Every finding on record at Russellville Nursing and Rehabilitation Center

Based on observation, record review, interview, and facility policy review, the facility failed to ensure Minimum Data Sets (MDS) were completed in a timely and accurate manner for two (Resident #106 and Resident #70) of two residents reviewed; specifically, that a quarterly MDS was accurately completed for (Resident #70) to indicate an appropriate smoking status, and that an admission MDS was completed within 15 days of admission for Resident #106. The findings include: Resident #106 A review of Resident #106's Care Plan revealed the facility admitted the resident on 02/05/2026, with diagnoses which included alcohol use, unspecified intoxication, cardiac arrythmias, and spinal stenosis. A review of the MDS portion of Resident #106's electronic record on 02/24/2026 revealed an in progress status with a start date of 02/09/2026 for the admission MDS. During an interview on 02/24/2026 at 3:45 PM, MDS Coordinator #9 confirmed Resident #106's admission MDS was delinquent, due to MDS Coordinator #9 having an extended medical leave that started in October 2025. During an interview on 02/25/2026 at 11:43 AM, the Administrator and Assistant Administrator stated because they had two MDS Coordinators, when one MDS coordinator was absent, the other was expected to complete all assessments within the allotted timeframe, which was within a15 days after admission. During an interview on 02/26/2026 at 9:17 AM, the Director of Nursing (DON) stated that if admission assessments were delinquent, information would not be relayed to the appropriate people and correct treatments could be delayed. The DON stated that the DON should oversee the MDS Coordinators but had not yet reached that point in training. During an interview on 02/26/2026 at 9:26 AM, the Assistant Director of Nursing stated that a failure to complete assessments could result in a resident decline or change not being relayed to staff, leading to a delay in proper care. During an interview on 02/26/2026 at 10:58 AM, Medical Director (MD) #10 stated her expectation for facility staff was that assessments were completed in a timely manner. MD #10 then reported if assessments were not completed timely, it could result in resident's not receiving proper care and having missed appointments. MD #10 then reported that she strived for completing [MDS assessments] in the 48-hour window but definitely no longer. During an interview on 02/26/2026 at 12:56 PM, MDS Coordinator #9 reported the Resident Assessment Instrument (RAI) manual was used for guidance when coding to the MDS. This surveyor requested a copy of section in the RAI manual that indicated a time frame for completing admission MDS assessments from the MDS coordinator. On 02/26/2026 at 1:12 PM, this surveyor received a document regarding the time frame for completing admission MDS assessments from the RAI Manual dated [DATE] chapter 2: section 2-6The RAI Manual indicated the time frame for an MDS to be completed upon admission was 15 days post admission. Resident #70 During an observation on 02/24/2026 at 1:50 PM, Resident #70 was smoking while wearing a protective apron and staff provided the resident with cigarettes and the lighter. A review of Resident #70's Medical Diagnosis revealed the resident had diagnoses which included right side hemiplegia, heart disease with heart failure, wheezing, cerebral infarction (stroke), depression, hypertension (high blood pressure), and chronic obstructive pulmonary disease. A review, conducted on 02/23/2026 at 2:15 PM, of Resident #70's Care Plan, revised 01/07/2026, revealed there was no documentation of the resident's smoking status. Resident was initially admitted on [DATE] and review of records indicate that resident was assessed for smoking on 07/29/2025. A review of Resident #70's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/01/2026 did not indicate the resident smoked. A review of Resident #70's quarterly smoking safety evaluation revealed the evaluation was 19 days past the required completion date of 02/05/2026. A review of resident's medical record indicated that Resident #70's last quarterly smoking assessment was completed on 11/05/2025. The next scheduled assessment should have been 90 days after the last quarterly assessment. A review of Resident #70's closet Care Plan on 02/26/2026 at 11:49 AM, revealed the resident was listed as a smoker, despite the official Care Plan lacking the information. During an interview on 02/24/2026 at 2:06 PM, Licensed Practical Nurse (LPN) #3 stated that smoking assessments were required upon admission, quarterly, or with a significant change in condition by any charge nurse for admissions. LPN #3 stated MDS Coordinators #8 and #9 were responsible for the residents' quarterly and significant change assessments. During an interview on 02/25/2026 at 9:05 AM, MDS Coordinators #8 and #9 stated the assessments, both smoking and quarterly MDS, were not completed in the allotted timeframe due to MDS Coordinator #9 being off work for an extended period. MDS Coordinators #8 and #9 confirmed the assessments fell behind and that had any incidents occurred, updates would have been made. During an interview on 02/25/2026 at 11:43 AM, the Administrator acknowledged that if the condition of a resident changed without a new assessment, the facility might not identify new safety risks. During an interview on 02/26/2026 at 8:31 AM, LPN #3 stated that the floor nurses did not perform smoking assessments, as this task was assigned to the MDS Coordinators, unless it was an admission assessment. During an interview on 02/26/2026 at 11:48 AM, CNA #1 stated that a closet Care Plan was used to identify smokers and confirmed the need for a smoking apron.

Based on record review, interview, and facility document review, the facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the 90-day regulatory timeframe for 11 (Residents #25, #36, #38, #50, #60, #62, #67, #69, #73, #76, and #83) of 15 residents reviewed for quarterly assessments. The findings include: During a review of the resident's quarterly MDS assessments on 02/24/2026 at 11:01 AM, the following past due quarterly assessments were identified: - Resident #25's last quarterly MDS was completed on 10/16/2025, their next assessment was due on 01/16/2026.- Resident #36's last quarterly MDS was completed on 10/21/2025, their next assessment was due on 01/21/2026.- Resident #38's last quarterly MDS was completed on 10/10/2025, their next assessment was due on 01/10/2026.- Resident #50's last quarterly MDS was completed on 10/15/2025, their next assessment was due on 01/15/2026.- Resident #60's last quarterly MDS was completed on 10/17/2025, their next assessment was due on 01/17/2026.- Resident #62's last quarterly MDS was conducted on 10/17/2025, their next assessment was due on 01/17/2026.- Resident #67's last quarterly MDS was conducted on 10/10/2025, their next assessment was due on 01/10/2026.- Resident #69's last quarterly MDS was conducted on 10/07/2025, their next assessment was due on 01/07/2026.- Resident #73's last quarterly MDS was conducted on 10/14/2025, their next assessment was due on 01/14/2026.- Resident #76's last quarterly MDS was conducted on 10/14/2025, their next assessment was due on 01/14/2026.- Resident #83's last quarterly MDS was conducted on 10/15/2025, their next assessment was due on 01/15/2026. During an interview on 02/24/2026 at 3:35 PM, Minimum Data Set (MDS) Coordinator #8 stated that assessments were the responsibility of the MDS department and must be completed every 90 days. MDS #8 acknowledged that many assessments were delinquent, because the other MDS Coordinator [MDS Coordinator #9] was absent for six weeks and no backup was provided to assist with the workload. During an interview on 02/24/2026 at 3:45 PM, MDS Coordinator #9 confirmed that the assessments for several residents were delinquent, due to MDS Coordinator #9 having an extended medical leave that started in October of 2025. MDS Coordinator #9 stated that no staff filled the position during the absence. During an interview on 02/25/2026 at 11:43 AM, the Administrator and Assistant Administrator stated that if one MDS Coordinator was absent, the other MDS Coordinator was expected to complete all assessments within the required timeframe. Both the Administrator and Assistant Administrator further acknowledged being unaware that the facility's quarterly assessments were delinquent at that time. During an interview on 02/26/2026 at 9:17 AM, the Director of Nursing (DON)—employed at the facility for nearly a year—stated that delinquent quarterly assessments could prevent the relay of information to the appropriate people and may cause delays in correct treatments. The DON further noted that the DON was responsible for overseeing MDS Coordinators, but the DON had not yet reached the required point in training to fulfill this duty. During an interview on 02/26/2026 at 9:26 AM, the Assistant Director of Nursing stated that a failure to complete quarterly assessments could result in a resident decline or change not being relayed to staff, which could lead to a delay in proper care. During an interview on 02/26/2026 at 10:58 AM, Medical Director (MD) #10 stated that failure to complete quarterly assessments accurately and on time could result in negative outcomes, improper care, and missed appointments. MD #10 stated that the facility's expectation was that assessments would be completed 100% of the time and no more than a 48-hour window for delays. During an interview on 02/26/2026 at 12:30 PM, the Administrator stated that changes and incidents were discussed every morning during morning meetings. The Administrator further noted that if any situation required an immediate update, the update was completed once the meeting concluded. During a review of facility documents on 02/26/2026 at 9:59 AM, the Administrator provided this surveyor with the Policy and Procedure for Resident Assessment, which utilized the Resident Assessment Instrument (RAI) manual, dated 10/20/2025. The RAI manual required three quarterly assessments to be completed within the year, between comprehensive assessments, to ensure timing requirements were met.

Based on observations, record reviews, and interviews, the facility failed to ensure hand hygiene and gloving were appropriately performed for one (Resident #57) of one sampled resident observed during perineal care, and the facility failed to ensure appropriate Personal Protective Equipment (PPE) was worn when administering medication and water flushes through a feeding tube for one (Resident #11) of one sampled resident, to prevent the risk for infection. Specifically, LPN #11 wore gloves and no gown when administering medication and flushes through a feeding tube, a high-contact care activity. The findings include: Resident #57 A review of Resident #57's Medical Diagnosis revealed the resident had diagnoses which included Huntington's disease (rare disorder associated with progressive loss of brain and muscle function), bipolar disorder, and anxiety disorder. A review of Resident #57's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/05/2025, revealed a Brief Interview for Mental Status (BIMS) score of 02, which indicated the resident had severe cognitive impairment. Resident #57's MDS also revealed the resident was frequently incontinent of urine, always incontinent of bowel, and was dependent on staff for toileting. During an observation on 02/23/2026 at 12:25 PM, this surveyor entered Resident #57's room and observed Certified Nursing Assistant (CNA) #13 providing perineal care to the resident. CNA #13 leaned forward and dropped a wet brief into a trash can resting on the left side of the resident's bed. CNA #13 appropriately wiped Resident #57's perineal area with wipes, closed the lid to the wipes, and leaned forward to place the package of wipes on the bedside table, with their contaminated gloves still on. CNA #13 picked up a clean brief and rolled it onto Resident #57 and attached the brief, without changing gloves. CNA #13 revealed they normally changed Resident #57 as a team of two staff members. CNA #13 did not address why she chose to provide perineal care alone at this time. CNA #13 confirmed no she did not change out of dirty gloves before touching a clean brief that was placed on Resident #57. CNA #13 also verified that not doing so could spread germs. During an interview on 02/24/2026 at 1:54 PM, Licensed Practical Nurse (LPN) #11 confirmed CNA #13 was working under her charge and revealed she expected CNAs to wipe residents front to back, not use the same side of a washcloth, be as clean as possible, ensure CNAs were wearing gloves, and provided privacy and dignity during perineal care. LPN #11 stated they would expect staff to change their gloves during perineal care, so they were not transferring bacteria or causing a urinary tract infection. During an interview on 02/24/2026 at 2:10 PM, CNA #14 stated that during perineal care, she took several pairs of gloves, bags, and a clean brief to the resident's room. CNA #14 revealed they would perform hand hygiene and puts on gloves, pull down linens and remove the resident's brief, after wiping the resident. CNA #14 stated they would then sanitize their hands and replace their gloves throughout perineal care. CNA #14 revealed they would remove the gloves and make sure their hands are clean before touching the residents' call light or blankets. CNA #14 stated they would wash their hands again when finished with perineal care. During an interview on 02/24/2026 at 3:54 PM, the Director of Nursing (DON) said staff were expected to have one clean and one dirty CNA during perineal care. The DON also stated that they should change their gloves throughout the process. They [the CNAs] were to wipe the resident at least three times, deglove and wash hands and put on clean gloves to reduce the risk for infection. During an interview on 02/24/2026 at 3:55 PM, the Administrator revealed that during perineal care, they expected there to be a clean and dirty person and for them to change gloves during perineal care, to prevent cross contamination and perform hand hygiene after the task was completed. A review of policy and procedure titled Perineal/Catheter Care, revised, 11/22/2016, revealed staff would need two plastic bags and 3-5 pairs of gloves for perineal care. After removing the wet brief and wiping the resident, then staff were expected to change gloves. Staff would then place a clean incontinent brief pad under the resident and replace the sheet and blanket. A review of an in-service dated 10/09/2025, using a policy titled Perineal/Catheter, revised 11/22/2016, revealed LPN #11 and CNA #14 attended the in-service. The name of the in-service instructor was not documented. A review of an in-service dated January, the year provided confirmed by the administrator as 2026, using a policy titled Perineal/Catheter, revised 11/22/2016, revealed LPN #11 attended the in-service, but CNA #13 and CNA #14 were not in-serviced. CNA #13 did not attend this in-service. The name of the in-service instructor is not documented. Resident #11 During an observation on 02/25/2026 at 9:26 AM, LPN #11 arrived at Resident #11's bedside and stated LPN #11 was going to give a laxative, an anti-gas medication, an anti-heartburn medication, and a protein supplement through Resident #11's feeding tube. LPN #11 was wearing gloves, without a gown for PPE. LPN #11 then revealed the resident's feeding pump was off, because Resident #11 was vomiting on 02/24/2026. LPN #11 pulled down the blanket and raised Resident #11 shirt to reveal a closed Percutaneous Endoscopic Gastrostomy (PEG) tube. LPN #11 flushed Resident #11's PEG tube with 30ml of water and verbalized to the resident she would be giving Resident #11 100cc of water. LPN #11 then opened the resident's feeding tube and administered what she said was medication through the feeding tube. This surveyor observed LPN #11 administer a 30cc water flush, then another 100cc of water through Resident #11's PEG tube to prevent dehydration. LPN #11 did not wear a gown throughout care. During an observation on 02/25/2026 at 9:41 AM, LPN #11 was standing outside Resident #11's room, near a small EBP sign posted outside the door. LPN #11 revealed she had gloves on for infection control measures and did not think nursing staff had to wear gowns when putting anything through a feeding tube. LPN #11 read off wear gloves and gown for the following high-contact resident care activities from the EBP sign and said, I think I should have worn a gown and gloves, to reduce the risk for infection. PPE was available at Resident #11's door. A review of Resident #11's Medical Diagnosis revealed the resident had diagnoses which included stroke, heart failure and respiratory failure. A review of Resident #11's quarterly MDS with an ARD of 11/14/2025, revealed the resident received tube feedings via PEG tube, while a resident. A review of Resident #11's Care Plan revealed the resident had a feeding tube for all food and nutrition (revised 09/11/2018). Resident #11's Care Plan specified interventions for staff to administer tube feeding as ordered, and the head of the bed should be at 30-45 degrees. Lastly, Resident #11's Care Plan revealed the resident was on EBP, initiated 03/29/2024, and that staff were to gown and glove during high-risk resident care activities. A review of Resident #11's Physician Orders dated 05/21/2025, revealed Resident #11 was on EBP, related to feeding tube. A review of Resident #11's Physician Orders dated 01/15/2026, revealed Resident #11 was on bagged nutrition at 34 ml/hour, with water flushes every two hours. During an interview on 02/25/2026 at 10:00 AM, RN #12 stated staff should gown and glove during high contact resident care and revealed signage was placed on the door and closet. RN #12 confirmed EBP signage should always be on the resident's door. During an interview on 02/25/2026 at 9:47 AM, the Assistant Director of Nursing (ADON) said nurses should prepare medications, wear a gown and gloves then follow the proper procedure for administering medications through a feeding tube. The ADON then revealed that gowning and gloving was part of the enhanced barrier process, to keep us from transferring germs to the resident. Infection Preventionist [IP] revealed that staff were in-serviced on infection control at least yearly. The ADON revealed a Centers for Medicare and Medicaid Services (CMS) document titled, Enhanced Barrier Precautions in Nursing Homes, dated 03/20/2024, was used for policy and EBP guidance at the facility. During an interview on 02/26/2026 at 4:00 PM, the Administrator stated that he expected staff to follow policy when administering medications through a feeding tube. A review of a CMS document titled Enhanced Barrier Precautions in Nursing Homes, dated 03/20/2024, revealed EBPs were designed to reduce the transmission of Multi-Drug-Resistant Organisms [MDRO] that may target gown and gloves in high contact resident care activities including PEG or feeding tubes. MDROs were common in nursing home facilities and could contribute to resident mortality. A review of an Infection Control in-service, dated 02/2025, revealed although EBP were not directly addressed, staff were to perform all procedures in a way that cut down on splashing, spraying or splattering. Wear disposable gloves and gowns whenever providing care where body fluids could splash. RN #12 did not sign the attendance sheet, and LPN #11 was marked as PRN [as needed], without a signature to indicate attendance.

Based on record review and interview, the facility failed to ensure wounds were identified, documented, accurately reported to the physician, and treated for one (Resident #20) of four sampled residents reviewed. Specifically, an undated, unsigned, and undocumented dressing was discovered by staff on the lower right extremity of Resident #20, which had been applied without physician orders, and Resident #20 was found to have a small fist sized wound under the dressing, with myiasis [a parasitic infection of maggots in human tissue], which was not reported to the resident's physician. The findings include: A review of Resident #20's Medical Diagnosis revealed the resident had diagnoses which included osteoarthritis, major depressive disorder, and anxiety. A review of Resident #20's annual Minimum Data Set (MDS) with an Assessment Reference Date of [DATE], revealed an admission date of [DATE] and Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact. Resident #20's MDS also revealed the resident had an open lesion, required set-up assistance with meals, toileting, and bathing, and was independent for dressing and personal hygiene. A review of Resident #20's Care Plan indicated the resident had a potential and actual risk for skin integrity related to weakness, fragile skin, decreased mobility, history of healed open lesion to the right lower leg. Resident #20's Care Plan included interventions, with an initiated date of [DATE], to encourage good nutrition and hydration, keep skin clean and dry. Other interventions, with an initiation date of [DATE], included to avoid scratching skin and to keep hands and body parts from excessive moisture, educate family and caregivers of causative factors, monitor and document size and location of skin injury, and report failure to heal maceration and signs and symptoms of infection. Lastly, Resident #20's Care Plan specified that treatment should be completed per Medical Director (MD) orders, initiated on [DATE]. A review of Resident #20's Weekly Skin Assessment, dated [DATE] at 1:14 PM, revealed the resident's skin was intact, with no breakdown. LPN/Treatment Nurse revealed that he alone assessed Resident #20 and denied finding any skin breakdown. During an interview on [DATE] at 2:59 PM, Certified Nursing Assistant (CNA) #19 revealed seeing 2-3 flies at the foot of Resident #20's bed on the night of [DATE] and stated, I thought that looked unusual to me, for flies to sit in one area. CNA #19 revealed uncovering Resident #20 for toileting at the beginning of the shift and there was drainage leaking from the resident's lower right leg, CNA #19 stated, it was a lot. CNA #19 said she had not worked with Resident #20 in a while, and immediately called and told LPN #15 the bandage needed to be changed. CNA #19 revealed there was so much drainage, CNA #19 thought it had gone the whole day without being changed. CNA #19 described the bandage as undated, wrapped, saturated and the white wrapping was a yellow green color. There was a strong smell, like something died. CNA #19 stated they and LPN #15 gowned up, due to Enhanced Barrier Precautions (EBP) and the large amount of drainage. We did not know what was going on. LPN #15 started unwrapping the dressing and maggots started falling out, there was so many, way too many. CNA #19 revealed CNA #19 was asked to go get LPN #17 to come assist. LPN #17 came over and helped remove the dressing and examined the area. CNA #19 stated the wound was fist size and it looked like raw skin with holes, and it had the texture of ground meat, and it was pink and red. CNA #19 confirmed maggots could be seen on the wound and they were removed and bagged up in a red bag and tied off and we threw the bag away. Resident #20, who sometimes refused care, did not want us to clean the wound, and we told them it was best that they let us work on their leg, so that it would get better. CNA #19 revealed interventions for Resident #20 were explain what we need to do and why, leave and come back later, we will try to get another to come and see if talking to the resident will allow them help. Sometimes [the resident] will refuse and will be persistent. CNA #19 said to her knowledge none of the residents ever had maggot therapy to clean wounds. During an interview on [DATE] at 11:23 AM, LPN #15 called via phone and confirmed that when providing care for Resident #20, on the [DATE] 11-7 PM shift a fist sized open lesion was found on the posterior right calf with maggots. LPN #15 said a CNA called LPN #15 to Resident #20's room, because the resident's leg was weeping and their dressing was saturated. LPN #15 had not been told in report that Resident #20 had any wounds or dressings and knew both legs wept the previous weekend, and the PA had said to leave it open to air. LPN #15 then revealed they raised Resident #20's pant or pajama leg and a few maggots fell out, unrolled the bandage three times and more maggots fell out, so I asked LPN #17 to come assist. LPN #15 and LPN #17 used supplies from the treatment cart to clean up the wound and a lot of maggots were removed. LPN #15 said she texted the DON, Administrator, Medical Director or PA, LPN or RN Treatment Nurse, and Assistant Director of Nursing (ADON). LPN #15 revealed that Resident #20 did not have an order for a dressing on the lower right leg. LPN #15 stated that it was nighttime and she did not hear back from her text right away, so she talked to the ADON and DON the next morning and was told they would investigate it. LPN #15 stated she did not know who put an undocumented dressing on Resident #20, how long the dressing was on Resident #20, or why a dressing was placed on the lower right calf. During an interview on [DATE] at 9:14 AM, LPN #17 confirmed that LPN #15 called for help cleaning and bandaging a wound because maggots started falling out when LPN #15 started unwrapping a bandage. LPN #17 said, The more we removed the more maggots we found. LPN #17 stated they cleaned and rebandaged the wound, maggots were put in a clear bag, then placed in a biohazard bag. LPN #17 stated the ADON contacted LPN #15 and told her to throw out the bag of maggots. LPN #17 stated the smell was pretty bad. Resident #20's legs had been weeping so the bandages were wet and yellow. The area was the size of a small fist. LPN #15 sent a text to Administrator, DON, ADON, MD, and PA. LPN #17 stated they were working on a new system now to take pictures, but the facility did not have it at that time. LPN #17 said the process following discovery of a wound was to call the doctor and family, ADON/DON, and staff were to clean and address the wound until the doctor or wound care nurse can look at it. During an interview on [DATE] at 12:01 PM, the LPN/TX nurse stated, we go in resident rooms to do body audits. The LPN/TX Nurse did not remember seeing anything on Resident #20's right lower leg, and revealed that on the [DATE] weekly skin audit for Resident #20, there was not a dressing on Resident #20's right leg, and it would have been noted on the skin assessment. The LPN/TX Nurse, when asked how staff would respond to discovering an unexpected dressing, revealed nurses would ask around to see if anyone knew what the dressing was for and then would remove the dressing to see what was underneath. The nurse or I would contact the doctor. The LPN/TC Nurse did not reference checking orders. The LPN/TX Nurse stated at no time did staff tell him they were putting a dressing on Resident #20. The RN/TX Nurse said, I did not even know [Resident #20's lower extremity] was weeping. A review of Resident #20's Progress Notes on [DATE] at 12:20 PM, revealed that on [DATE] at 12:00 PM, Resident #20 was observed with 2+ edema (moderate pitting edema, characterized by a 3–4 mm indentation in the skin that takes up to 15 seconds to disappear), redness, and weeping with an open lesion to the left posterior thigh related to a ruptured blister, an open lesion to right medial calf, and that the PA was notified. The PA initiated the following: 1. Reinflate [Name Brand air filled support cushion] to bedside chair every Thursday and as needed. 2. Change to an inflatable cushion in sitting chair at the bedside at all times as tolerated for pressure relief. 3. Treat open lesion to right medial calf, cleanse with wound cleanser, pat dry, apply foam, cover with 1-2 pads, and wrap with dressing for drainage. Treatment provided twice a day per LPN or RN Treatment Nurse, floor nurse to dress on 11-7 shift, due to weeping. 4. Treatment for protection of left medial ankle, cleanse, apply skin prep, wrap in roll gauze or left lower extremity twice a day as needed. 5. Cleanse ruptured blister on left upper posterior thigh with wound cleanser, apply medical grade honey dressing, cover with an antimicrobial dressing, and cover with a foam dressing. Change dressing on Monday/Wednesday/Friday, and as needed. 6. Venous and arterial ultrasound of both lower extremities related to wounds. 7. Antibiotic one capsule by mouth, 300mg twice a day, for cellulitis. A review of Wound Provider New Order, dated [DATE] indicated Resident #20 had a wound to the right medial calf, with instructions to cleanse wound, change to a water insoluble dressing daily and as needed. Resident #20 to be seen by wound care provider weekly, encouraged both legs to be elevated to reduce edema and weeping. A review of Resident #20's Clinical Notes, dated [DATE], indicated Resident #20 was seen with rash, lesions and weeping consistent with cellulitis [bacterial infection of the skin] on the right lower extremity, with an open area posterior to the right lower extremity measuring length 11 centimeter [cm], width 3.4cm x depth 0.1cm. Left inner ankle had a full thickness venous ulcer measuring length 1.9cm x width 1.3cm and depth unable to determine. During an interview on [DATE] at 8:54 AM, the ADON said that [on [DATE]] the morning after being notified via text that a dressing was found on Resident #20, the facility started checking to see who put a dressing on Resident #20 and why, because there was not an order for a dressing. The ADON confirmed no longer having text records and could not remember how LPN #15 described the wound but, I did tell her if there were maggots in the building, then the trash needed to be taken out, and I made sure the PA was notified. The ADON said she called LPN #15 just after midnight, and the PA was at Resident #20's bedside as soon as she got to the facility that morning to assess the right calf wound. According to the ADON, the staff process when finding a skin problem was to notify the ADON/DON, the PA, and to put in a general order to clean the wound until the PA or doctor could come and look at it. The facility could not take pictures at that time. The IP informed the ADON she believed it was on the 11-7 shift on [DATE] because, I did a skin audit the next day. A skin audit on the prior day, [DATE], documented no skin issues. The ADON said during a skin audit, staff should physically look and assess the resident's skin, and that the facility had not used maggot wound therapy in the past. The ADON revealed the facility had flies in the summer, but they did not have an infestation. The ADON then said LPN #18 reported she changed the dressing on Resident #20's right leg because there was already a dressing there, and thought dressings were applied, due to the saturation from weeping. LPN #18 did not call the doctor. The ADON then revealed that Resident #20's legs were edematous from fluid buildup, [Resident #20] was sitting around at that time with [their] legs dependent. The ADON stated, One of our interventions was to get [Resident #20] a recliner. The IP informed the ADON that cellulitis arose after wounds were found on Resident #20's lower extremities. The ADON confirmed that to her knowledge, the facility was never able to confirm who put the first dressing on Resident #20's right lower leg. During an interview on [DATE] at 1:10 PM, LPN #18 confirmed they remembered an incident that occurred in June 2025, when a wound was found on the back of Resident #20s right calf with maggots. LPN #18 said no staff reported weeping from Resident #20's lower legs, until LPN #15 found the wound. LPN #18 verbalized seeing a dressing to Resident #20's lower extremity on [DATE] during the 3-11 shift, but did not report it to the provider. LPN #18 revealed they were supposed to call the Medical Director, and MD usually tells us to notify the wound nurse, and we get orders to provide care when you have a skin or wound finding after identifying the unexpected dressing to Resident #20's lower extremity. LPN #18 denied wrapping or telling other staff to wrap the right lower extremity. A review of a Counseling Form, dated [DATE], revealed Licensed Practical Nurse (LPN) #18 was counselled by the ADON. The counseling form revealed that if a resident was seen with an undocumented dressing on, to look for treatment orders. If there were no treatment orders, staff were to put in a wound order, and call the doctor, treatment nurse, ADON or the Director of Nursing [DON]. During an interview on [DATE] at 7:58 AM, the DON stated they did not believe a reportable was done for this incident. The DON revealed he was unable to establish a timeline and confirmed there were no progress notes displaying that the discovery of maggots was documented. The DON said he believed that LPN #15 had changed the dressing that was found on 11-7 shift, but the DON found out about maggots after the right calf wound was discovered. The DON said he thought he was notified by LPN #15 via text on Monday, and the next morning the PA was at the bedside looking at the wound. I believe it was Monday morning I was told [Resident #20] had a wound on the leg. The DON revealed maggots were not mentioned in the text and believed there was already a dressing on the lower right leg when LPN #15 found the open lesion. The DON then stated LPN #18 put the dressing on the open lesion and received verbal counseling for not reporting a dressing that was found on Resident #20 on the 3-11 shift. The DON revealed the process was as soon as staff found a wound, they were supposed to call the PA about the wound and get orders. The DON was unsure how long the doctor or PA had to assess the resident after a finding a wound of this nature, but stated as soon as a wound is found, staff should report it to the PA. The DON revealed they had not had a resident use maggot wound therapy. The DON confirmed that Resident #20 was not a smoker, did not go out a lot, and was not sure how the resident developed maggots. The DON revealed that [during the facility's investigation] no CNAs were interviewed about Resident #20's skin or wound. The DON reported having not yet identified who put the initial undated, untimed, and undocumented wound dressing on Resident #20. During an interview on [DATE] at 11:14 AM, the Administrator (Admin) was told Resident #20 had developed maggots in a wound but could not recall the nurse who made the discovery. The Admin stated, I know that the LPN and RN Treatment nurses and PA looked [the following day] and did not see any maggots. The Admin then provided an investigation file, which revealed body audits were done, and daily skin checks were done for two weeks, [DATE]-[DATE], on Resident #20. Resident #20's body audit showed a right hip open area with redness and edema up to the hip, both legs weeping, open area to the right ankle, open area to the back of the left thigh, and wounds and red area to both lower extremities. The file included an in-service dated [DATE] was given to the LPN Treatment Nurse on Body Audit Review and Nursing Weekly Skin Audit given by Wound Consultant. During an interview on [DATE] at 10:48 AM, the PA said she was asked to assess a wound on Resident #20 's posterior right calf but could not remember when this was. The PA described the wound as appearing vascular, arterial or venous, and weeping. The PA then revealed the wound had already been cleaned by LPN #15 and she did not see maggots. During an interview on [DATE] at 3:00 PM, the Medical Doctor (MD) revealed she was told Resident #20 had a wound in June 2025 but was not told nursing had reported maggots were found in the wound. The MD revealed that Resident #20 was seen by the PA, and the LPN and RN Treatment Nurses the next day. The MD revealed that had she known about the existence of myiasis, she definitely would have made sure Resident #20's right calf wound was cleaned very well and would have met and had a conversation with leadership to discuss how the wound got there. We would have had a discussion about wound care. The MD revealed she operates a wound clinic and depending on the stage, she would expect staff to notify her for treatment recommendations and try to heal the wound. She then stated that depending on how bad a wound was, the MD would see them in the wound clinic or come by [the facility]. The MD stated she definitely expected to be notified if maggots were found in a wound. The MD revealed it would be difficult for a nursing home resident to get maggots in a wound, but not impossible. Larvae are very tiny and might not be seen, it would depend on if they were getting ready to hatch. A review of a policy titled, Wound Dressing Change, Sterile, revised [DATE], revealed to cleanse wound per order. The policy did not address the procedure to follow with new skin findings. A review of an article titled About Myiasis, dated [DATE], by the Centers Disease Control revealed myiasis was a parasitic infection of fly larva or maggots in human tissue. People who had untreated open wounds were at high risk for getting myiasis, and it could be spread by ticks, mosquitos, and flies. A person with myiasis would normally develop a lump in their tissue that may begin to move as the larvae grows. The areas would likely to become infected without treatment. Some larvae move deep into the body, and some flies dropped their eggs on or near a person's wound, sores, or nose. Treatment was removal of larvae, and daily wound care is important for healing.

Based on observation, record review, interview, and facility policy review, it was determined the facility failed to ensure one (Resident #8) of one resident reviewed for respiratory care, had an order for oxygen. The findings include: During an observation on 02/23/2026 at 11:49 AM, this surveyor observed Resident #8 resting with their mouth open, while receiving oxygen (O2) at two liters per minute (L/M) via Nasal Cannula (NC) with a Continuous Positive Airway Pressure (CPAP) device stored on the left bedside table. During a concurrent observation and interview on 02/24/2026 at 11:32 AM, this surveyor observed that Resident #8 remained on O2 at two L/M via NC. Resident #8 was alert and oriented. The resident revealed that they were on oxygen for COPD [Chronic Obstructive Pulmonary Disease]. A review of Resident #8's Medical Diagnosis revealed the resident had diagnoses which included anemia, heart disease, and wheezing. There was no diagnosis of COPD listed. A review of a Resident #8's quarterly Minimum Data Set (MDS) with an assessment reference date of 01/02/2026, revealed a Brief Interview for Mental Status score of 12, which indicated the resident had moderate cognitive impairment. Resident #8's MDS also indicated the resident was on oxygen while a resident [at the facility]. A review of Resident #8's Order Summary Report, dated 11/22/2023, revealed a discontinued order with no end date specified, for O2 at 2 L/M via Nasal Cannula PRN [as needed] to keep O2 sat [saturation] above 90%. A review of Resident #8's Oxygen Saturation Summary, dated 11/30/2025-02/22/2026, revealed the resident had no documentation of hypoxia, and demonstrated Resident #8 had saturations above 90% while on and off oxygen therapy. During an interview on 02/24/2026 at 1:37 PM, Licensed Practical Nurse (LPN) #11 checked Resident #8's electronic record and confirmed, [Resident #8] does not have an order for oxygen. LPN #11 called the Assistant Director of Nursing (ADON) via phone and asked, where to find oxygen orders. LPN #11 then stated, I am not seeing it. LPN #11 revealed the Medication Assistant-Certified (MA-C's) were responsible for checking to make sure oxygen was ordered and that tubing and water were changed. LPN #11 revealed she was not sure if oxygen orders were on the MAR or not, and when Resident #8 was sent to the hospital it looked like the order for oxygen was not put back in the electronic record by admissions. LPN #11 stated, It [O2] is technically a medication, so it requires an order. LPN #11 spoke with the ADON via telephone with this surveyor present and revealed the ADON was unable to locate an oxygen order. During the call, the ADON also verified that oxygen was a medication and a resident should not get oxygen without an order. During an interview on 02/24/2026 at 3:47 PM, the Director of Nursing (DON) stated, floor nurses should make sure they have oxygen orders, and new orders should be compared to the old orders when a resident returns from the hospital. The DON revealed that nurses should be monitoring a resident with oxygen. The DON stated, Nursing should set up the oxygen when the resident comes in, make sure it is at the right flow and check the rate when doing medication pass. The DON also stated nursing was responsible for oxygen [administration and set up]. MA-C 's were responsible for checking tubing and water each shift. The DON confirmed MA-C's just put eyes on oxygen, but they do not check the order. During an interview on 02/24/2026 at 3:50 PM, the Administrator stated, If a resident is on oxygen, the orders should be checked to see if they have new orders to make sure the orders are in place. Staff are expected to follow policy. This surveyor requested an oxygen policy/procedure and any in-services provided to staff. The Administrator provided a policy, but no oxygen in-service documentation. A review of a facility policy titled Oxygen Safety, revised on 11/22/2016, revealed oxygen is administered to the resident only upon the written order of a licensed physician. The facility would properly handle oxygen and flammable gases.

Based on observation, interview, and facility policy review, the facility failed to ensure expired medication was not stored in the medication cart for one (300-Hall) of two medication carts observed. The findings include: During an observation on 02/24/2026 at 10:50 AM, this surveyor observed 10 vials of [Brand Name] eye drops stored in the bottom drawer of a medication cart on the 300-Hall, with a manufacturer's expiration date of August 2025. During an interview on 02/24/2026 at 10:53 AM, Medication Assistant (MA-C) #21 confirmed that the 10 closed vials of eye drops stored in the medication cart were expired, and that expired medications should be stored in the medication room, in a box. MA-C #21 indicated that the expired eye drops were not being administered to any of the residents. During an interview on 02/24/2026 at 10:54 AM, Licensed Practical Nurse #11 indicated that expired medications were kept in a box in the medication room. During an interview on 02/26/2026 at 1:45 PM, the Administrator indicated that the last medication in-service was completed with all the staff. The Administrator indicated that there was not a medication pass in-service with just the nurses. The Administrator then stated that the in-service was verbal, and there was no documentation on the specific information that was presented. During an interview on 02/24/2026 at 2:05 PM, the Director of Nursing indicated that the nurses were supposed to dispose of expired medications in a box that was in the locked medication room. Review of a facility policy titled Medication Ordering, Receiving and Storage Policy indicated the facility shall store all medications in a safe, secure, and orderly manner. The policy also indicated, if the facility had discontinued, or outdated medication the dispensing pharmacy should be contacted for instructions regarding returning or destroying the items.

Based on observation, interview, and policy review, the facility failed to ensure food was discarded prior to the use by date, staff hands were washed between clean and dirty tasks and that meals were served in a manner as to not promote cross contamination for 80 residents who receive their meal from one of one kitchen. The findings are: On 08/19/24 at 10:35 AM, a large plastic container of soup was observed with a use by date of 8/18/24. A large plastic container, approximately 1/3 full of sliced tomatoes, had a use by date of 08/16/24. A large plastic container, approximately 1/4 full of sliced onions, was observed with a use by date of 8/16/24. On 08/19/24 at 10:43 AM, a tray containing four 4-ounce glasses of orange juice, one 4-ounce glass of tomato juice, and one 8-ounce glass of tea was observed on the middle shelf of the 2-door refrigerator. The tray and the individual glasses were not labeled with a date. On 08/19/24 the refrigerator was observed to contain no interior thermometer. On 08/20/24 at 11:25 AM, Dietary Employee #1 was observed to wash her hands prior to obtaining a steam table pan, a can of cooking spray, and handling a scoop. Employee then applied gloves to contaminated hands. On 08/20/24 at 11:46 AM, Dietary Employee #1 was observed to reach for a divided plate. Contaminated hands/fingers were placed into the interior of the plate where the food was placed for serving. This practice was observed on 3 occasions. On 08/20/24 at 11:50 AM, Dietary Employee #2 was observed as she placed the insulated dome over each lunch plate. Contaminated hands were placed inside the dome prior to placing it on top of the plate. On 08/22/24 08:19 AM, the Administrator reported the facility does not have a policy on hand washing specific to the kitchen. The policy titled Handwashing/Hand Hygiene indicated the facility considers hand hygiene as the primary means to prevent the spread of infection. The policy indicated all employees will follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. On 08/22/24 at 08:30 AM, a review of the facility food storage policy revealed all food not stored in original containers will be labeled and dated and stored in approved containers. On 08/22/24 at 10:15 AM, the Dietary Manager was asked when hands should be washed when working in the kitchen. The Dietary Manager reported that hands should be washed before moving from one task to the next, and before applying gloves. When asked how dishes should be handled when serving, she identified the need to handle a dish, glass, etc. ensuring hands do not go inside the dish where liquid or food comes into contact with the dish. The Dietary Manager explained that items being put into the refrigerator/freezer should be covered and dated with the date of being placed in the refrigerator and the use by date. When asked why this practice is important the Dietary Manager described how it is important as to not give a resident spoiled food which could result in illness.

51064 Based on observation, record review, and interview, it was determined that the facility failed to ensure staff followed isolation precautions including the appropriate use of personal protective equipment (PPE) prior to high contact resident care, to reduce transmission of resistance organisms for 1 (Resident #63) of 1 sampled resident observed during supplemental feeding via percutaneous endoscopic gastrostomy (PEG) tube. Specifically, the facility failed to ensure a gown was worn before a supplemental PEG tube feeding and flush and failed to ensure used personal protective equipment (PPE) was disposed of properly and the container was closed to prevent possible cross contamination to anyone passing the trash can sitting in the hallway. A review of an Admission Record indicated the facility admitted Resident # 63 with diagnoses that included gastroparesis, severe protein-calorie malnutrition, and adult failure to thrive. A review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/01/2024 revealed in Section K0100. Swallowing Disorder: C. Coughing or choking during meals or when swallowing medications and D. Complaints of difficulty or pain when swallowing .K0520. Nutritional Approaches: B. Feeding tube (e.g., nasogastric or abdominal (PEG)) while a resident: Yes. Review of Physician's Order (PO), dated 03/29/24, revealed an order for Enhanced Barrier Precautions related to PEG tube every shift. Review of a PO dated 05/09/24 revealed an enteral feed order two times a day Nutren 2.0 120cc via PEG tube, flush with water. Review of Resident # 63's Care Plan, initiated 03/29/24, revealed the resident required enhanced barrier precautions related to PEG tube to reduce transmission of resistant organisms, and that staff were to use gowns and gloves during high contact resident care activities. On 08/20/24 at 05:12 AM, Licensed Practical Nurse (LPN) # 3 was observed entering Resident #63's room to administer a tube feeding. LPN #3 did not apply appropriate PPE per Enhanced Barrier Precautions (EBP) signage posted on the wall outside of the resident's room. Upon exit, LPN # 3 said she did not see the EBP signage on the wall outside resident's room and was planning on washing her hands in the bathroom behind the nurse's station, but it would probably have been better to wash them in the resident's bathroom. On 8/21/2024 at 1:45 PM, the Administrator said the facility did not have a policy on Enhanced Barrier Precautions. During an interview on 8/22/2024 at 9:35 AM, the Director of Nurses (DON) said a gown, gloves, and masks should be worn with high contact resident care.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to provide appropriate treatment and services to prevent complications from enteral feedings for 1 (Resident #63) of 1 resident observed during supplemental feeding via percutaneous endoscopic gastrostomy (PEG) tube. Specifically, the facility failed to ensure placement of PEG tube before enteral feeding and flush. The findings include: A review of an Admission Record indicated the facility admitted Resident #63 with diagnoses that included gastroparesis, severe protein-calorie malnutrition, and adult failure to thrive. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 07/01/2024 revealed in Section K0100, Swallowing Disorder: C. Coughing or choking during meals or when swallowing medications and D. Complaints of difficulty or pain when swallowing .K0520. Nutritional Approaches: B. Feeding tube (e.g., nasogastric or abdominal (PEG) while a resident: Yes. Review of Resident #63's Care Plan, initiated 10/30/2023, revealed the resident has a nutritional problem or potential nutritional problem related to gastroparesis, severe protein-calorie malnutrition, and adult failure to thrive. Review of a Medication Administration Record (MAR): revealed a physician's order (PO) dated 05/09/24 revealed Resident #63 was to receive enteral feeding two times a day, [brand name] 120cc (cubic centimeter) via PEG tube, flush with H20 (water). On 08/20/2024 at 05:12 AM, Licensed Practical Nurse (LPN) # 3 was observed giving supplemental enteral feeding via PEG tube. LPN #3 performed a water flush, enteral feeding, then water flush before exiting resident's room. LPN #3 said she did not check for placement before feeding because she checked it last night before the 10 PM feeding and didn't want to have to keep Resident # 63 awake any longer than she needed to. During an interview on 8/22/2024 at 9:35 AM, the Director of Nurses (DON) said a nurse should check for placement every time before inserting flush, feeding, or medication. Review of a facility policy titled Enteral Feedings, Administration via Gastrostomy revised 11/22/2016 indicated The following equipment and Supplies may be utilized: 1. gavage bag and tubing 2. 30-60cc catheter tipped syringe 3. Stethoscope .Procedure 1. Obtain equipment 2. Explain procedure to resident 3. Check bowel sounds .1. Auscultate for air bolus over epigastric area or follow physician's orders for residual feeding as indicated.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, homelike environment for 1 (Resident #44) of 1 resident regarding linen changes, 2 (Resident #15 and #44) of 2 residents regarding plaster cracking, and 43 out of 43 residents who use the 100 Hall bath. 1. On 08/19/2024 at 11:36 AM, the surveyor noted Resident #44's bed to be unmade, covers pulled back, and bottom linens appeared soiled with two large, orange-colored spots on fitted sheet. The surveyor noted an orange colored spot on the pillowcase on pillow at the head of the bed. the surveyor noted multiple flies around the resident's bed and a urine odor present. The surveyor made additional observation of unmade bed with soiled linens on 08/20/2024 at 11:58 PM. The surveyor interviewed Certified Nursing Assistant (CNA) #5 and asked when Resident #44's bed linens were last changed, CNA #5 stated on shower days and when the resident wants the linens changed. When asked why the resident's linens were not changed when visibly soiled, CNA #5 stated I don't know. 2. On 08/19/2024 at 11:50 AM, the surveyor noted the sink in Resident #44 and Resident #15's personal bathroom to have cracks in plaster between wall and sink with large piece of plaster missing. The surveyor made additional observation of the sink with cracks in plaster between wall and sink with large piece of plaster missing on 08/20/2024. When interviewed the Maintenance Supervisor stated, I didn't even know about this sink. 3. On 08/19/2024 at 1:04 PM, the whirlpool tub in the bath room on 100 Hall was noted to have what appeared to be feces present. The surveyor made an additional observation of apparent fecal matter in whirlpool on 08/20/2024 at 9:56 AM. When interviewed CNA #4 stated housekeeping is responsible for cleaning baths. Housekeeper #6 was interviewed and stated baths are cleaned every day, and that no dirt or bodily material should be present following daily cleaning.

51064 Based on observation, interview, and record review, the facility failed to ensure an accepted power source was used for medical equipment to prevent the potential for fire hazards. The oxygen concentrator and pacemaker equipment were plugged into a small white 6 outlet power strip hanging on the wall behind the head of the bed of Resident #4. The facility failed to provide an environment that is free from accidents and hazards affecting 1 (Resident #12) resident. The findings are: 1. On 8/19/24 a physician orders indicated oxygen was to be continuous at 3 liters per minute utilizing a nasal cannula and every Thursday a nurse was to check the Heart Monitor which will be checked between the hours of 2-4 am every night shift on Thursdays by St [NAME] Medical phone. a. On 8/19/24 at 11:44 AM, the surveyor observed a small 6 outlet power strip hanging on the wall above the head of Resident #4. The resident's oxygen concentrator and pacemaker equipment were plugged into two of the outlets along with a cell phone charger. b. On 08/20/24 at 7:23 AM, the surveyor observed a small 6 outlet power strip hanging on the wall above the head of Resident #4. The resident's oxygen concentrator and pacemaker equipment were plugged into two of the outlets along with a cell phone charger. c. On 08/20/24 at 8:12 AM, the surveyor observed the back of the power strip, and it does not have one of the two numbers, (UL1363 or UL1363A as identified by Life Safety surveyor) accepted medical grade power strips. d. On 8/21/24 at 9:49 AM, during an interview in the resident's room, with the Administrator, he said the power strip was a concern due to the medical equipment being plugged in to it because medical equipment cannot be plugged into this type of power strip. 2. On 08/19/2024 at 11:35 AM, the surveyor was told by Resident #12 that the toilet in the resident's bathroom moves when resident's roommate uses the bathroom, and after it is moved it is difficult for the resident to use the bathroom. Resident #12 reported notifying staff and administration, but it had not been fixed. The surveyor observed the toilet in Resident #12's bathroom was easily moved several inches from its original location. Resident #12 reported the toilet had been like that for months. a. The surveyor made an additional observation of the toilet moved from its original location on 08/20/2024 at 11:45. b. During an interview on 08/20/2024 at 1:30 PM the Maintenance Supervisor stated Yeah, I know about this toilet, the people who built this home shouldn't have put tile in the bathroom. I can caulk it if I need to. 3. On 08/19/2024 at 11:37 AM, the surveyor noted a small white pipe sticking out of Resident#47's wall, the pipe was hollow with no contents inside. The resident's walker was placed in front of pipe. The surveyor made an additional observation of pipe on 08/20/2024 at 12:00 PM. a. On 08/20/2024 at 1:30 PM the Maintenance Supervisor stated the pipe was in place to move television to other side of wall. When asked why the television had not yet been moved, the Maintenance Supervisor stated, I am not sure. When asked if there were plans to move the television soon, the Maintenance Supervisor stated, I do not know. When asked how much of pipe appeared to be sticking out from wall, the Maintenance Supervisor said approximately 4 inches. b. On 08/20/2024 at 1:50 PM, Certified Nursing Assistance (CNA) #4 was asked why the pipe was in wall, CNA #4 stated I think because of the TV. When asked how long the pipe had been present CNA #4 stated I do not know. When asked why the pipe should not be sticking out of the wall in front of where resident places their walker CNA #4 stated, Because it could tear skin. It really should be capped.

Based on record review and interview, it was determined the facility failed to ensure a comprehensive Minimum Data Set (MDS) assessment was completed within 14 days after a significant change was identified to facilitate the ability to determine if any changes in care were necessary for 1 (Residents #58) sampled resident admitted to hospice care. The findings are: A review of an Admission Record indicated the facility admitted Resident # 58 with diagnoses that included hypertensive heart disease with heart failure and Alzheimer's disease. A review of the Order Summary Report, dated 03/16/2024, revealed an order reading, Admit to: Long Term Care/ Hospice. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/13/2024 revealed in Section O0110, Special Treatments, Procedures, and Programs, K1. Hospice care While a resident? Yes. Review of Resident # 58's Care Plan, initiated 03/04/2024, revealed the resident was admitted to [company name] hospice on 03/04/2024 for hypertensive heart disease with heart failure. Interventions included 2 hospice aides to come 5 times/week, Registered Nurse (RN) two times a week and PRN (as needed), weather permitting and on call for holidays. During an interview on 08/22/2024 at 8:06 AM, the MDS Coordinator said she uses the RAI (Resident Assessment Instrument) Manual as the criteria for a significant change such as a decline in 2 areas like weight loss, a decline in ADLs (Activities of Daily Living) or going on/coming off hospice. The MDS Coordinator said she is familiar with Resident #58 and realized she overlooked doing a significant change MDS when resident was admitted on hospice.

Based on observation, interview, and record review, the facility failed to follow a grievance policy signed by the facility and resident upon resident admission to include completing a grievance form and prompt resolution of grievance for 1 (Resident #16) of 1 sampled resident. On 08/19/2024 at 10:30 AM, Resident #16 reported a lost tablet. A family member at bedside reported the tablet purchased by family was lost or stolen while the resident was in the facility. The family member reported Administration was made aware, and an investigation was supposed to be initiated. On 08/20/2024 at 2:44 PM, the Assistant Director of Nursing (ADON) was interviewed regarding Resident #16's family member reporting the missing tablet to the Administrator. When asked if tablet was found, the ADON stated she was never notified. On 08/20/2024 at 2:44 PM, the Administrator was interviewed and asked if Resident #16's tablet was reported missing. He stated he could not recall an incident where tablet had been reported missing. On 08/20/2024 at 2:50 PM, the Assistant Director of Nursing stated that yes, the resident and resident family had reported to the Administrator the tablet was missing On 08/20/2024 at 3:00 PM, the Administrator stated he did recall a family member stating a resident's tablet had been missing, and that he had requested information on the tablet so it could be located or replaced, however no information was received. When asked if a grievance report was completed regarding the incident the Administrator stated he did not interpret this as a grievance. On 08/20/2024 at 3:30 PM, the surveyor called the family representative who stated the tablet was provided by family and was lost or stolen while Resident #16 was in the facility. When asked if facility administration had requested information regarding tablet so it could be located or replaced, the family representative stated no information had been requested. When asked if the facility offered any restitution for missing property, the family representative stated no restitution had been offered. On 08/20/2024, review of a document titled, Grievance Policy and Procedure. dated 11/22/2016, provided by facility showed the resident has the right to voice grievances without discrimination or reprisal, and the facility must make prompt efforts to resolve grievances. The facility will make all efforts to resolve the grievance promptly. The expected timeframe for resolution of grievances is 5 business days.

Based on observation, record review and interview, the facility failed to ensure meals were prepared and served in accordance with the planned written menu for preparation of pureed foods, alterative foods, and enhanced food items to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 3 residents who received pureed diets, 2 residents who received alterative foods, and enhanced food items 24 residents who received enhanced food items from 1 of 1 kitchen. The findings are: Review of the facility Spring/Summer 2023 menu for lunch showed residents on pureed diets were to receive 2 #8 scoops (1 cup) of pureed goulash. During observation on 10/09/23 at 12:04 PM, Dietary Employee # 4 served 3 chicken wings to the residents who dislike goulash. At 12:19 PM, the Surveyor asked Dietary Employee #4 to weigh 3 pieces of chicken wings to check if it equals the same amount of goulash served to residents who disliked goulash, and it weighed 1.3 ounces. At 12:20 PM, the Surveyor asked the Dietary Supervisor how much protein should have been given to the residents who received chicken, instead of goulash? She said 3 ounces of chicken. During observation on 10/09/23 at 12:16 PM, Dietary Employee #4 used a #8 scoop (1/2 cup) to serve a single portion of goulash to residents on pureed diets, instead of 2 #8 scoops of pureed goulash. At 12:21 PM, the Surveyor asked Dietary Employee #4 what size spoon she used when serving pureed goulash and how many servings she gave to each resident on pureed diets. She stated, I used 4-ounce spoon (1/2 cup) and gave a serving each. Review of the facility Spring/Summer 2023 menu for supper showed residents on enhanced foods were to receive super pudding. During observation on 10/09/23 at 5:01 PM, during the supper meal service there was no super pudding served to the residents on super pudding. On 10/09/23 at 12:04 PM, the surveyor asked Dietary Employee #1 if she would have served enhanced food items to the residents who required enhanced foods. She stated, I only gave enhanced juice to 3 residents. We are supposed to give enhanced pudding. I didn't know it was in the refrigerator. Review of the facility Spring/Summer 2023 menu for breakfast meals showed residents on enhanced foods were to receive super cereal. During observation on 10/09/23 at 7:46 AM, Dietary Employee #4 served the residents on enhanced foods 1/2 cup of super cereal, instead of a cup. At 7:48 AM, the Surveyor asked Dietary Employee #4 what size spoon did you used to serve enhanced foods and how many servings did you gave each? She stated, I used 4-ounce spoon (1/2 cup) and a gave a serving each.

Based on observation and interview, the facility failed to ensure that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 3 residents who received pureed diets. The findings are: The following observations were made on 10/09/23: a. At 7:46 AM, the pureed sausage served to residents who required pureed diets was not smooth, with pieces of meat visible in the mixture. At 7:48 AM , the surveyor asked Dietary Employee #4 to describe the consistency of the pureed sausage served to the residents on pureed diets. She stated, It has a little lump. b. At 7:46 AM, the pureed sausage served to residents who required pureed diets was not smooth, with pieces of meat visible in the mixture. At 7:48 AM, the surveyor asked Dietary Employee #4 to describe the consistency of the pureed sausage served to the residents on pureed diets. She stated, It has a little lump. c. At 4:01 PM, Dietary Employee #4 used a spatula to scoop pureed breaded chicken and buns into a pan. The consistency was not smooth, thick, and sticky. d. At 4:13 PM, Dietary Employee #4 placed 5 servings of tarter tots into a blender, added warm milk and pureed. At 4:17 PM, Dietary Employee #4 poured pureed tarter tots into a pan and placed it in the oven. The consistency was thick and not smooth. During observation on 10/10/23 12:06 PM, the pureed meat loaf served to the residents on pureed diets had pieces of meat in it. The pureed cookie delight was lumpy and not smooth. The Surveyor asked the Dietary Supervisor to describe the consistency of the pureed cookie delight and meat loaf served to the residents on pureed diets. She said, the pureed meatloaf had pieces of meat in it, and the pureed cookie delight still has crumbs in it. On 10/10/29 at 12:06 PM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed breaded chicken with buns and tarter tots served to the residents who are on pureed diets at the supper meal on 10/09/23. She stated, They were thicker. On 10/09/23 5:02 PM, the Surveyor asked Certified Nursing Assistant #1 to describe the consistency of the pureed food items served to the residents on pureed diets for supper. She stated, The pureed breaded chicken with buns was thick and the pureed tarter tots was thicker.

Based on observation and interview, the facility failed to ensure food items stored in the refrigerator were covered or sealed; staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents dietary; hot food items were maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 64 residents who received meals from the kitchen The findings are: On 10/09/23 at 10:40 AM, the following observations were made on a shelf in the walk-in refrigerator. a. An opened box of sausage uncovered and unsealed. b. An opened box of bacon uncovered and unsealed. c. At 10:46 AM, Dietary Employee #1 picked up packages of gelled thickener from a container under the food preparation counter and placed them on the counter. Without washing her hands, she picked up glasses by the rims and poured beverages to be served to the residents for lunch. d. At 10:48 AM, Dietary Employee #2 used a maker to write a date on a bag. Without washing his hands, he placed gloves on his hands. Then, removed slices of bread from the bag and spread peanut butter and jelly to be served to residents . e. At 10:53 AM, Dietary Employee #3 wore gloves on her hands when she removed a container from the refrigerator and placed it on the counter. Without changing gloves and washing her hands, she untied a bag of bread, removed slices of bread, and placed them in a saucepan. f. At 10:57 AM, the temperatures of food items when checked on the steam table by Dietary Employee (DE) #4 showed the following results: 1. Fried squash 125 degrees Fahrenheit. 2. Regular mechanical soft squash 127 degrees Fahrenheit. 3. Vegetable blend 126 degrees Fahrenheit. 4. Mashed potatoes 120 degrees Fahrenheit. 5. Gravy 123 degrees Fahrenheit. 6. Ground chicken 120 degrees Fahrenheit. The above food items were not reheated before being served to the residents. g. At 11:27 AM, Dietary Employee #3 with gloved hands removed two bags of broccoli from the walk-in freezer and placed them on the counter. Without changing gloves and washing her hands, she picked up a pan and placed it on the counter with her gloved fingers touching inside the pan. She opened bags of broccoli and emptied them into a pan to be cooked and served to the residents for the supper meal. h. At 11:43 AM, Dietary Employee #1 with gloved hands opened the walk-in refrigerator door and removed a container of cheese and a cheese block and placed them on the counter. Without changing gloves and washing her hands, she unwrapped the cheese packet and transferred them into a container to be used in making grill cheese sandwiches for residents. i. At 11:56 AM, Dietary Employee #1 carried a pan with tomatoes to the food preparation sink, turned on the faucet and rinsed tomatoes, and turned off the sink. She picked up tomatoes with her hands and placed them on a cutting board. The Surveyor immediately asked Dietary Employee #1 what should you have done after touching dirty objects and before handling food items or clean equipment? She stated, I should have washed my hands. j. At 12:06 PM, Dietary Employee #3 gloved hands, rinsed lettuce, and placed rinsed lettuce on the cutting board. Without washing her hands, she placed gloves on her hands, picked up a knife, cut the lettuce and placed the lettuce on a plate. She removed slices of ham from a packet and placed the ham on top of the lettuce to be served to resident for the lunch meal. The Surveyor immediately asked Dietary Employee #3 what should you have done after touching dirty objects, before handling food items or clean equipment? She stated, I should have washed my hands. k. At 3:46 PM, Dietary Employee #4 removed two pans of breaded chicken from the oven and placed them on the counter. Without washing her hands, she picked up a clean blade and attached it to the base of a blender to be used in grounding or pureeing food items to serve to residents who require mechanical soft or pureed diets. The Surveyor asked Dietary Employee #3 what should you have done after touching dirty objects and before handing clean equipment? She stated, Washed my hands. Review of facility policy titled Infection control procedure for food service showed, Practice proper hand washing. Before beginning your work shift. When entering a food preparation area. Before engaging in food preparation and before putting on clean, single-use glove for working with food and between glove change.

Based on observation, interview and record review, the facility failed to ensure medications were not left in a resident's room unattended for 1 Resident (Resident #39) of 2 case mix sample Residents (Resident #33 and #39). This failed practice had the potential to affect 17 residents receiving medications residing in the facility on hall 300. The findings are: On 10/09/23 at 11:20 AM, the Surveyor observed a medication cup with 2 pills resting on the armrest of a recliner to the left of Resident #39's bed. During interview on 10/09/23 at 11:37 PM, Medication Assistant -Certified confirmed medications were left on the armrest of the recliner in Resident #39's room unattended. Review on 10/11/23 at 1:20 PM of facility policy titled Medication Ordering Receiving and Storage showed, medications and biologicals shall be locked when not in use and should not be left unattended.

Based on observation, interview and record review, the facility failed to store nebulizer mask and tubing, for 3 Residents (Resident #2, #13 and #22), and ensure humidifier bottles were filled for 1 (Resident #22) and failed to enter a physicians order prior to administering oxygen to 1 Resident (Resident #13) receiving supplemental oxygen and/or utilizing nebulizer treatments in order to prevent the potential for infection and respiratory complications for (Resident #2, #4, #8, #12, #13, #15, #22, #25, #30, #58 and #68) sampled residents who received respiratory therapy. The findings are: Review of Resident #2's Order Summary Report showed the following: a. A physician's order dated 8/5/23 to administer O2 (oxygen) at 2 L (Liters)/M (minute) via NC (Nasal Canula) as needed. b. A physician's order dated 3/15/23 to change O2 tubing, and date all tubing every Wednesday night on 11-7 shift. During observation on 10/09/23 at 12:30 PM, Resident #2's nebulizer mask was sitting on the nightstand between the Resident's bed and wall. The mask was not in a plastic bag and open to air. During observation on 10/10/23 at 3:01 PM, Resident # nebulizer mask was on the nightstand uncontained. Review of Resident #13's progress noted dated 09/19/23 by the Dietary Manager showed, Resident was readmitted back to the facility post hospital stay for chronic respiratory failure on oxygen 2 liters via nasal cannula continuous, but there was no documentation of an order in place for oxygen therapy. During observation on 10/09/23 at 9:43 AM, Resident #13 had an oxygen tubing around her neck, and the nebulizer mask was lying uncovered on the nightstand with tubing connected. During observation on 10/10/23 at 2:15 PM, Resident #13's oxygen was being delivered at 3 liters via nasal cannula, and the nebulizer mask lying on nightstand uncovered. During interview on 10/11/23 at 8:41 AM, LPN #3 said she would come back later and put Resident #13's nebulizer mask in a bag. During interview on 10/11/23 at 2:25 PM, LPN #3 confirmed there was not a physician order to administer oxygen to Resident #13 during the time frame of 9/10/23 to 10/10/23. Review of Resident #22's Order Summary Report showed a physician order dated 9/14/23 to administer O2 at 1-3 L/M via nasal cannula continuously every shift. The following observations were made on 10/09/23: a. At 2:00 PM, Resident # 22 was receiving O2 via n/c (nasal canula). The humidifier bottle on the oxygen concentrator was empty, swollen, and dated 10/5/23. b. At 2:46 PM, Resident # 22 was receiving O2 via n/c at 3 Liters. The humidifier bottle on the concentrator was empty. c. At 3:24 PM, Resident #22 was receiving O2 via n/c at 3 Liters. The humidifier bottle was swollen and empty. During observation on 10/10/23 at 8:49 AM, Resident # 22 was receiving O2 via n/c at 3 Liters/minute. The humidifier bottle was empty and swollen. During interview on 10/11/23 at 1:21 PM, the DON said the humidifier bottles should be changed weekly, sooner if they are empty or very low, and tubing is changed at least one time a week and should be checked every time someone goes into a room. The DON said oxygen tubing should be stored in one of the O2 storage bags either hanging on the bedside table or hanging on a hook. Nebulizers are supposed to be rinsed out after use, laid out to dry, and stored in a bag after drying. Review on 10/11/23 at 10:52 AM of facility policy titled Oxygen Safety showed, the facility will properly handle oxygen and oxygen therapy is administered to the resident only upon the written order of a licensed physician. 48977

Based on observation, interview and record review, the facility failed to post a contact isolation precaution sign to notify staff of appropriate precautions to follow during resident care for 1(Resident #55) of 1 sampled resident. The findings are: Review of Resident #55's progress noted dated 09/18/22 by Physician Assistant showed the Resident with urinary tract infection with multiple organisms, one of which being Methicillin-resistant Staphylococcus Aureus (MRSA). The following observation were made on 10/09/23: a. At 12:49 PM, personal protective equipment (PPE) was hanging on Resident #55's door with no contact isolation precaution sign on the door. b. At 8:43 AM, PPE was hanging on Resident #55's door with no contact isolation precaution sign on the door. c. At 9:14 AM, PPE was hanging on Resident #55's door. No contact isolation precaution sign was observed on the door. During observation on 10/11/23 at 8:36 AM, PPE was hanging on Resident #55's door. No contact isolation precaution sign was observed on the door. During interview on 10/11/23 at 10:56 AM Certified Nursing Assistant (CNA) #3 confirmed she has not seen any signs on Resident #55's door concerning isolation. Review on 10/12/23 at 10:30 AM of Resident #55's nursing-hot rack entry dated 10/09/23 and 10/10/23 showed Resident was to remain on contact isolation. Review on 10/11/23 at 11:34 AM of facility policy titled Isolation Precautions, Categories of showed, color coded signs will be used on a resident's door to alert staff of the implementation of isolation precaution, the type of precaution, and to alert all visitors to report to the nurses' station before entering the resident's room.

Based on record review and interview, the facility failed to clearly determine and document the Advanced Directives for 1 of 1 (Resident #25) residents reviewed. Review of a document DNR (Do Not Resuscitate)/ Cardiopulmonary Resuscitation (CPR) Instructions, signed on [DATE] by Resident #25, which showed the resident did not want CPR. Review of a document Acknowledgment of Receipt of Advance Directive Information signed on [DATE] by Resident #25 Power of Attorney noted the resident is a full code . Review of the electronic medical record Miscellaneous tab showed on [DATE] Resident #25 was coded as DNR. During an interview on [DATE] at 9:15 AM, the Administrator said I would go by the most recent signature which was in [DATE]. The Administrator confirmed Resident #25 did not have a decline in status between May and November of 2019, which would prevent the resident from signing the code status. The Surveyor asked if there was any concern with the conflicting documents. The ADON answered, Yes, I can see the issue with that The Assistant Administrator confirmed the resident did not have a decline, and confirmed the conflicting documents are confusing. A review of the Advance Directive policy, last revised on [DATE] showed the facility will review existing advance directives upon admission and will provide residents who do not have advance directives in place an opportunity to formulate an advanced directive, if desired, and will follow those directives in accordance with applicable state law.