- Diagnoses of unspecified dementia with unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the resident's quarterly MDS, dated [DATE], showed:- Severe cognitive impairment;- Diagnosis of non-Alzheimer's dementia;- Able to understand others and to be understood. Review of the resident's Care Plan, dated 02/23/26, showed:- Did not address dementia;- Did not address specific problems, interventions, or goals for dementia care;- Did not address specific problems, interventions, or goals for activities for a resident diagnosed with dementia. Observations of the resident showed:- On 03/17/26 at 11:50 A.M., the resident lay in bed, with his/her eyes closed;- On 03/18/26 at 3:00 P.M., the resident sat in his/her wheelchair in his/her room with the television on, not watching it, and looking around the room. During an interview on 03/19/26 at 6:05 P.M., the Director of Nursing (DON) and the Administrator said they would expect dementia care to be care planned individually and to address the resident's diagnosis and needs.

Based on observation, interview, and record review, the facility failed to follow appropriate infection control practices with hand hygiene and glove changes during wound care, and suprapubic catheter (a sterile tube inserted into the bladder through the abdominal wall to drain urine) care for one resident (Resident #1) and incontinent care for three residents (Residents #5, #38, and #75) out of three sampled residents. The facility failed to follow appropriate infection control practices when inserting a nasal cannula (a device used to deliver oxygen with two small tubes that fit into the nostrils) into the nares of one resident (Resident #38) after it lay on the floor. The facility census was 71. Review of the facility's policy, Handwashing/Hand Hygiene, dated October 2023, showed:- This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections;- All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infection;- Hand hygiene is indicated immediately before touching a resident, before performing aseptic tasks, after contact with blood, body fluids, or contaminated surfaces, after touching a resident, after touching the resident's environment, before moving from work on a soiled body site to a clean, and immediately after glove removal;- Single use disposable gloves should be used before aseptic procedures, when anticipating contact with blood or body fluids, and when in contact with a resident or equipment or environment of a resident, who is on contact precautions;- To apply and remove gloves: perform hand hygiene before applying non-sterile gloves, when applying only touch top of the cuff; when removing gloves, pinch at wrist and peel away turning glove inside out, perform hand hygiene. Review of the facility's policy, Perineal Care, dated February 2018, showed:- The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition;- For a catheter, gently wash the juncture of the tubing from the urethra down the catheter about three inches. Review of the facility policy, Urinary Catheter Care, dated August 2022, showed:- The purpose of this procedure is to prevent urinary catheter-associated complications, including infections;- Use aseptic technique when handling or manipulating the drainage system;- To clean, cleanse around the catheter insertion site, use a clean washcloth to cleanse and rinse the catheter from the insertion site to approximately four inches outward, remove gloves and wash hands. The facility did not provide a policy for wound care. 1. Observation of Resident #38's incontinent care on 03/17/26 at 1:24 P.M., showed:- Certified Nursing Assistant (CNA) E and Nursing Assistant (NA) F entered the room, put on gloves, and did not perform hand hygiene;- CNA E unfastened the urine saturated brief, wiped fecal matter off of the resident's buttocks with the back of the brief, and removed the soiled brief;- NA F removed gloves, did not perform hand hygiene, exited the room, retrieved a clean incontinent pad from the clean utility room, entered the room, performed hand hygiene, and put on gloves;- CNA E used a wipe to clean fecal matter from the resident's buttocks with fecal matter on his/her left glove, did not change gloves, did not perform hand hygiene, used a clean wipe to wipe the buttock again, changed the left glove, did not perform hand hygiene, touched the resident's shirt, rolled and placed a clean incontinent pad under the resident, changed gloves, did not perform hand hygiene, and placed a clean brief under the resident;- NA F removed the incontinent pad soiled with urine and fecal matter from the bed, did not change gloves, did not perform hand hygiene, removed two wipes from the package, and handed them to CNA E;- CNA E cleaned part of the upper area of the groin, did not clean all of the upper area and the lower area of the groin, did not change gloves, did not perform hand hygiene, and fastened the clean brief into place;- CNA E and NA F removed gloves and did not perform hand hygiene;- NA F picked up the resident's nasal cannula from the floor and placed it into the resident's nostrils;- CNA E covered the resident with linens, performed hand hygiene, and exited the room. 2. Observation of Resident #75's incontinent care on 03/18/26 at 5:32 A.M., showed:- CNA B and NA C performed hand hygiene and put on gloves;- CNA B unfastened brief, placed new brief on bed beside resident;- CNA B cleaned the groin area, did not clean the perineal area, did not perform hand hygiene, and changed gloves;- CNA B wiped the resident's buttocks and perineal area with same area of the wipe going over the same area in a circular motion multiple times, did not perform hand hygiene, and changed gloves;- CNA B put a clean brief under the resident and fastened the brief, did not perform hand hygiene, changed gloves, and pulled the blankets up over the resident;- CNA B performed hand hygiene and did not put on gloves;- NA C removed gloves, did not perform hand hygiene, and tied up the bags of dirty laundry and trash;- CNA B and NA C pulled the resident up in bed with the incontinent pad with their bare hands;- CNA B did not perform hand hygiene, exited the room, took the bag of dirty trash and laundry to the dirty utility room, and performed hand hygiene;- NA C performed hand hygiene and exited the room. 3. Observation of Resident #1's wound care on 03/18/26 at 7:45 A.M., showed:- EBP signage on the door;- Licensed Practical Nurse (LPN) A performed hand hygiene, put on a gown and gloves, and entered the resident's room;- LPN A removed the dressing from the resident's left gluteal fold (the skin crease under the buttock that separates the buttock from the upper thigh), did not change gloves, and did not perform hand hygiene;- LPN A cleaned the wound bed with gauze saturated with normal saline (salt water), changed gloves, and did not perform hand hygiene;- LPN A packed the wound with gauze wet with Dakins solution (an antiseptic wound cleanser), did not perform hand hygiene, did not change gloves, applied skin prep (a protective barrier wipe) around the outside of the wound, changed gloves, and did not perform hand hygiene;- LPN A removed the gauze dressing around the suprapubic catheter with a brown substance on the gauze and the catheter tubing site, changed gloves, and did not perform hand hygiene;- LPN A cleaned down the catheter tubing towards the insertion site with a gauze wet with normal saline from the top to bottom three times with the same area of the wet gauze, did not perform hand hygiene, did not change gloves, placed a clean split gauze to the catheter insertion site, changed gloves, and did not perform hand hygiene;- LPN A applied tape to secure the split gauze in place, used a marker off the bedside table to write the date on the tape, did not change gloves, and did not perform hand hygiene;- LPN A detached the catheter tubing from the catheter drainage bag, did not change gloves, did not perform hand hygiene, used a syringe to flush the suprapubic catheter as ordered, reattached the catheter tubing to the catheter drainage bag, did not perform hand hygiene, and changed gloves;- LPN A applied skin prep wipe around the wound vacuum (vacuum-assisted closure used to conduct negative pressure wound therapy to promote healing) dressing to the right thigh, did not perform hand hygiene, did not change gloves, assisted the resident to roll to the right side, sprayed the left side of the resident's back with skin prep spray, removed gown and gloves, performed hand hygiene, and exited the room. 4. Observation of Resident #5's incontinent care, catheter care, and transfer on 03/18/26 at 9:40 A.M., showed: - EBP signage on door;- CNA B and NA C put on gowns, entered the room, performed hand hygiene, and put on gloves;- CNA B cleaned the groin area, did not perform hand hygiene, changed gloves, cleaned the genital area with the same area of the wipe, did not perform hand hygiene, changed gloves, dabbed with a wipe around the insertion point of the catheter, performed hand hygiene, changed gloves, and emptied the urine from the catheter bag into a clean canister;- CNA B performed hand hygiene, changed gloves, rolled the resident to the right and NA C cleaned the resident's buttocks;- NA C did not change gloves and did not perform hand hygiene;- CNA B and NA C rolled the resident from side to side and placed a Hoyer lift (a mechanical lift used to transfer residents from one position to another) sling under the resident and transferred the resident into the wheelchair with the Hoyer lift;- NA C removed gloves and gown, performed hand hygiene, and exited the room;- CNA B removed gown and gloves, picked up the trash, exited the room, took the trash to the dirty utility room, and performed hand hygiene. During an interview on 03/19/26 at 2:43 P.M., LPN A said glove changes should occur at the start, end, and anytime the gloves might have been contaminated when doing care. Hands should be washed at the start, end, and when visibly soiled, or sanitized if not visibly soiled. A nasal cannula should never be placed in the nares of a resident if it had touched the floor. A catheter should be cleaned from the insertion point down, using one wipe each time. During an interview on 03/19/26 at 3:07 P.M., CNA B said sanitize hands before care, when entering a resident room, should change gloves a lot, and wash hands at the end. Should wash hands if used sanitizer three times. If a nasal cannula was found on the floor, it should be replaced and not placed on a resident. During an interview on 03/19/26 at 3:15 P.M., NA C said hands should be washed before putting gloves on at the start and end of care. Soiled gloves should be changed during care. If a nasal cannula was found on the floor, it should be replaced with a new one. During an interview on 03/19/26 at 3:24 P.M., CNA D said hands should be washed when you go into a room, touch anything dirty, and leave the room. Gloves should be changed when dirty or as many times as needed. A nasal cannula found on the floor should be thrown away. During an interview on 03/19/26 at 3:32 P.M., CNA E said gloves should be changed as needed when going from dirty to clean care, hands should be sanitized at the start, when you walk out, and as needed. A nasal cannula should not be placed on a resident if found on the floor but should be replaced. During an interview on 03/19/23 at 5:09 P.M., the Assistant Director of Nursing (ADON) and Director of Nursing (DON) said hand washing should occur before and after care. Hands should be sanitized with glove changes, and gloves changed when going from dirty to clean care and use one wipe per swipe. If a nasal cannula was found on the floor it should be thrown away and a new one obtained. During an interview on 03/19/23 at 5:43 P.M., the Administrator said she would expect staff to follow policy and procedure for hand hygiene and glove changes and follow infection control standards. A nasal cannula that was found on the floor should never be placed back on a resident, instead a new one should be obtained.

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment. This deficient practice had the potential to affect all residents at the facility. The facility census was 70. Review of the facility's policy titled, Homelike Environment, revised on February 2021, showed; - Residents are provided with a safe, clean, comfortable and homelike environment. The facility did not provide a maintenance log. 1. Observations on 01/08/25 at 8:22 A.M., and 01/09/25 at 8:52 A.M., of the dining room and the C unit showed: - A deep crack in the laminate flooring across the middle of the dining room, approximately 15 foot (ft) in length and approximately 1 inch (in) deep causing a shift in the walking surface; - Approximately 20 ft of missing baseboard trim along the entire dining room wall near the kitchen; - Exposed sheetrock approximately 20 in x 20 in in the C unit hallway. During an interview on 01/09/25 at 10:27 A.M., the Maintenance Supervisor (MS) said the crack in the dining room floor had been there since he/she had worked there. No one had not discussed fixing it. The foundation shifted which caused the crack. During an interview on 01/09/25 at 10:44 A.M., the Administrator said she was aware of the crack in the dining room floor and it had been there for a long time. She said they had no current plans to fix it.

Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for three residents (Residents #16, #24, and #58) out of five sampled residents. The facility census was 70. Review of the facility's policy titled, Tapering Medications and Gradual Dose Reduction, revised July 2022, showed: - After medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences; - Residents who use psychotropic (medications that affect the mind, emotions, and behavior) medications shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; - The staff and practitioner will consider tapering of medications as one approach to finding an optimal dose or determining whether continued use of a medication is benefiting the resident; - The physician will review periodically whether current medications are still necessary in their current doses. For example, whether an individual's conditions or risk factors are sufficiently prominent or enduring that they require medication therapy to continue in the current dose, or whether those conditions and risks could potentially be equally well managed or controlled without certain medications, or with a lower dose; - Residents who use psychotropic medications shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs. Pertinent behavioral interventions (non-pharmacological attempts to influence an individual's behavior, including environmental alterations and staff approaches to care) will also be attempted; - Within the first year after a resident is admitted on a psychotropic medication or after the resident has been started on a psychotropic medication, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, the facility shall attempt a GDR at least annually, unless clinically contraindicated; - For any individual who is receiving a psychotropic medication to treat a psychiatric disorder other than behavioral symptoms related to dementia {for example, schizophrenia, bipolar mania, or depression with psychotic features), the GDR may be considered contraindicated, if: the continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying psychiatric disorder; or the resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder. 1. Review of Resident #16's medical record showed: - admitted [DATE]; - Diagnoses of catatonic disorder (syndrome marked by not able to move normally), anxiety (persistent worry and fear about everyday situations), schizophrenia (long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations), and drug induced akathisia (movement disorder causing feeling of restlessness and an urge to move); - An order for Paxil (an antidepressant mediation) 40 milligrams (mg) by mouth at bedtime daily for anxiety disorder, dated 07/29/24; - An order for quetiapine (an antipsychotic (medications that treat symptoms of psychosis, such as hallucinations and delusions) medication) 100 mg by mouth at bedtime daily for schizophrenia, dated 05/07/24; - An order for mirtazapine (an antidepressant medication) 30 mg by mouth at bedtime daily for anxiety disorder, dated 12/18/23; - No documentation of attempted GDRs for Paxil, quetiapine, or mirtazapine; - No documentation of contraindications of medication adjustments for Paxil, quetiapine, or mirtazapine. 2. Review of Resident #24's medical record showed: - admitted [DATE]; - Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), suicidal ideations, bipolar (a mental disorder that causes unusual shifts in mood) disorder, major depressive disorder (long-term loss of pleasure or interest in life), transient cerebral ischemic attack (TIA - a neurologic deficit that produces stroke symptoms that resolve within 24 hours), cerebral infarction (damage to the brain from interrupted blood supply), insomnia (difficulty sleeping), and anxiety; - An order for escitalopram (an antidepressant medication) 10 mg by mouth every morning for anxiety disorder, dated 07/15/24; - An order for trazodone (an antidepressant medication) 50 mg by mouth at bedtime for insomnia, dated 01/29/24; - An order for quetiapine 50 mg by mouth at bedtime daily for major depressive disorder, dated 01/17/24; - No documentation of attempted GDRs for escitalopram, trazodone, or quetiapine; - No documentation of contraindications of medication adjustments for escitalopram, trazodone, or quetiapine. 3. Review of Resident #58's medical record showed: - admitted [DATE]; - Diagnoses of cerebrovascular disease (a condition that impacts the brain's blood vessels and blood flow), rheumatoid arthritis (a chronic disease marked by inflammation of multiple joints), bipolar disorder, hypertension (high blood pressure), and diabetes mellitus (DM - a condition that affects the way the body processes blood sugar); - An order for aripipazole (an antipsychotic medication) 5 mg by mouth in the morning related to bipolar disorder, dated 01/29/24; - No documentation of attempted GDRs for aripipazole; - No documentation of contraindications of medication adjustments for aripipazole. During an interview on 01/09/25 at 11:30 A.M., Pharmacist A said he/she did the monthly medication reviews at least once a month if not more. He/She sent the monthly information to the facility. The facility was responsible for sending the recommendations or considerations to the physicians. A GDR was done when needed unless the resident had bipolar, schizoaffective disorder, or schizophrenia diagnoses. For those diagnoses, the resident did not need a GDR and he/she would let the psychiatric physician handle the resident's medication titrations. A GDR was usually done within the first three months of admission, then every six months, then every year on average for residents without a diagnosis of bipolar, schizoaffective disorder, or schizophrenia. During an interview on 01/09/25 at 11:50 A.M., the Administrator said she expected GDRs to be done for all residents on any psychotropic medication unless they were contraindicated. The GDRs should be completed per the facility's policy. 49152

Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 28 opportunities with two errors made, resulting in an error rate of 7.14% for two residents (Residents #23 and #58) out of six sampled residents. The facility's census was 70. Review of the facility's policy titled, Insulin Administration, revised September 2014, showed: - The staff will have access to specific instructions from the manufacturer on all forms of insulin delivery systems; - The policy did not address insulin pen administration technique. Review of the Fiasp (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) Flextouch Pen (insulin in a pen-type device) instructions, revised, June 2023, showed: - Prime the pen by turning the dose knob to two units; - Hold the pen with the needle is pointing up; - Tap the cartridge holder gently to collect air bubbles at the top; - Push the dose knob in until it stops, and zero is seen in the dose window, count to five slowly, the insulin will be visible at the tip of the needle; - Select the dose; - Give the injection after selecting the area and cleaning the site with an alcohol swab. 1. Review of Resident #23's Physician Order Sheet (POS), dated January 2025, showed: - An order for Fiasp insulin pen 100 units per milliliter (ml) subcutaneous (an injection just below the skin) per a sliding scale of blood sugar of if 140-180 = 2 units, 181- 240 = 3 units, 241-300 = 4 units, 301 - 350 = 6 units, 351-400 = 8 units, dated 11/11/24. Observation of Resident #23's medication administration on 01/08/25 at 11:11 A.M., showed: - Certified Medical Technician (CMT) B administered 3 units of of Fiasp insulin for a blood sugar of 199 subcutaneously with the resident's Fiasp Flextouch Pen; - CMT B failed to prime the Fiasp Flextouch Pen per the manufacturer's instructions prior to the administration of the insulin to the resident. 2. Review of Resident #58's POS, dated January 2025, showed: - An order for Fiasp insulin pen 100 units per ml subcutaneous with meals per a sliding scale of blood sugar of if 0-149 = 0 units, 150-199 =3 units, 200 - 249 = 6 units, 250 - 299 = 9 units, dated 11/28/24. Observation of Resident #58's medication administration on 01/08/25 at 11:26 A.M., showed: - CMT B administered 3 units of Fiasp insulin for a blood sugar of 189 subcutaneously with the resident's Fiasp Flextouch Pen; - CMT B failed to prime the Fiasp Flextouch Pen per the manufacturer's instructions prior to the administration of the insulin to the resident. During an interview on 01/09/25 at 8:19 A.M., CMT B said when administering insulin, he/she would prime the insulin pen when it was brand new, and then after that, he/she did not prime the pen before each dose. He/She had not ever been told to prime the insulin pens before administering each dose. During an interview on 01/09/25 at 10:48 A.M., the Director of Nursing (DON) said all insulin pens should be primed before each individual dose according to the manufacturer guidelines. During an interview on 01/09/25 at 10:50 A.M., the Administrator said she would expect staff to follow manufacturer guidelines, and prime insulin pens before giving each dose.

Based on observation, interview, and record review, the facility failed to implement Enhance Barrier Precautions (EBP) during tube feeding (liquid food delivered into the stomach by a tube) and incontinent care for one resident (Residents #21) out of four sampled residents. The facility census was 70. Review of the facility's policy titled, Enhanced Barrier Precautions, not dated, showed: - EBP is used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms; - Gloves and gown are applied prior to performing high contact resident care activity; - Examples of high-contact resident activities requiring EBP include: dressing, bathing, transferring, hygiene care, changing linens, changing briefs and assistance with toileting, device care or use for central line, feeding tube, tracheostomy/ventilator etc.) and wound care. 1. Observation on 01/08/25 at 11:12 A.M., of Resident #21's tube feeding administration showed: - EBP signage posted outside of the resident's room; - Licensed Practical Nurse (LPN) C did not put on an isolation gown, entered the resident's room, performed hand hygiene, put on gloves, and administered the resident's tube feeding; - LPN C removed the gloves, performed hand hygiene, and left the resident's room. 2. Observation on 01/08/25 at 6:06 P.M., of Resident #21's incontinent care showed: - EBP signage posted outside of the resident's room; - Certified Nursing Assistant (CNA) E and Nursing Assistant (NA) D did not put on an isolation gown, entered the resident's room, performed hand hygiene, put on gloves, performed the incontinent care, removed the gloves, performed hand hygiene, and left the resident's room. During an interview on 01/09/25 at 10:02 A.M., LPN C said he/she did not wear a gown when doing tube feedings for Resident #21. During an interview on 01/08/25 at 6:26 P.M., CNA E said he/she did not normally wear a gown when performing any kind of care for Resident #21. CNA E asked the Director of Nursing (DON) before doing care if he/she needed a gown and was told no. During an interview on 01/08/25 at 6:27 P.M., NA D said he/she did not wear a gown when performing incontinent care on Resident #21. During an interview on 01/09/25 at 10:50 A.M., the DON said she would expect staff to follow EBP precautions. Staff should wear a gown when administering tube feedings and during incontinent care. 49152

Based on observation, interview, and record review, the facility failed to provide resident care for activities of daily living (ADL's) when the facility did not provide showers at least weekly for five residents (Resident #8, #18, #23, #26, and #31) and at least twice weekly for one resident (Resident #38) out of 17 sampled residents. The facility census was 69. The facility did not provide a policy related to shower frequency. Review of the shower list showed: - Resident #8 scheduled for a shower once a week on Tuesdays; - Resident #18 scheduled for a shower once a week on Wednesdays; - Resident #23 scheduled for a shower once a week on Fridays; - Resident #26 scheduled for a shower once a week on Tuesdays; - Resident #31 scheduled for a shower once a week on Wednesdays; - Resident #38 scheduled for a shower twice a week on Tuesdays and Fridays. 1. Review of Resident #8's medical record showed: - An admitted [DATE]; - Diagnoses of hypertension (high blood pressure), malnutrition, anxiety (persistent worry and fear about everyday situations), chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and respiratory failure. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 07/20/23 showed: - Cognitive status severely impaired; - Extensive assistance of one staff for dressing and personal hygiene; - Physical help to transfer for shower only; - Received oxygen therapy. Review of Resident #8's September 2023 shower calendar showed: - The resident received a shower on 09/07/23 and on 09/20/23; - No documentation of a shower on 09/14/23 or 09/28/23; - Two out of four opportunities for showers missed. Review of the resident's care plan, last revised on 06/15/23, showed the resident required ADL assistance with showers with assist of one staff due to poor endurance and shortness of breath. Observation on 09/27/23 at 10:35 A.M., showed the resident asked staff to wash his/her face and had facial hair about 1/4 inch (in.) long. During an interview on 09/27/23 at 10:40 A.M., Resident #8 said he/she preferred to have his/her face shaven but didn't remember the last time it had been done or the last shower he/she had received. Review of Resident 18's medical record showed: - An admitted [DATE]; - Diagnoses of fractures, hypertension, benign prostatic hyperplasia (BPH) (enlargement of the prostate causing difficulty in urination), anxiety disorder, schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations), COPD, and Stage 3 pressure ulcer (damage to the skin and/or underlying tissue as a result of pressure) to the left heel. Review of the resident's quarterly MDS, dated [DATE], showed: - Severely impaired cognition; - Total dependence of two staff for dressing; - Extensive assist of one staff for personal hygiene; - Total dependence of one staff for bathing. Review of the resident's September 2023 shower calendar showed: - The resident received a shower on 09/06/23, 09/19/23 and 09/22/23; - No documentation of a shower on 09/13/23 or 09/27/23; - Two out of four opportunities for showers missed. Review of the resident's care plan, revised on 09/05/23, showed the resident required assistance for showers. Observation of the resident on 09/26/23 at 9:50 A.M., showed: - Multiple open areas and scabs on his/her neck and the right side of the face; - Red, excoriated and open areas to the buttocks; - A urinary catheter (a tube inserted into the bladder through the urethra that allows urine to drain from the bladder for collection). Review of Resident #23's medical record showed: - An admitted [DATE]; - Diagnoses of traumatic brain dysfunction (an injury that affects how the brain works), aphasia (loss of ability to understand or express speech caused by brain damage), quadriplegia (paralysis caused by illness or injury that results in the loss of use of all limbs and torso), seizure disorder (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness), and traumatic brain injury (an injury that affects how the brain works). Review of the resident's quarterly MDS, dated [DATE], showed: - Severely impaired cognition; - Extensive assistance of two staff for dressing and personal hygiene; - Total dependence of two staff for bathing. Review of the resident's care plan, revised on 08/21/23, showed the resident required assist of one to two for showers. Review of the resident's September 2023 shower calendar showed: - The resident received showers on 09/01/23, 09/15/23, and 09/22/23; - No documentation of a shower on 09/08/23; - One out of four opportunities for showers missed. Observation on 09/27/23 at 10:45 A.M., showed the resident lay in bed with hair unkempt. Review of Resident #26's medical record showed: - Date of admission of 10/16/17; - Diagnoses of hypertension, BPH, renal (kidney) failure, obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow), Diabetes Mellitus (DM) (a condition that affects the way the body processes blood sugar), Alzheimer's disease (progressive mental deterioration), dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), and cerebrovascular accident (CVA) (stroke). Review of the resident's annual MDS, dated [DATE], showed: - Extensive assistance of one staff for dressing and personal hygiene; - Assist of one for bathing. Review of the resident's care plan, revised on 08/21/23, showed the resident required assist of one to two for showers. Review of the resident's September 2023 shower calendar showed: - The resident received showers on 09/13/23 and 09/19/23; - No documentation for showers on 09/05/23 or 09/26/2; - Two out of four opportunities for showers missed. Observation on 09/26/23 at 2:40 P.M., showed the resident to have 1/2 in. full facial hair and resident with a urinary catheter. During an interview on 09/26/23 at 2:40 P.M., Resident #26 said he/she liked to have his/her face shaven with showers and would prefer to have showers every other day. He/she could not remember when his/her last shower was, but he/she could use a shave. Review of Resident #31's medical record showed: - An admitted [DATE]; - Diagnoses of Duchenne or [NAME] Muscular Dystrophy (Duchenne muscular dystrophy (DMD) is a genetic disease that causes progressive muscle weakness and damage. [NAME] muscular dystrophy (BMD) is the less severe, and less common, form of the disease,) anxiety, quadriplegia (paralysis caused by illness or injury that results in the loss of use of all limbs and torso), tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help with breathing), dependence on supplemental oxygen, chronic respiratory failure with hypoxia (a condition with not enough oxygen in the tissues of the body), obesity (excessive body fat), contracture of the right and left foot, and congestive heart failure (CHF) (occurs when either disease or defect causes the heart muscle to lose the ability to pump blood efficiently). Review of the resident's quarterly MDS), dated [DATE], showed: - Cognitively intact; - Total dependence of 2 or more staff for bed mobility, dressing, personal hygiene and bathing; - Impairment on both sides of the upper and lower extremities; - Always incontinent of bladder and bowel; - Received oxygen therapy and tracheostomy care. Review of Resident #31's September 2023 shower calendar showed: - The resident received a shower on 09/19; - No documentation for showers on 09/06/23, 09/13/23 or 09/27/23; - Three out of four opportunities for showers missed. Observations of the resident showed: - On 09/25/23 at 11:19 A.M., the resident lay in bed wearing a dark blue shirt with red writing; - On 09/26/23 at 9:28 A.M., the resident lay in bed with crumbs on the front of same dark blue shirt with red writing; - On 09/26/23 at 12:27 P.M., and 3:18 P.M., the resident lay in bed wearing the same dark blue shirt with red writing; - On 09/27/23 at 10:05 A.M., the resident lay in bed wearing the same dark blue shirt with red writing; - On 09/27/23 at 11:24 A.M., the resident lay in bed wearing the same dark blue shirt with red writing and hair with flakes in it; - On 09/28/23 at 8:25 A.M., the resident lay in bed wearing the same dark blue shirt with red writing. Review of the resident's care plan, last revised on 09/07/23, showed: - Required assistance with showers of dependent assist of one due to muscular dystrophy with limited movement in the arms and hands, and fixed dorsiflexion contractures (a bent (flexed) joint that cannot be straightened actively or passively) of the right and left foot; - Resident preferred bed baths; - Refused showers at times with interventions of staff will provide bed bath on days the resident refused showers. 2. Review of Resident #38's medical record showed: - Date of admission of 05/12/21; - Diagnoses of schizophrenia, intermittent explosive disorder (IED) (a mental condition marked by frequent impulse anger outbursts or aggression) and obesity Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Limited assistance of one staff for dressing; - Supervision with set up for hygiene; - Supervision with set up for bathing. Review of the resident's care plan, dated 08/24/23, showed: - Cognition varied daily, staff to ensure needs and cares were met; - Assist in shower completion, washing back, drying, etc; - Assist in dressing as needed; - Required supervision/assist to make sure the resident was clean and dry, remind the resident to change clothes if he/she was wet or had a urine odor; - If the resident refused or become agitated with care, stop if possible and approach at a later time. Review of the resident's July 2023 shower calendar showed: - The resident received showers on 07/05/23, 07/11/23, 07/19/23, and 07/25/23, with no refusals documented; - No documentation of showers on 07/07/23, 07/14/23, 07/21/23 and 07/28/23; - Four opportunities out of eight missed. Review of the resident's August 2023 shower calendar showed: - The resident received showers on 08/01/23, 08/07/23, 08/16/23, 08/22/23, and 08/29/23, and refused on 08/25/23; - No documentation of showers on 08/04/23, 08/11/23, and 08/18/23; - Three opportunities out of nine missed. Review of the resident's September 2023 shower calendar showed: - The resident received showers on 09/04/23, 09/14/23, and 09/22/23, and refused on 09/01/23; - No documentation of showers on 09/08/23, 09/12/23, and 09/19/23; - Three opportunities out of seven missed. During an interview on 09/25/23 at 10:35 A.M., Resident #38 said more help was needed with showers and dressing. The showers weren't provided as they should be. Observations of the resident showed: - On 09/25/23 at 10:35 A.M., the resident sat in a recliner in his/her room, dressed in a black t-shirt and black sweat pants, stained with food, and smelled of strong body odor; - On 09/25/23 at 12:40 P.M., the resident sat in the dining room eating, wearing the same black t-shirt and black sweat pants, stained with food, and smelled of strong body odor; - On 09/26/23 at 9:08 A.M., the resident sat in his/her room wearing the same black t-shirt and sweat pants, stained with food, and smelled of strong body odor; - On 09/27/23 at 8:45 A.M., the resident sat in his/her room, wearing a gray shirt, navy sweat pants, and smelled of strong body odor. During an interview on 09/27/23 at 8:45 A.M., Resident #38 said he/she changed clothes that morning, but it was hard to do. He/She didn't get a shower because nobody got it ready. A shower can't be taken if someone doesn't get everything ready for him/her because there were no towels. Staff had to get the towels for the residents. During an interview on 09/26/23 4:15 P.M., Licensed Practical Nurse (LPN) E said towels were not kept on the linen cart because some residents would grab 10 or more and they wouldn't have any. They were kept behind the cart in a cabinet and staff get them out as needed when showers were set up. Resident #38 was scheduled for two showers a week on Tuesdays and Fridays. During an interview on 09/27/23 8:52 A.M., Student Nurse Assistant (SNA) A said Resident #38 was offered a shower yesterday but refused. During an interview on 09/27/23 9:08 A.M., LPN B said Resident #38 refused showers often and would expect staff to reproach the resident later and offer it again. If the resident still refused, the nurse should be notified. When showers were given and refusals should be documented. The residents were scheduled for two showers a week, but they could get them as often as they want. During an interview on 09/28/23 at 12:23 P.M., the Administrator said she would expect residents to have showers two times per week if that was how they were scheduled. If a resident refused, they should be reproached and it should all to be documented. During an interview on 09/28/23 at 12:54 P.M., the Assistant Director of Nursing (ADON) said she would expect all residents to get a shower at least once a week, and try to offer them twice a week. She would expect the resident to get a bed bath or at least cleaned up if they refuse a shower or bed bath. She would expect shower the aide and/or CNA to talk to the nurse if a resident refused a shower or bed bath, and expected the nurse to talk to resident. If staff weren't getting anywhere with the resident, she would expect staff to talk to her or the Director of Nursing (DON). Sometimes they had to go to the Administrator to talk to the resident and call the physician to make them aware. She would expect the resident refusals to be documented by the shower aides, the CNA, the nurse, herself, the DON and the Administrator. 45693 47445

Based on observation, interview, and record review, the facility failed to provide care in a manner that enhanced the resident's dignity while eating for one resident (Resident #65) out of four sampled residents. The facility census was 69. Review of the facility's policy titled, Resident Rights and Dignity, revised February 2021, showed: - Each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; - Residents will be treated with dignity and respect at all times; - Residents will be provided with a dignified dining experience. 1. Review of Resident #65's annual Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility,dated 07/27/23, showed: - Cognition moderately impaired; - Requires limited assist of one staff for eating. Review of the resident's medical record showed: - admitted [DATE]; - Diagnoses of autistic disorder (a serious developmental disorder that impairs the ability to communicate and interact), schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), obsessive compulsive disorder (a disorder with excessive thoughts that lead to repetitive behaviors). Review of the resident's care plan, reviewed 08/24/23, showed: - Cue and assist with meals as needed, set up to eat. Resident able to feed him/herself; - The resident required assist by one staff to eat; - The resident needed encouragement and reminded to eat as he/she was easily distracted; - Would not eat if anything gets on his/her clothes. Observations of the resident in the dining room showed: - On 09/25/23 at 12:45 P.M., the resident sat at a table with his/her face in the plate of pork tenderloin, green beans, and a baked potato, sliding food to his/her mouth with a fork or just picked the food up with his/her mouth and no utensils. Staff not present; - On 09/26/23 at 01:11 P.M., the resident used a fork and a spoon with one in each hand to move the enchiladas to his/her mouth. The resident then lowered his/her face to the plate, picked up food with his/her mouth and left his/her face in the plate as he/she chewed the food. No staff present; - On 09/26/23 at 1:16 P.M., Certified Medication Technician (CMT) F walked into the dining room and asked the resident to sit up so his/her face wasn't in the plate. CMT F walked out of the dining room, the resident placed his/her face back in the plate and continued eating with no staff present; - On 09/27/23 at 8:25 A.M., the resident sat in the dining room eating, with his/her face in the plate of biscuits, scrambled eggs, gravy, sausage. The resident lifted his/her head up with his/her face covered with food from up on his/her nose to his/her chin. No staff present; - On 09/27/23 at 8:28 A.M., Licensed Practical Nurse (LPN) B walked into the dining room and asked the resident to lift his/her head up so he/she didn't go to sleep. LPN B walked out of the dining room and the resident put his/her face back into the plate and continued eating. No staff present. During an interview on 09/27/23 at 9:12 A.M., LPN B said the resident did require supervision in the past while eating but didn't require it now. There was usually a staff member on the hall and he/she also went into the dining room at times. During an interview on 09/28/23 at 11:11 A.M., Physician Therapy Assistant (PTA) said occupational therapy (OT) had just started looking at the resident, mostly for positioning. The resident has just been seen a couple of times and no observations have been made of him/her eating. During an interview on 09/28/23 at 12:01 P.M., the MDS Coordinator said the resident required varied assistance from day to day. There was no way to know on any given day. The resident required limited to extensive assistance, and the MDS Coordinator had to physically pull the resident's face out of the plate the other day. During an interview on 09/28/23 at 12:06 P.M., the Administrator said a staff member should be present during meals and that there was a concern with the resident's eating that needed to be addressed.

Based on observation, interview and record review, the facility failed to maintain a safe, clean, comfortable, and homelike environment. The deficient practice had the potential to affect all residents in the facility. The facility's census was 69. The facility did not provide a policy regarding a safe, clean, comfortable, and homelike environment. Observations of E hallway showed: - On 09/26/23 at 9:01 A.M., Room E3 with a 2 foot (ft.) x 4 inch (in.) puddle of liquid in the floor under the bedside table at the side of the bed; - On 09/26/23 at 12:17 P.M., Room E3 with a 2 ft. x 4 in. puddle of liquid in the floor under the bedside table at the side of the bed. The floor was sticky and the room had a strong urine odor. The bathroom floor with a 1/2 in. gap in tile in front of the toilet; - On 09/26/23 at 12:20 P.M., Room E5's bathroom with the cove base pulled away from wall behind the right side of the toilet and with an approximate 20 in. x 3 in. hole in the sheet rock behind the cove base with a black discoloration to the insulation; - On 09/26/23 at 12:24 P.M., Room E8's bathroom with a broken florescent light cover; - On 09/26/23 at 3:35 P.M., Room E3 with damaged window screens separated approximately 1 in. away from the bottom frame in the window next to the bed; - On 09/27/23 at 10:20 A.M., Room E3 with a strong urine odor; - 09/28/23 at 8:20 A.M., Room E3 with a strong odor of urine and approximately 1 ft. x 4 in. puddle of liquid on the floor by the bedside. Observations on 09/28/23 at 10:51 A.M., and 09/28/23 at 11:57 A.M., of B hallway showed: - Room B7 with the bathroom wall area behind the toilet with a 1 ft. x 4 ft. damaged wall board with peeled paint, a damaged bedroom window screen separated 1 in. away from the frame, 3 ft. damaged flooring transition strip to the hallway, and a strong urine odor; - Room B2 with four 3 in. diameter unpainted wall sections on the wall adjacent to the hallway; - Room B9 with a damaged bedroom window screen separated 1 in. away from frame; - The dining room entrance with a damaged 4 ft. flooring transition strip in the doorway from the dining room to the hall. During an interview on 09/28/23 at 11:18 A.M., the resident in Room B7 said the urine odor in his/her bathroom was a problem. Observations on 09/28/23 at 1:35 P.M., of A hallway shower room showed: - A strong musty odor, a 4 ft. section of wall paper border peeled away above the vanity mirror, a 2 ft. section of wall paper border ripped away above the shower; - A black ring on the floor behind the toilet and a black substance on the baseboard area tiles behind the toilet; - The shower base area tiles with a brown substance below the faucet; - A 3 ft. right side section of the shower stall with the outside corner tiles damaged and missing near the floor; - The interior side of the entrance/exit door with chipped and damaged paint along the edges. Observations on 09/28/23 at 1:40 P.M., of E hallway shower room showed: - A 4 ft. x 6 in. section of black grime on the shower wall below the faucet near the floor; - A 4 in. x 6 in. section on the left side of the shower wall missing tiles near the floor; - A 1 ft. section of the outside corner wall tiles damaged and missing near the wooden cabinet; - The interior side of entrance/exit door with chipped and damaged paint along the lower half. During an interview on 09/28/23 at 9:17 A.M., the Maintenance Director said maintenance log books were kept in two places in the facility. Staff could place repair requests in the log book and it was checked daily. Staff may also speak directly with the department supervisors about repair issues. During an interview on 09/28/23 at 12:56 A.M., the Administrator said staff repair request were added to a maintenance log book or verbally spoken to the Maintenance Director. The facility should be in good repair. During an interview on 09/28/23 at 1:55 P.M., Student Nurse Assistant (SNA) A said the A hall shower room and E hall shower room were both used frequently for bathing the residents. Both shower rooms were cleaned by housekeeping but they were in need of repairs and were supposed to be remodeled.

Based on observation, interview, and record review, the facility failed to obtain a physician's order for the use of a trapeze (a device designed to assist residents in changing positions) for two residents (Resident #7 and #21) out of two sampled residents and failed to complete a resident assessment and safety evaluation for the use of a trapeze for one resident (Resident #21) out of two sampled residents. The facility census was 69. The facility did not provide a policy regarding trapeze use. 1. Review of Resident #7's Physician's Order Sheet (POS), dated September 2023, showed: - admitted [DATE]; - Diagnoses of renal (kidney) failure, obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow), diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), anxiety (persistent worry and fear about everyday situations), and depression (a serious medical illness that negatively affects how you feel, the way you think and how you act); - No order for a trapeze. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility, dated 08/25/23, showed: - Cognition intact; - Required extensive assist of one staff for bed mobility, transfers, dressing, and personal hygiene; - Required total assist of two staff for toileting. Review of the resident's medical record showed a Safety Evaluation Assessment for the use of a trapeze, dated 03/20/23, showed the resident safe to use the trapeze. Review of the resident's care plan, revised on 03/20/23, showed the resident used a trapeze to assist with positioning. Observation on 09/27/23 at 11:20 A.M., showed a trapeze over the resident's bed. During an interview on 09/26/23 at 9:31 A.M., Resident #7 said the trapeze had been over his/her bed since shortly after being admitted to the facility. During an interview on 09/28/23 at 11:36 A.M., Physical Therapy Assistant (PTA) E said therapy provided a plan of treatment regarding the trapeze for Resident #7. Plan of treatment consists of short term goals, long term goals, and rehab potential. During an interview on 09/28/23 at 10:00 A.M., the Assistant Director Of Nursing (ADON) said therapy took care of orders for therapy and she wasn't sure if there was an order. 2. Review of Resident #21's POS, dated September 2023, showed: - admitted [DATE]; - Diagnoses of borderline personality disorder (a personality disorder characterized by unstable moods, behaviors and relationships), neuropathy (nerve damage leading to pain, weakness and or tingling to one or more parts of the body), major depressive disorder, Type 2 diabetes mellitus with a foot ulcer (an open sore that will not heal or returns over a long period of time), chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and osteoarthritis (a type of arthritis that occurs when the flexile tissue at the end of bones wear down); - No order for a trapeze. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognition intact; - Required extensive assist of one staff for bed mobility, transfers, dressing, toileting and personal hygiene. Review of the resident's medical record showed no Safety Evaluation Assessment for the use of a trapeze. Review of the resident's care plan, dated 08/24/21, showed: - No intervention for the use of a trapeze to assist with positioning. Observations showed: - On 09/25/23 at 10:41 A.M., a trapeze over the resident's bed; - On 09/28/23 at 9:18 A.M., the resident lay in bed with a trapeze over the bed. During an interview on 09/26/23 at 2:41 P.M., Resident #21 said he/she sometimes used the trapeze to help with getting up and down in bed. During an interview on 09/28/23 at 11:19 A.M. PTA E said he/she had no safety evaluation assessment for the trapeze for Resident #21. The resident must have gotten it prior to the therapy starting at the facility. The trapeze looked like it might be too low and not sure how effective it was. There should be a safety evaluation assessment completed. During an interview on 09/28/23 at 12:08 P.M., the Administrator said she didn't know about the trapeze. The facility had no assessments for them or related to them and didn't know if they had to have a physician's order for one. She didn't realize Resident #21 had a trapeze. Therapy might have taken care of all that. 49150

Based on observation, interview, and record review, the facility failed to follow physician's orders for two residents (Resident #8 and #21) out of 17 sampled residents. The facility census was 69. The facility did not provide a policy related to following physician's orders. 1. Review of Resident #8's Physicians Order Sheet (POS), dated August 2023, showed: - Diagnoses of chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and chronic respiratory failure whether with hypoxia (the absence of enough oxygen in tissues to sustain bodily functions) or hypercapnia (buildup of carbon dioxide in bloodstream); - An order for oxygen tubing (the tube delivering oxygen from the oxygen container to the person) to be changed, dated 04/12/23. The order did not address how often to change the oxygen tubing; - An order for oxygen five liters per minute (LPM), dated 04/12/23. Review of the resident's medical record showed the oxygen initialed by staff which indicated the resident received oxygen five LPM daily. Observations on 09/25/23 at 11:30 A.M., 09/26/23 at 8:45 A.M., 09/27/23 at 9:45 A.M., and 09/28/23 at 8:30 A.M., showed the resident lay in bed with oxygen on at four LPM via nasal cannula (a tube delivering oxygen to a person's nose) (NC). During an interview on 09/26/23 at 11:00 A.M., Resident #8 said his/her oxygen should be at five LPM and staff should change the oxygen tubing weekly. The tubing did not always get changed weekly and he/she couldn't remember the last time it had been changed. During an interview on 09/28/23 at 3:00 P.M., the Assistant Director of Nursing (ADON) said staff should follow orders and keep oxygen at the correct setting for the resident. During an interview on 09/28/23 at 3:30 P.M., the Administrator said she would expect physician orders to be followed. 2. Review of Resident #21's POS, dated August 2023, showed: - Diagnoses of Type 2 Diabetes (a chronic condition that affects the way the body processes blood sugar) with a foot ulcer (an open sore that will not heal or returns over a long period of time); - An order for tubigrips (an elasticized tubular compression bandage) to be worn from the toes to below the knees every day shift for light compression related to Type 2 Diabetes with a foot ulcer, dated 08/31/23. Observations of Resident #21 showed: - On 09/26/23 at 12:55 P.M., the resident sat in the dining room with tubigrips to the right and left foot that extended right above the ankles; - On 09/27/23 at 8:51 A.M., the resident sat in the dining room with one tubigrip to the right foot that extended right above the ankle and no tubigrip to the left foot; - On 09/28/23 at 8:36 A.M., the resident walked down the hall with no tubigrips on either leg. The resident said the nurse hadn't changed the dressing yet and they were usually put on after that was done; - On 09/28/23 at 9:20 A.M., Licensed Practical Nurse (LPN) B preformed wound care for the resident and did not apply the tubigrips to the resident's legs after the completion of the wound care. During an interview on 09/28/23 at 9:34 A.M., LPN B said he/she was sure tubigrips were put on both feet on the 09/27/23 when the dressing change was completed. The resident sometimes removed them. He/She was unsure about the order for the placement of the tubigrips from the toe to below the knee. During an interview on 09/28/2023 at 09:34 A.M., the Administrator said she would expect the physician's order to be followed and the tubigrips should have been applied to below the knee as ordered.

Based on observation, interview, and record review, the facility failed to provide adequate supervision of two residents residing on the secured behavioral unit during smoking which affected one resident (Resident #51) out of two sampled residents and one resident (Resident #20) outside of the sample. The facility census was 69. Review of the facility's policy titled, Smoking, dated 5/2021, showed: - Smoking is allowed in designated areas only; - All residents will be monitored by facility staff when smoking; - No resident may smoke unattended unless specifically care planned to do so. 1. Review of Resident #20's medical record showed: - Date of admission of 04/21/21; - Diagnoses of major depressive disorder (MDD) (a persistent depressed mood, or loss of interest), unsteadiness of feet, muscle weakness, unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decision and solve problems), chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), traumatic brain injury (TBI) (brain dysfunction caused by outside forces); - The resident had a guardian. Review of the resident's smoking assessment, dated 08/02/23, showed: - The resident required supervision for smoking; - Staff to store cigarettes and lighter. Review of the resident's care plan, reviewed 08/05/23, showed: - Safe to smoke with supervision; - Behavior problems and made poor decisions; - At risk to smoke unattended; - The resident will not smoke unattended. 2. Review of Resident #51's medical record showed: - Date of admission of 04/21/21; - Diagnoses of MDD, unspecified dementia with other behavioral disturbances, (a mental disorder in which a person loses the ability to think, remember, learn, make decision and solve problems, including impaired concentration, apathy, anxiety and agitation), frontotemporal neurogenic disorder ( FTD) (damage to the neuron in the frontal and temporal lobes of the brain, resulting in unusual behaviors, emotional problems, trouble communicating, difficulty with work or difficult with walking, sometimes called frontotemporal dementia), and COPD. Review of the resident's smoking assessment, dated 06/21/23, showed: - The resident was safe to smoke with supervision; - Lighter and cigarettes are kept in the medication room; - Resident is on a secured unit and is supervised with smoking. Review of the resident's care plan, reviewed 09/26/23, showed: - Safe to smoke with supervision; - Behavior problems and made poor decisions; - At risk to smoke unattended; - The resident will not smoke unattended. Observations on 09/26/23 at 1:43 P.M., 09/27/23 at 8:33 A.M., and 09/28/23 at 8:34 A.M., showed: - Student Nursing Assistant (SNA) A took Resident #20 and #51 out to smoke in the designated smoking area; - SNA A handed Resident #20 and #51 two cigarettes each, lit their cigarettes, and the residents sat on benches against the wall of the building out of view of SNA A; - SNA A walked around the corner of the building and brought out a second group of residents to another designated smoking area; - SNA A remained with the second group of residents during the smoke break and Resident #20 and #51 were not monitored during the smoke break. During an interview on 09/28/23 at 9:06 A.M., SNA A said he/she was not able to see the first group of residents that smoked around the corner of the building. During an interview on 09/28/23 at 12:25 P.M., the Administrator said she would expect staff to be able to visually supervise residents that require supervision with smoking.