Every finding on record at Russell Park Rehabilitation & Living Center

Based on observations and interviews the facility failed to ensure the kitchen was maintained in a clean and sanitary manner; failed to ensure foods were labeled and/or dated in the kitchen and a reach in refrigerator for 1 of 1 kitchen tour (8/17/26); failed to label foods in a dining room kitchenette and failed to ensure food was served in accordance with professional standards for food service safety for 2 of 2 dining room observations.(8/18/26-lunch meal).Findings:On 8/17/26 from 6:10 p.m. to 6:35 p.m., two surveyors conducted a kitchen tour in which the following findings were observed:- The stove hood filters had greasy dust/dirt on them.- There were three stove hood lights that had greasy dust/dirt on them.- The floor shelving unit, under the spice shelves, that had a bottom shelf and legs that were dusty/dirty.- A reach-in refrigerator had previously open packages of parsley, parmesan cheese and butter that were not dated. - There was a large previously opened package of fruit rings cereal, on a shelf near the bread shelf, that was not labeled. On 8/17/26 at 6:40 p.m., two surveyors discussed the findings with the Administrator.On 8/17/26 at 6:45 p.m., in an interview with a surveyor, the Food Service Director confirmed the findings. 2. On 8/18/26 at 8:35 a.m., a surveyor observed five unlabeled bags of assorted cereals in the main dining room kitchenette. On 8/18/26 at 8:40 a.m., in an interview with a surveyor, the Server/Cook confirmed the finding. On 8/18/26 at 8:45 a.m., a surveyor discussed the findings with the Administrator. 3. On 8/18/26 at 12:00 p.m., a surveyor observed the dining room server with gloves on touch a box of plastic wrap, his shirt, many different utensils, plates and bowls and then grab 2 pieces of bread with the same gloved hand and make a sandwich repeatedly touching the bread and then holding it and cutting it in half. The surveyor brought up cross contamination, and he said he always changes his gloves after touching food. The surveyor stepped outside the kitchenette and watched the service through a doorway and observed the server not change his gloves or sanitize his hands and go back to touching many counters and utensils and a saran wrap box and then grab 2 slices of bread, with the same gloved hands to make another sandwich. At 12:05 p.m., a surveyor and the [NAME] President of Clinical Operations stopped the Server and discussed the cross possible cross contamination with him. On 8/19/26 at 8:30 a.m., a surveyor discussed the finding with the Food Service Director and the Administrator. They both confirmed that the cook/serve's practice of wearing gloves and going back and forth touching food then other items and back to food with same gloves created possible cross contamination.

Based on record review, observations and interviews the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and failed to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for multiple shifts, on 3 of 3 medication carts reviewed (Cart A, Cart B & C and the Nurse Treatment cart). Findings: On 5/20/25 during medication storage observation the following was reviewed: 1. Cart A Controlled Substance Book and Shift Counts were reviewed, which indicated the facility counts at the change of each shift, approx. 3 times a day. The person authorized to administer medications coming on duty and/or the person authorized to administer medications going off duty both failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was done on the following dates: 2/3/25, 2/11/25, 2/12/25, 2/15/25, 2/18/25, 2/26/25, 2/28/25, 3/5/25, 3/7/25, 3/12/25, 3/18/25, 3/19/25, 3/21/25, 3/28/25, 3/29/25, 4/1/25, 4/3/25, 4/4/25, 4/7/25, 4/12/25, 4/16/25, 4/17/25, 4/18/25, 4/21/25, 4/22/25, 4/23/25, 4/25/25, 4/28/25, 5/2/25, 5/3/25, 5/5/25, 5/6/25, 5/7/25, 5/8/25, 5/9/25, 5/10/25, 5/16/25 and 5/17/25. 2. Cart B &C Controlled Substance Book and Shift Counts were reviewed, which indicated the facility counts at the change of each shift, approx. 3 times a day. The person authorized to administer medications coming on duty and/or the person authorized to administer medications going off duty both failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was done on the following dates: 3/5/25, 3/19/25, 3/31/25, 4/8/25, 4/11/25, 4/13/25, 4/16/25, 4/22/25, 4/26/25, 5/2/25, 5/6/25, 5/11/25, 5/16/25, 3. Nurse Treatment Cart Controlled Substance Book and Shift Counts were reviewed, which indicated the facility counts at the change of each shift, approx. 3 times a day. The person authorized to administer medications coming on duty and/or the person authorized to administer medications going off duty both failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was done on the following dates: 7/9/24, 7/12/24, 7/13/24, 7/14/24, 7/15/24, 7/16/24, 7/20/24, 7/21/24, 7/27/24, 7/28/24, 7/29/24, 7/30/24, 7/31/24, 8/2/24, 8/4/24, 9/1/24, 9/2/24, 9/3/24, 9/4/24, 9/7/24, 9/8/24, 9/10/24, 9/11/24, 9/14/24, 9/15/24, 9/16/24, 9/17/24, 5/15/25, 5/16/25, 5/17/25 and 5/18/25. On 5/20/25 at 9:02 a.m., during an interview, the Director of Nursing Services confirmed the above stating she had looked through all the narcotic books and they are missing quite a bit. A review of the facility's Inventory Control of Controlled Substances policy and procedure dated 8/1/24 states: Facilities should ensure the incoming and outgoing nurses count all Schedule 2 controlled substances and other medications with a risk of abuse or diversion at the change of shift . and document the results on a Controlled Substance Count Verification/Shift Count Sheet.

Based on observations and interviews, the facility failed to adequately maintain maintenance and housekeeping services necessary to maintain the facility in good repair and sanitary condition for 1 of 1 environmental tour (5/21/25). Findings: On 5/21/25 from 8:20 a.m. to 8:45 a.m., an Environmental Services tour was conducted with the Environmental Services Director and the Administrator, in which the following findings were observed: A Unit - Shower/Spa room - The caulking around the base of the toilet was stained and dirty. The four shower curtains were stained and/or ripped. The heater unit had chipped/missing paint and the entrance metal door and door frame had chipped/missing paint creating uncleanable surfaces. - Resident room [ROOM NUMBER] - The privacy curtain was missing hooks, hanging down and in disrepair. - Resident room [ROOM NUMBER] - The wall across from the sink had chipped/missing paint and was marred with black marks creating an uncleanable surface. There was a wash basin sitting on the floor under the sink. - Resident room [ROOM NUMBER] - The caulking around the base of the toilet was stained and dirty. The flooring around the toilet was stained and discolored. - Resident room [ROOM NUMBER] - The wall across from the sink had chipped/missing paint and was marred with black marks creating an uncleanable surface. - Resident room [ROOM NUMBER] - The caulking around the base of the toilet was stained and dirty. - Resident room [ROOM NUMBER] - The caulking around the base of the toilet was stained and dirty. The bathroom exhaust fan was dusty/dirty. - Resident room [ROOM NUMBER] - The room entrance wooden door had chipped/gouged and missing laminate. B Unit - Resident room [ROOM NUMBER] - The caulking and floor around the base of the toilet was stained and dirty. There were two pieces of grey duct tape, approximately eight inches long, stuck onto the middle of the bathroom floor that had started peeling up creating uncleanable surfaces. - Resident room [ROOM NUMBER] - The baseboard heater had metal parts that had separated and unhooked from brackets. The caulking around the base of the toilet was stained and dirty. - Resident room [ROOM NUMBER] - Resident #17's electric wheelchair was dirty/dusty around the controller and the foot base area had food crumbs and debris in it. - Resident room [ROOM NUMBER] - The caulking around the base of the toilet was stained and dirty. C Unit - Resident room [ROOM NUMBER] - The room entrance wooden door had chipped/gouged and missing laminate. On 5/21/25 at 8:45 a.m., during an interview, the Environmental Services Director and the Administrator confirmed the findings.

Based on record reviews and interviews, the facility failed to implement a resident's care plan in the area of indwelling urinary catheters for 2 of 2 residents reviewed. (Resident #150, #35) Findings: 1. A review of the clinical record revealed Resident #150 was admitted in May, 2024, and had diagnoses which included obstructive uropathy and neuromuscular dysfunction of the bladder. Resident #150 required an indwelling catheter for urinary elimination. A review of Resident #150's care plan included a problem area of Alteration in Elimination related to obstructive uropathy with urinary retention as evidenced by insertion of indwelling catheter. Interventions included record amount, color and characteristics of urine, and monitor output. 2. A review of the clinical record revealed Resident #35 was admitted in September, 2024, and had diagnoses which included neurogenic bladder and a history of urinary tract infections. Resident #35 required an indwelling catheter for urinary elimination. A review of Resident #35's care plan included a problem area of Alteration in Elimination related to neuropathic bladder with urinary retention and need for a foley catheter. Interventions included record amount, color, and characteristics of urine. Document output each shift. A review of CNA (Certified Nurse Assistant) and Nurse Treatment Administration Record (TAR) documentation lacked evidence that staff consistently monitored and documented urinary output for either Resident #150 or #35. On 5/21/25 at 9:30 a.m., in an interview with a surveyor, the Administrator stated residents with indwelling catheters do not have urinary output documented unless there is a physician's order. On 5/27/25 at 11:30 a.m., in a telephone interview with the Director of Nursing Services (DNS), a surveyor discussed that although there were no provider orders to monitor and record urinary output for Residents #150 and #35, their care plans indicated that staff would monitor and record the amount of urinary output. The DNS confirmed that this had not been done as written in the care plan.

Based on observations, interviews, record reviews, and the smoking policy, the facility failed to ensure a smoking assessment of resident capabilities and deficits to determine resident safety was completed for 2 of 2 resident reviewed for smoking. (#302 and #22) Findings: 1. On 5/19/25 at 9:12 a.m., during an interview, Resident #302 stated he/she has been smoking cigarettes since admission, approx. 2 weeks and the facility has a smoking area outside that is fenced in. He/she confirmed that on several occasions a staff member, called a helper has gone out with him/her. On the bedside table was a pack of cigarettes with a lighter. Review of Resident #302's medical record lacked evidence of a smoking assessment upon admission or upon the facilities knowledge of him/her smoking and lacked a smoking contract. On 5/20/25 at 1:52 p.m., during an interview, the Director of Nursing Services (DNS) confirmed a smoking assessment was not completed upon admission or upon the facility knowledge of the resident smoking until 5/20/25. 2. On 5/19/25 at 8:58 a.m., during an interview with Resident #22, it was determined that he/she is a smoker. At this time a surveyor observed 3 boxes of cigarettes in his/her room. One in his/her shirt pocket and two on the windowsill. On 5/19/25 at 9:00 a.m., during an interview, the Licensed Practical Nurse #1 (LPN) stated Resident #22 goes out alone to smoke. Review of Resident #22 clinical record indicated that he/she was admitted in February of 2025, furthermore the record lacked evidence of a completed smoking assessment. On 5/20/25 at 9:05 a.m., during an interview with the DNS, it was confirmed that a smoking assessment was never completed on Resident #22. The DNS then discussed that the smoking assessment is what triggers the decision if residents are able to keep their cigarettes and lighter at bedside or if they need to be in a secured place within the facility. The facilities Resident Smoking Policy last revised on 8/22 states, For Residents who wish to smoke, the Resident Smoking Assessment will be completed upon admission, or once they begin smoking, and then quarterly for the remainder of their stay. If assessed as safe to smoke independently, residents, who smoke, will be required to sign a smoking contract and to abide by this policy at all times. Not all residents are permitted to have lighters for safety reasons. If a resident is deemed capable and safe to maintain a lighter, it should be with them, or appropriately secured and not shared with others.

Based on observations, record reviews, interviews and the facility policy, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 5 of 5 residents reviewed for respiratory care. (Residents #2, #29, #11, #40, and #302) Findings: 1. On 5/19/25 at 8:45 a.m., and on 5/20/25 at 9:00 a.m., Resident #2 was observed receiving oxygen at 3 Liters Per Minute (LPM) via nasal cannula. The tubing was dated 5/6/25. A review of the clinical record revealed a diagnosis of Acute and Chronic Respiratory Failure with Hypoxia and Congestive Heart Failure requiring use of oxygen supplementation. Physician orders, dated 3/25/25, included oxygen 1-3 Liters via nasal cannula to maintain oxygen saturation greater than 88% or more, and change the oxygen tubing one time weekly. Review of the Treatment Administration Record (TAR) for May of 2025 indicated the O2 nasal cannula tubing is changed weekly. Documentation on the TAR revealed staff last changed the oxygen tubing on 5/13/25. 2. On 5/19/25 at 9:30 a.m., and on 5/20/25 at 9:00 a.m., Resident #29 was observed receiving oxygen at 2.5 Liters Per Minute (LPM) via nasal cannula. The tubing was dated 5/6/25. A review of the clinical record revealed a diagnosis of Acute Respiratory Failure with Hypoxia requiring use of oxygen supplementation. Physician orders, dated 4/18/25, included oxygen 3 Liters via nasal cannula and change the oxygen tubing one time weekly. Review of the TAR for May of 2025 indicated the O2 nasal cannula tubing is changed weekly. Documentation on the TAR revealed staff last changed the oxygen tubing on 5/13/25. On 5/20/25 at approximately 9:10 a.m., the findings were confirmed by the Charge Nurse, who stated the oxygen tubing is usually changed every 2 weeks. On 5/20/25 at 9:30 a.m., the surveyor discussed the findings with the Director of Nursing Services (DNS). 3. On 5/19/25 at 8:29 a.m., and at 3:36 p.m., Resident #11 was observed receiving oxygen at 4 LPM via nasal cannula with the tubing dated 5/6/25. On the bedside dresser was a nebulizer pipe stored on top. A review of the clinical record revealed a diagnosis of COPD (chronic obstructive pulmonary disease), metastatic lung cancer and end stage emphysema requiring use of oxygen supplementation. Physician orders dated 4/2/25 included oxygen 3-4 Liters via nasal cannula and change the oxygen tubing one time weekly. The care plan initiated on 4/11/25 for Impaired Respiratory Status had an intervention of Change oxygen tubing weekly; label and date. Review of the TAR for May 2025 indicated the oxygen nasal cannula tubing is changed weekly. Documentation on the TAR revealed staff last changed the oxygen tubing on 5/13/25. 4. On 5/19/25 at 11:23 a.m., observation of Resident #40's nebulizer mask with tubing, unlabeled and stored on the dresser. At this time, Resident #40 stated he/she has not used the nebulizer for probably 2 or more months when he/she had pneumonia. Further review, a Physician order for the nebulizer was discontinued on 1/16/25. On 5/19/25 at 4:19 p.m., during an interview, the DNS stated oxygen tubing and Nebulizer kits are changed every 2 weeks per the policy, but some residents have orders for weekly changes. At this time both the DNS and the surveyor observed the above and discussed resident #11's oxygen tubing dated 5/6 with the documentation on the TAR as the tubing being changed on 5/13/25. On 5/20/25 at 7:01 a.m., after the discussion with the DNS the day prior, the surveyor again observed resident #11 utilizing the oxygen tubing dated 5/6. 5. On 5/19/25 at 9:12 a.m., observation of Resident #302 to have an oxygen cylinder stored in the room with the nasal cannula tubing wrapped around the caddy handle. At this time, Resident #302 stated he/she uses the oxygen tank while working with therapy. On 5/20/25 at 2:22 p.m., both the surveyor and the Quality Improvement Specialists observed Resident #302's nasal cannula tubing wrapped around the cylinder caddy handle. A review of the facility's Oxygen Use and Storage Policy, with a revision date of 4/2025, stated under Section V. Respiratory Care - a. Nasal cannulas will be discarded and changed every 2 weeks . When the nasal cannula is not in use, on both the concentrator and portable tanks, the cannula will be stored in a plastic bag to avoid the risk of it becoming contaminated. b. Nebulizer parts should be rinsed after each use, allowed to dry while being covered with a paper towel and placed in respiratory setup bag once dried. d. Staff changing the tubing should document on the Treatment Administration Record (TAR) when the tubing has been changed following this policy.

Based on the review of annual evaluations and interviews, the facility failed to complete an annual performance evaluation for Certified Nursing Assistants (CNA) at least every 12 months, for 5 of 5 CNA's reviewed with employment greater than 1 year. (CNA#1, CNA#2, CNA#3, CNA#4, and CNA#5 ) Findings: 1. CNA #1 was hired on 11/28/2012. The employee record lacked evidence of an annual performance evaluation being completed for 2024. 2. CNA #2 was hired on 4/28/2016. The employee record lacked evidence of an annual performance evaluation being completed for 2024. 3. CNA #3 was hired on 11/6/2002. The employee record lacked evidence of an annual performance evaluation being completed for 2024. 4. CNA #4 was hired on 4/26/21. The employee record lacked evidence of an annual performance evaluation being completed for 2024. 5. CNA #5 was hired on 9/8/23. The employee record lacked evidence of an annual performance evaluation being completed for 2024. On 5/20/25 at 11:10 a.m., during an interview, the Director of Nursing Services stated and confirmed that the 5 CNAs did not receive their annual performance evaluations for 2024.

Based on observations, interviews and facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for 1 of 1 kitchen tour. Furthermore, the facility failed to ensure staff were wearing proper beard restraints for 1 of 3 days of survey (5/20/25). Findings: 1. On 5/19/25 a surveyor toured the kitchen and observed the following: > The kitchen floor was dirty with food debris and trash around the entire floor, under the equipment, and shelving. > Dirt and debris observed in the hood system, in the fan in the walk-in refrigerator, and in the [NAME] Fli fly zapper. > The reach in refrigerator was noted to have dirt, debris, and spillage. > The walk-in refrigerator and walk-in freezer had dirt, debris, and spillage on the floors. > The plastic coverings on the racks containing clean dishes are in despair and were soiled with dry liquid residue. On 5/19/25 at 8:30 p.m., during an interview with 2 surveyors, the above information was confirmed with the Food Service Director. 2. On 5/20/25 at 12:25 p.m., observation of a Dietary Aid, with facial hiar, not wearing a beard restraint while in the kitchen. Upon surveyor intervention the Dietary Aid applied a beard restraint. On 5/20/25 at 12:30 p.m., the above information was discussed with the Food Service Director. The Facility policy Employee Sanitary Practices under procedure, states all employees shall wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food.

Based on Certified Nursing Assistant (CNA) employee education record review and interview, the facility failed to monitor and ensure that the CNAs received the required 12 hours of annual in-service education training including Dementia, Resident Rights and Abuse/ Neglect training for 5 of 5 CNAs employed greater than 1 year. (CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5). Findings: On 5/20/25 a surveyor reviewed the following employee files: 1. CNA #1 was hired on 11/28/2012. A review of CNA #1's education records lacked evidence that she had received the required 12 hours of education/in-service training including Dementia, Resident Rights and Abuse/ Neglect in 2024. 2. CNA #2 was hired on 4/28/2016. A review of CNA #2's education records lacked evidence that she had received the required 12 hours of education/in-service training including Dementia, Resident Rights and Abuse/ Neglect in 2024. 3. CNA #3 was hired on 11/6/2002. A review of CNA #3's education records lacked evidence that she had received the required 12 hours of education/in-service training including Dementia, Resident Rights and Abuse/ Neglect in 2024. 4. CNA #4 was hired on 4/26/21. A review of CNA #4's education records lacked evidence that she had received the required 12 hours of education/in-service training including Dementia, Resident Rights and Abuse/ Neglect in 2024. 5. CNA #5 was hired on 9/8/23. A review of CNA #5's education records lacked evidence that she had received the required 12 hours of education/in-service training including Dementia, Resident Rights and Abuse/ Neglect in 2024. On 5/20/25 at 10:45 a.m., in an interview, the Business Office Manager confirmed that the 5 CNAs did not have documentation to show they received 12 hours of education including Dementia, Resident Rights and Abuse/ Neglect in 2024. On 5/20/25 at 11:10 a.m., in an interview, the Director of Nursing Services confirmed that that the 5 CNAs did not have documentation to show they received 12 hours of education including Dementia, Resident Rights and Abuse/ Neglect in 2024.

Based on record review and interview, the facility failed to provide evidence of documentation to justify the continued use of a psychotropic medication and failed to ensure an as needed (PRN) psychotropic medication met the required 14-day limit for 2 of 6 residents reviewed for unnecessary medications. (#33, #11) Finding: 1. A review of the clinical record revealed Resident #33 was admitted in September, 2024. On 12/9/25, the pharmacist consultant submitted the following recommendation to the physician: (Resident #33) recently experienced a fall on 11/29. A review of the medical record was conducted, identifying the following medications which may contribute to falls: Risperidone, Lorazepam, Fluoxetine, Trazodone. Recommendation: Please evaluate these medications as possibly causing or contributing to this fall and consider decreasing the dose of one of these medications, possibly Risperidone. If this therapy is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that the medication is not believed to be contributing to falls in this individual, and b) the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences. The Physician's response, dated 12/17/24, was Thank you. No change. On 5/20/25 at 3:50 p.m., in an interview with the Director of Nursing Services (DNS), the surveyor discussed the physician had not provided an adequate indication for continued use of the medications, specifically the antipsychotic Risperidone. At this time, the DNS took the consultant pharmacist's report back to discuss with the physician, and returned with the physician's response on the form: Please review record, actively titrated for dementia, meds for safety/dignity. 2. Resident #11's medical record contained a provider order, dated 4/4/25, for Lorazepam 0.5 mg (milligram) tablet orally PRN every 4 hours for anxiety disorder, with no stop date. As of 5/20/25, the medical record lacked evidence of clinical rational to continue the medication longer than 14 days. On 5/20/25 at 3:45 p.m., the above was confirmed with the Director of Nursing Services.

Based on clinical record review and interviews, the facility failed to follow physician orders for 1 of 25 residents reviewed. (Resident #41). Findings: Review of Resident #41's clinical record noted the following doctor's order dated 1/4/25 for Aspart insulin 100 unit/ml (milliliter), 7 units subcutaneously 3 times daily. A nursing progress note dated 3/19/25 at 6:35 p.m., stated, nurse on duty completed 1600 hs (evening) blood glucose check upon resident arrival from dialysis. Nurse on duty informed charge nurse of the resident blood glucose level which was 91. Nurse on duty informed charged nurse that resident did have a sliding scale parameter for 1600. Nurse on duty stated she had already given resident insulin but was unable to verify the amount to the nurse on duty or the resident. Resident stated to nurse on duty that charge nurse had informed [him/her] that the wrong amount was given and was unable to specify the specific number that was administered to [him/her]. Charge nurse also informed the resident that she was going to administer [him/her] some orange juice and to report and s/s of any reactions the resident may feel regarding a reaction. Charge nurse did inform nurse on duty that she administered orange juice to resident and told the resident to report any s/s of adverse reactions. Resident asked nurse on duty how many units were administered to [him/her] in the abdomen. Nurse on duty was unable to provide an accurate answer. Nurse on duty informed NOC (night) charge nurse of the situation. Resident will continue to be monitored for any and all adverse reactions or responses. Safety precautions are in place and resident states [he/she] feels anxious at this present time and is requesting [his/her] blood glucose to be rechecked at this time. Resident states [he/she] is upset at the situation and informed nurse on duty that [he/she] did call [his/her] sister to inform her of the incident. Nurse on duty will recheck resident blood glucose at this time. On 5/19/25 at 3:32 p.m., during an interview, the Director of Nursing Services (DNS) confirmed that the resident had an order for 7 units of Aspart insulin but was given 12 units of Humalog insulin instead on 3/19/25 at 1600 and confirmed that the doctor's order was not followed.

Based on observation and interview, the facility failed to adequately date and properly dispose of open biologicals according to manufacturer specifications in 1 of 3 medication carts observed for medication storage. Finding: On [DATE] at 7:33 a.m., observation of the Nurse Treatment cart with the Licensed Practical Nurse (LPN) the following was observed; one opened and unlabeled Basaglar (insulin) Kwik Pen with the manufacturer's instructions of, after first use .discard after 28 days and a Epinephrine injection with manufactures exp date of 4/2025. At this time, the LPN confirmed they were either undated and/or expired. On [DATE] at 7:48 a.m., the above was discussed with the Director of Nursing Services

Based on observation and interview, the facility failed to maintain the garbage storage area in a sanitary condition to prevent the harborage and feeding of pests for 1 of 3 days of survey. (5/19/25) Findings: On 5/19/25 at 8:30 a.m., 2 surveyors and the Food Service Director (FSD) observed a heavily soiled garbage storage area containing 3 trash dumpsters, in which food and trash debris were noted behind all 3 trash dumpsters. At this time the above information was confirmed.

Based on record review and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction for identified deficiencies from the Annual Long Term Care Survey Process for Federal Recertification dated 5/21/25, was effective. The Federal citation F695 was cited again during the re-visit to the annual Long Term Care Recertification Survey, dated 7/15/25.During the follow-up survey on 7/15/25, it was determined that F695 for failure to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care. (see F695). On 7/15/25 at 3:45 p.m., during an interview, the above was confirmed with the Administrator and the Director of Nursing.

Based on record reviews and interview the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 sampled residents reviewed during a complaint investigation (Resident #3), in addition, the facility failed to ensure psychotropic medication orders included an appropriate diagnosis for 1 of 1 residents reviewed for medications (Resident #2). Findings: 1. Resident #3 was admitted on [DATE] and has diagnoses to include state 4 pressure ulcer on his/her coccyx. Review of signed provider orders active August 2024 reveled order with start date of 10/18/23 Resident information every two hours. Turn patient every 2 hours, waffle heel protectors at all times while in bed May remove for ADL's. Review of Resident #3's Treatment Administration Record dated August 2024 revealed nursing documentation indicating Resident #3 was repositioned every two hours from August 1st through 13th. Review of Resident #3's clinical record revealed positioning sheets between 7/11/24 through 8/13/24 lacked evidence that Resident #3 was repositioned every 2 hours. During an interview on 8/13/24 at 3:40 p.m., Resident #3 indicated staff are supposed to turn/reposition him/her every 2 hours and sign the repositioning sheet that it was done, but they don't do it like they're supposed to. At this time Resident #3 provided turn and reposition sheet dated 8/13/24 with multiple missing entries. During an interview on 8/13/24 at 1:05 p.m., Licensed Practical Nurse (LPN)1 indicated Resident #3 has a stage 4 pressure ulcer on his/her coccyx and is on a 2 hour repositioning schedule. LPN#1 indicated its assumed that CNAs are repositioning him/her every 2 hours and the nurses just sign off on it unless a CNA says otherwise. At this time RN reviewed turning sheets with surveyor and confirmed resident was not being turned as ordered. During an interview on 8/13/24 at 3:45 p.m., Certified Nursing Assistant (CNA)2 indicated that Resident #3 has a turning schedule for every 2 hours and he/she has a sheet staff are supposed to sign and if she refuses to be turned the sheet would still need to be signed as a refusal. During an interview on 8/13/24 at 3:05 p.m., CNA3 indicated that Resident #3 is on 2 hour reposition schedule and it needs to be signed, and if she refuses it [NAME] d be signed as a refusal and they should tell nurse. During an interview on 8/13/24 at 4:38 p.m., Director of Nursing confirmed with 2 surveyors Resident #3 does have an order for reposition every 2 hours and CNAs are supposed to document on bedside sheet when it has been done or was refused. Reviewed turning sheets and confirmed Resident #3 were not being done. 50218 2. Resident #2 was admitted to Facility on 5/2/24 with diagnosis to include encephalopathy and cerebral infarction resulting in restlessness and agitation . Review of Resident #2's active orders for August 2024 reveled the following: Sertraline 50mg tablet by mouth daily starting 5/29/24 (Diagnosis exempt), Lorazepam 0.5mg tablet by mouth two times daily starting 6/5/24 (restlessness and agitation), Trazodone 50mg tablet by mouth 2 times daily starting 8/10/24 (restlessness and agitation), Lorazepam 0.5mg tablet by mouth as needed starting 6/5/24 (restlessness and agitation). During interview on 8/13/24 at 4:43p.m., Director of Nursing confirmed Resident #2's phychotropic medications did not have appropriate diagnoses with 2 surveyors. Review of policy titled Psychoactive Medication Use Policy states .Procedure: . Psychoactive medications will only be used for residents with an appropriate diagnosis''

Based on record review, observations, interviews, Center for Medicare and Medicaid (CMS) guidance, and Center for Disease Control (CDC) guidance, the facility failed to maintain and implement an infection control program to help prevent the development and transmission of infectious disease for 3 of 3 residents reviewed for foley catheters (Residents #1, #2, and #3). Findings: Review of CMS guidance dated 3/20/24 states .Enhanced Barrier Precautions (EBP) recommendations now include use of EBP for residents with .indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. indwelling medical device, and secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO. Contact precautions until the organism is identified; EBP if they do not meet criteria for contact precautions . Review of CDC guidance dated 4/2/24 states .EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. Infection or colonization with an MDRO . Contact Precautions are intended to prevent transmission of infectious agents, like MDROs, that are spread by direct or indirect contact with the resident or the resident's environment. 1. Resident #1 was admitted to facility on 2/6/23 with diagnoses to include neurogenic bladder requiring a foley catheter. Review of Resident #1's clinical record lacked evidence he/she was placed on EBP upon admission. Further Review of Resident #1's clinical record revealed he/she was admitted to the hospital with urosepsis secondary to a urinary tract infection (UTI) on 1/27/24 through 1/31/24 and 7/29/24 through 8/7/24 for septic shock secondary to UTI. Review of Resident #1's Routine Microbiology collected 7/28/24 states Final report:100,000 cfu/ml Escherichia coli ESBL) 10,000-50000 cfu/ml Escherichia coli #2 presumptive. Further review of Resident #1's clinical record lacked evidence he/she was placed on contact precautions after this ESBL diagnoses. Observations of Resident #1 on 8/13/24 between 9:50 a.m. and 4:37 p.m., revealed no evidence that he/she was on contact precautions for ESBL infection. During an interview on 8/13/24 at 10:00 a.m., Practical Nurse (LPN)1 indicated Resident #1 did not have a current infection. During a follow up interview on 8/13/24 at approximately 3:34 p.m., LPN1 indicted she was unaware that Resident #1 had ESBL and has not been on any precautions since his/her admission. During an interview on 8/13/24 at 3:50 p.m., Certified Nursing Assistant (CNA)2 indicated that she was not aware that Resident #1 had an infection and was not aware of any precautions needed when providing care to Resident #1. 2. Resident #3 was admitted on [DATE] and has diagnoses to include history of urosepsis, and urine retention requiring a urinary catheter. Review of Resident #3's clinical record lacked evidence that he/she was placed on EBP precautions on admission. Review of Resident #3's clinical record revealed he/she was transferred to an acute care on and subsequently admitted with urosepsis secondary to a UTI on 3/30/24 through 4/5/24 and from 7/23/24 through 8/1/24 when he/she was admitted with septic shock) Further review of Resident #3's clinical record revealed Routine Microbiology results dated 5/4/24 states .The isolate above exhibits extended spectrum Beta Lactamase activity (ESBL).Further review of Resident #3's clinical record lacked evidence that he/she was placed on contact precautions after diagnosis of ESBL. On 8/13/24 at 1:05 p.m., Licensed Practical Nurse (LPN)1 indicated that Resident #3 has had a few UTI 's from his/her catheter and was not aware of ESBL diagnoses and has never been placed on any infection precautions. During an interview on 8/13/24 at 3:45 p.m., Certified Nursing Assistant (CNA) 2 indicated that no one has ever informed her that Resident #3 had an infection and has never been on any precautions. During an interview on 8/13/24 at 3:05 p.m., CNA3 indicated that no one has ever informed her that Resident #3 needed to be on precautions and does not know what precautions to take. During an interview on 8/13/24 at 4:38 p.m., Director of Nursing (DON) reviewed Resident #1 and #3's test results with 2 surveyors and Residential Care Director, confirming ESBL diagnoses and were not placed on contact precautions. DON also confirmed all three residents with catheters have had multiple infections and they were not placed on ESBL precautions on admission. DON stated, Now that I think of it, all residents with catheters should be on precautions. 50218 3. Resident #2 was admitted to the facility on [DATE] with diagnosis to include Retention of Urine, requiring an indwelling catheter. Observations of Resident #2 on 8/13/24 at 9:51 a.m, 12:30 p.m., 1:50 p.m., and 2:00 p.m., lacked evidence that that he/she was placed on Enhanced Barrier Precautions. Review of Resident #2's clinical record revealed order dated 8/2/24 for Macrobid100 mg capsule . orally two times daily for seven days for a urinary tract infection. During an interview on 8/13/24 at 10:01 a.m., Licensed Practical Nurse (LPN) #1 Indicated that there are three residents that have urinary catheters and are not on any precautions. During interview on 8/13/24 at 2:35 p.m., Director of Nursing (DON) indicated that any resident with a catheter should be on precautions. During follow-up interview at 3:01p.m., DON indicates that the facility follows CDC Guidelines.

Based on observations and interviews, the facility failed to make reasonable accommodations to maintain the call system within reach for 2 of 3 residents (Resident #2) observed for call bells. Findings: 1. Observations of Resident #2 on 8/13/24 at 12:30 p.m., and 1:56 p.m., revealed call bell handing from wall and attached to a wiffleball lying the end of his/her bed and not in reach. 2. Observation of Resident #1 on 8/13/24 at 1:56 p.m. revealed call bell tucked under Resident #1 and not in reach. During interview on 8/13/24 at 1:57 p.m., Certified Nursing Assistant (CNA) #1 indicated that Resident #2 rarely uses the call bell, but the resident's roommate, Resident #1, will use call bell for him/her. During interview on 8/13/24 at 2:03 p.m., CNA #2 indicated Resident #1 typically rings for Resident #2. CNA #2 further indicated that all staff should be ensuring that call bells are in reach for all residents.

Based on interview, record review, the facility failed to initiate and implement measures to prevent spread of disease regarding urinary catheters for 2 of 3 residents reviewed during a complaint investigation (Resident's #1 and #3). Findings: 1. Resident #1 was admitted on [DATE] with diagnoses and recent history of urosepsis, and neurogenic bladder requiring a urinary catheter. Review of Resident #1 Routine Microbiology results dated 8/1/24 states .The isolate . exhibits extended spectrum Beta Lactamase activity (ESBL).ID [Infectious Disease] consult is recommended. Further review of Resident #1's clinical record lacked evidence that a referral was made to infectious disease. 2. Resident #3 was admitted on [DATE] and has diagnoses to include history of urosepsis, paraplegia, and urine retention requiring a urinary catheter. Review of Resident #3's clinical record revealed Routine Microbiology results dated 5/4/24 state .The isolate above exhibits extended spectrum Beta Lactamase activity (ESBL).ID consult is recommended . Further review of Resident #3's clinical record lacked evidence that he/she was referred to Infectious Disease. During an interview on 8/13/24 at 4:38 p.m., Director of Nursing confirmed with 2 surveyors and Residential Care Director Resident's #1 & #3 were diagnosed with ESBL in urine and should have been referred to Infectious Disease and were not.

Based on record reviews, interviews, and policy review, the facility failed to obtain written consent for psychotropic medications for 1 of 1 (Resident #2) residents reviewed for unnecessary medications. Findings: Resident #2 was admitted on [DATE] with diagnosis to include encephalopathy, cerebral infarction resulting in restlessness and agitation. Review of Resident #2's active orders for August 2024 reveled the following: Sertraline 50mg tablet by mouth daily starting 5/29/24, Lorazepam 0.5mg tablet by mouth two times daily starting 6/5/24, Trazodone 50mg tablet by mouth 2 times daily starting 8/10/24, Lorazepam 0.5mg tablet my mouth as needed starting 6/5/24. Review of entire clinical record lacked evidence that Resident #2 or the Resident Representative was was given the opportunity to consent to the use of psychotropic medications. During a telephone interview on 8/12/24 at 1:03 p.m. Resident #2's Resident Representative indicated they were never asked for consent for psychotropic medication prescriptions. During an interview on 8/13/24 at 4:56 p.m., Director of Nursing and Residential Care Director reviewed Resident #2's clinical record and confirmed with 2 surveyors Resident #2 and/or Resident Representative that consent was not obtained for use of psychotropic medications. Review of policy titled Psychoactive Medication Use Policy states .Procedure: . Informed consent for psychoactive medication use will be obtained.

Based on record reviews and interview, the facility failed to ensure the Notice of Medicare Provider Non-Coverage (NOMNC) form was provided at least two days prior to the end of Skilled services for 2 of 3 residents whose Medicare Part A Skilled services were discontinued (Residents #302, 303). Findings: 1. On 10/6/23, Resident #302 was admitted from a hospital to receive skilled services. On 11/3/23, Resident #302 was discharged to the community with benefit days remaining. The medical record lacked evidence that Resident #302 or his/her legal representative received a NOMNC. 2. On 9/11/23, Resident #303 was admitted from a hospital to received skilled services. On 10/13/23, Resident #303 was discharged to the assisted living unit within the facility with benefit days remaining. The medical record lacked evidence that Resident #303 or his/her legal representative received a NOMNC. On 3/13/24 at 2:58 p.m., the Director of Nursing stated to 3 surveyors that the facility did not have the beneficiary notices as requested for Residents #302 and #303.