Every finding on record at Seminole Manor Nursing Home

Based on observations, staff interviews, record review, and review of the facility policy titled, Pureed Diets, the facility failed to ensure pureed, therapeutic diets were properly prepared for two out of nine sampled residents (R) (R20 and R60) receiving a therapeutic pureed diet. This deficient practice had the potential to cause medical complications and place the residents at risk for unmet nutritional needs.Findings includedReview of the facility policy titled Pureed Diets (last revised/reviewed 08/19/2022) documented: It is the policy of [Facility] for the Dietary Department to provide puree consistency diets to all who need them per Dr. (doctor) orders. PROCEDURE: All puree foods will be prepared following recipe. Portioned correctly per menu. These foods are pre cooked and then blended until correct consistency. Sometimes a thickening agent will be added per recipe. Patients/Residents with the following may benefit from a puree diet. Puree diets can only be served to a person with a Dr. order for puree.Review of the dietary recipe procedure titled Egg, Scrambled (liquid/margarine) - 1/4 Cup (not dated) documented: [Notes] 1. For Pureed: Measure out desired number of servings into a food processor. Blend until smooth. Add thin liquid if the product needs thinning. Add commercial thickener if product needs thickening. Note: Liquid and thickener measurements are approximate and slightly more or less may be required to achieve desired pureed consistency.1 Review of R20's electronic health record (EHR) revealed R20 had diagnoses that included, but were not limited to, Alzheimer's disease, gastro esophageal reflux disease without esophagitis (GERD), ulcerative esophagitis, and malignant neoplasm of the prostate.Record review of R20's Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated severely impaired cognition, meaning never/rarely makes decisions. Section GG (Functional Abilities) and Section K (Swallowing/Nutritional Status) revealed the resident received a mechanically altered diet (which required change in texture of food or liquid, puree food) due to dysphagia, oral or dental surgery, injury to the jaw or gums, digestive disorders, oral infection, bariatric surgery, missing teeth, or dementia.Review of R20's Physician Order Form (POF) revealed a dietary order dated 08/18/2025 for CCD Dys Puree (Consistent Carbohydrate Diet - Dysphagia Puree).Observation on 05/01/2026 at 9:45 AM revealed R20 sitting in bed in an upright position, eating his meal, a non pureed diet, independently without staff assistance. Continued observation of the resident's meal revealed pureed scrambled eggs (appearance was thick and lumpy). Review of R20's meal tray card revealed a diet for Regular - Dys Puree, Pureed Scrambled Eggs.Observation on 05/02/2026 at 8:37 AM revealed R20 in the dining room sitting at a table with another resident, eating his meal, a non pureed diet, independently without staff assistance. R20's meal tray stated Pureed Diet. Continued observation of the resident's meal revealed pureed scrambled eggs. The texture appearance was thick, scrambled, with large grainy curds.Record review of R20's Registered Dietitian progress note dated 03/04/2026 documented the resident had a history of weight loss, a diagnosis of ulcerative esophagitis, and was followed by Hospice.2.Record review of R60's EHR revealed R60 had diagnoses that included, but were not limited to, vascular dementia, senile degeneration of the brain, and excessive salivary secretions.Record review of R60's Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated severely impaired cognition, meaning never/rarely makes decisions. Section GG (Functional Abilities) and Section K (Swallowing/Nutritional Status) revealed the resident received a mechanically altered diet (which required change in texture of food or liquid, puree food).Review of R60's Physician Order Form (POF) revealed a dietary order dated 08/18/2025 for CCD Dys Puree (Consistent Carbohydrate Diet - Dysphagia Puree).Review of R60's Registered Dietitian notes dated 01/26/2026 and 03/10/2026 documented R60 had a diagnosis of senile degeneration of the brain and a past history of weight loss. R60 was NPO (Nothing by Mouth) and was upgraded to a puree diet by Hospice. The RD's progress notes stated that at this time the resident's weight was stable.Observation on 05/02/2026 at 8:43 AM revealed R60 in the dining room sitting at a table with four other residents, eating her meal, a non pureed diet, independently without staff assistance. Continued observation of the resident's meal revealed pureed scrambled eggs (appearance was thick and lumpy). Review of R60's meal tray revealed a diet for pureed consistency (CCD Dys Puree), Pureed Scrambled Eggs.Interview on 05/02/2026 at 1:20 PM with the Registered Dietitian (RD) revealed she reviewed the photos of the pureed food items (eggs) served to R20 and R60 on 05/01/2026 and 05/02/2026. The RD described the food item (eggs) as non pureed due to dietary staff failure to achieve the correct consistency. She described the eggs on 05/01/2026 as thick with custard like curds, soft scrambled, and lumpy. She described the eggs on 05/02/2026 as lumpy due to lack of milk to ensure a smooth, moist consistency. She reported the eggs could have been left in the Robot Coupe mixer longer or staff could have added more milk to reduce thickness and make the texture smoother. When asked about the risk of residents consuming food of non pureed consistency, the RD reported that both residents would be at risk of choking or aspirating.Interview on 05/03/2026 at 10:55 AM with the Dietary Manager (DM) revealed she reviewed the photos of the pureed food item (eggs). She confirmed that dietary staff served all pureed diet residents, including R20 and R60, non pureed eggs on 05/01/2026 and 05/02/2026. She confirmed receiving in service training on pureed appearance and preparation. The DM reported she was unaware that the eggs were not pureed to a pureed consistency until it was brought to her attention by the surveyor team. She reported that all pureed food items were prepared by the hospital dietary staff and delivered to the nursing home dietary staff to serve on the steam table. The DM reported receiving training yesterday along with the hospital staff by the Registered Dietitian.

Based on observations, staff interviews and review of the policy titled, Safe Homelike Environment, the facility failed to ensure that dust and grime buildup was addressed in three of 13 rooms (N115, N118, and N122) in the facility with portable units. The facility also failed to repair one room (N122) with a hole in the wall and failed to fix or replace one fixture on the wall border interior in the same room.Findings include:A review of a policy titled Safe and Homelike Environment with review date of January 2025 documented: Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility, both inside and outside, maximizes resident independence and does not pose a safety risk. Definitions: Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas. A homelike environment is one that de emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A determination of homelike should include the resident's opinion of the living environment.Observations on 05/01/2026 at 8:17 AM, on 05/02/2026 at 1:31 PM, and on 05/03/2026 at 9:10 AM revealed that the air conditioning unit filter was dark and dusty.Observations on 05/01/2026 at 8:24 AM, on 05/02/2026 at 2:34 PM, and on 05/03/2026 at 9:11 AM revealed that the air conditioning unit filter was dark and dusty.Observations on 05/01/2026 at 9:17 AM, on 05/02/2026 at 1:34 PM, and on 05/03/2026 at 9:11 AM revealed that the air conditioning unit filter was dark and dusty. The observations also revealed a hole in the wall that had been patched with drywall plaster, and a cracked wall border interior that required replacement.Observation and interview on 05/03/2026 at 10:00 AM with Utility Mechanic 1 and the Maintenance Director, who is on call for the facility, confirmed that the air vents in Rooms N115, N118, and N122 contained dark black substance, grime, and bugs. They also confirmed that Room N122 had holes in the wall that needed repair and a wall fixture that required replacement. The Maintenance Director stated that air conditioning unit filters are cleaned quarterly or as needed.Interview on 05/03/2026 at 10:10 AM with the Administrator confirmed that the identified rooms required air filter cleaning, and that the hole and wall fixture in Room N122 needed to be repaired or replaced. She stated this would be added to their PIP. She reported that housekeeping was responsible for notifying maintenance when repairs were needed and that maintenance conducts walk throughs to ensure a safe, clean, and homelike environment.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Resident Self Administration of Medication, the facility failed to ensure one of 30 sampled residents(R) (R8) did not have unauthorized and unsecured medications and medicated treatment products at the bedside. This deficient practice had the potential to cause adverse effects for R8 and allow unsecured medications and medicated treatment products to be accessible to other residents.Findings include:Review of the facility's policy titled Resident Self-Administration of Medication with review date of August 2025 revealed under the section titled Policy stated, It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Under the Policy Explanation . and Compliance Guidelines section included 2. Upon notification of the use of bedside medication by the resident, the medicication nurse record the self-administration on the (medication administration record) MAR. 3. Families or responsible parties are reminded of policy and procedures regarding resident self-administration when necessary.6. When the interdisciplinary team determines that bedside storage of medication would be a safety risk to other residents, the medications of residents permitted to self-administer are stored in the medication cart or medication room. 7. The care plan must reflect resident self-administration and storage arrangements for such medications.Review of R8's Electronic Health Records (EHR) revealed diagnoses that included, but were not limited to, cerebral infarction due to unspecified occlusion or stenosis of the right posterior cerebral artery, pressure ulcer of the sacral region, stage 3, and an encounter for attention to a gastrostomy.Review of R8's Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition; Section GG (Functional Abilities and Goals) revealed the resident required setup or clean-up assistance with personal hygiene and was dependent on staff for lower/upper body dressing and mobility.Review of R8's physician orders revealed an order dated 04/8/2026 for [Name] solution (sodium hypochlorite) 0.125%; miscellaneous special instructions: use [Name] to cleanse coccyx wound and pack wound with [Name] moist 4x4 gauze once a day; an order dated 12/12/2025 to clean the (gastrostomy tube) G-tube site with wound cleanser and apply dry dressing daily; and an order dated 03/25/2026 for coccyx wound care-clean with [Name], prep peri-wound with skin prep, pack with [Name] moist 4x4 gauze, cover with ABD (abdominal) pad and secure with tape; change dressing daily and PRN (as needed) for soiling or dislodgement; do pack with one 4x4 gauze daily. There was no order for self-administration of medications.Review of R8's Electronic Medical Records (EMR) revealed there was no evidence that a self-administration of medication evaluation had been completed.During a concurrent observation and interview on 05/01/2026 at 8:57 AM, a bottle of [Name] Solution 0.125%, a tube of hemorrhoidal ointment, a bottle of H Chlor 12 solution, a bottle of spray cleanser, two bottles of [Name] eye drops, and one jar of [Name] menthol topical ointment were observed lying on top of R8's bedside table. Interview with R8 revealed that he had a wound on his bottom and that the nurses provided all treatments and administered medications for him.During a concurrent observation and interview on 05/02/2026 at 8:04 AM, a bottle of [Name] Solution 0.125%, a tube of hemorrhoidal ointment, a bottle of H Chlor 12 solution, a bottle of spray cleanser, two bottles of [Name] eye drops, and one jar of [Name] menthol topical ointment on the bedside table were observed lying on top of R8's bedside table. Interview with R8 revealed that he was unable to do his own wound care or administer eye drops himself. He stated that stuff (eye drops and medicated treatment products) had been on the table since he admitted from the hospital.Interview on 05/02/2026 at 12:30 PM with the Registered Nurse (RN) Unit Manager BB confirmed the medications and medicated treatment products on top of the bedside table. She reported that the medicated treatment products came from the hospital and the eye drops and the [Name] menthol topical ointment came from home. She reported that R8's family brought them in when the resident was readmitted from the hospital. She stated they were going to provide education to the family immediately. The RN Unit Manager BB acknowledged that it was the staff's responsibility to ensure all unauthorized medications and medicated treatments were not kept at the bedside.Interview on 05/02/2026 at 1:30 PM with the Director of Nursing (DON) confirmed that R8 had not been assessed to self-administer his own medications or medicated treatments. She reported her expectations of staff were to make sure medications and medicated treatment products were properly stored at all times.

Based on observations, staff interviews, record reviews, and review of the facility's policy titled, Comprehensive Care Plans, the facility failed to develop a comprehensive care plan for three of 30 sampled residents (R) (R19, R10, and R11). The facility failed to address wound care for R19 and failed to address oxygen therapy use for R10 and R11 related to oxygen administration. This failure had the potential to affect residents by resulting in inconsistent care, unmet needs, and an increased risk of adverse outcomes.Findings include: Review of the facility's policy titled Comprehensive Care Plan (revised October 2025) documented: Policy: It is the policy of this center to develop and implement a comprehensive, person centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs as identified in the resident's comprehensive assessment. 1.Review of R10's Electronic Health Record (EHR) revealed the following diagnoses, but not limited to, chronic obstructive pulmonary disease. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed for Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of nine, which indicates moderate cognitive impairment. Section O (Special Treatments, Procedures, and Programs) revealed an assessment for oxygen therapy use. R10's EHR listed a physician order dated 11/10/2025 for oxygen at 4 liters via N/C PRN (four liters per minute (LPM) via nasal cannula as needed). During observations on 05/01/2026 at 9:00 AM, 05/02/2026 at 9:15 AM, and 05/02/2026 at 12:09 PM of R10's room, R10 was observed lying in bed receiving oxygen from an oxygen concentrator by nasal cannula at a flow rate of three and a half liters per minute (3.5 LPM) instead of 4 LPM. Record review of R10's care plan revealed no focus area for oxygen therapy. 2.Review of R11's EHR revealed the following diagnoses, but not limited to, shortness of breath and COVID 19 acute respiratory disease. The Annual Minimum Data Set (MDS) assessment dated [DATE] assessed for Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of four, which indicates severe cognitive impairment. Section O (Special Treatments, Procedures, and Programs) revealed no assessment for oxygen therapy use during the seven day look back period. R11's EHR listed a physician order dated 01/01/2026 for oxygen at 2 liters per minute via N/C PRN (two liters per minute via nasal cannula as needed). During observations on 05/01/2026 at 8:57 AM, 05/02/2026 at 9:16 AM, and 05/02/2026 at 12:11 PM of R11's room, R11 was observed lying in bed receiving oxygen from an oxygen concentrator by nasal cannula at a flow rate of 1.5 LPM instead of 2 LPM. Record review of R11's care plan revealed no focus area for oxygen therapy. During an interview on 05/03/2026 at 10:22 AM with the Director of Nursing (DON), the DON reviewed R10 and R11's EHR records for oxygen orders and oxygen care plans. She confirmed that both residents, R10 and R11, did not have a plan of care for oxygen therapy use. She confirmed that the new MDS Coordinator failed to create a care plan for oxygen therapy for both residents. She stated that the new MDS Coordinator was new to her position and currently in training to learn all aspects of the care planning process. The DON reported she was currently responsible for training the new MDS Coordinator. The DON further stated that she takes sole responsibility for R10 and R11's care plans not being created. 3.Review of R19's EHR revealed diagnoses that included, but were not limited to, pressure ulcer of the left hip, stage 3, and pressure ulcer of the sacral region, stage 2. Review of R19's Significant Change Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of seven, which indicated severe cognitive impairment. Section GG (Functional Abilities and Goals) revealed the resident was dependent on staff for activities of daily living care. Section M (Skin Conditions) revealed the resident was at risk for pressure ulcers, had no wounds, and was receiving applications and ointments. Review of R19's physician orders revealed an order dated 03/17/2025 to perform care to the wound area of the back as follows: cleanse with wound cleanser, pat dry, apply Puracol followed by foam dressing once a day on Monday, Wednesday, and Friday. Orders dated 05/02/2026 for wound care to the coccyx included: cleanse with wound cleanser, apply Puracol to wound bed, cover with adhesive foam dressing three times weekly and PRN soiling or dislodgment once a day on Monday, Wednesday, and Friday. Orders for wound care to the left hip included: cleanse with wound cleanser, apply Medihoney sheet to wound bed followed by Silver Agrope, and cover with adhesive foam dressing daily and PRN soiling or dislodgment once a day. Review of R19's skin assessments revealed a pressure ulcer to the left hip identified on 03/23/2026, a pressure ulcer to the right thoracic back identified on 03/31/2026, and a pressure ulcer to the coccyx identified on 02/04/2026. Review of care plans revealed there was no care plan that addressed R19's wounds. Interview on 05/02/2026 at 12:20 PM with the Registered Nurse (RN) MDS Coordinator revealed that she was responsible for developing and updating care plans when completing MDS assessments and that nurses should be updating care plans with any new changes. She confirmed that there was no care plan for R19's wounds. She acknowledged that the care plan addressing R19's wounds should have been developed. Interview on 05/02/2026 at 1:30 PM with the DON confirmed that R19 should have had a care plan to address her wounds. The DON stated her expectation was that all residents with wounds should have a care plan to address their wounds.

Based on observations, staff interviews, record review, and review of the facility policy titled, Policies and Procedures, the facility failed to assure two of 15 residents (R) (R10 and R11) receiving oxygen therapy was administered oxygen in accordance with the physician's order. Specifically, the facility failed to ensure that residents received oxygen at the rate prescribed by the physician and failed to ensure oxygen signage was posted during the administration of oxygen therapy to prevent accident hazards. This deficient practice had the potential to result in residents not receiving adequate oxygenation as ordered and increased the risk of fire hazards due to the absence of appropriate safety signage. Findings include:Review of the facility policy titled Policies and Procedures (dated June 2018) documented that oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person centered care plan, and the resident's goals and preferences.1.Review of R10's electronic health record (EHR) revealed the following diagnoses, but not limited to, chronic obstructive pulmonary disease and vascular dementia.Record review of R10's EHR physician order dated 11/10/2025 revealed the following order: oxygen at 4 liters via N/C as needed (PRN) (four liters per minute via nasal cannula as needed).Observations on 05/01/2026 at 9:00 AM, 05/02/2026 at 9:15 AM, and 05/02/2026 at 12:09 PM revealed R10 lying in bed receiving oxygen from an oxygen concentrator by nasal cannula at a flow rate of three and a half liters per minute (3.5 LPM) instead of 4 LPM. Continued observation revealed no oxygen signage posted on the exterior door of the room or inside the resident's room to alert oxygen usage.Record review of R10's EHR Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of nine, which indicates moderate cognitive impairment. Section O (Special Treatments, Procedures, and Programs) revealed an assessment for oxygen therapy use.Record review of R10's EHR care plan revealed no focus area for oxygen therapy.During a tour of R10's room on 05/02/2026 at 12:09 PM with the Director of Nursing (DON), the DON confirmed that R10's flow rate was set at 3.5 LPM instead of 4 LPM per physician order. The DON adjusted the oxygen flow rate to 4 LPM prior to exiting the resident's room. She reported that her expectations are for nursing staff to adjust the flow rate at eye level to assure accuracy of the setting. She confirmed that R10 had no known history of self adjusting the dial meter on his oxygen concentrator.2.Review of R11's EHR revealed the following diagnoses, but not limited to, shortness of breath and COVID 19 acute respiratory disease.Review of R11's EHR physician order dated 01/01/2026 revealed the following order: oxygen at 2 liters per minute via N/C PRN (two liters per minute via nasal cannula as needed).Observations on 05/01/2026 at 8:57 AM, 05/02/2026 at 9:16 AM, and 05/02/2026 at 12:11 PM revealed R11 lying in bed receiving oxygen from an oxygen concentrator by nasal cannula at a flow rate of 1.5 LPM instead of 2 LPM. Continued observation revealed no oxygen use signage posted on the exterior door of the room or inside the resident's room.Record review of R11's EHR Annual Minimum Data Set (MDS) assessment dated [DATE] for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of four, which indicates severe cognitive impairment. Section O (Special Treatments, Procedures, and Programs) revealed no assessment for oxygen therapy use during the seven day look back period.Record review of R11's EHR care plan revealed no focus area for oxygen therapy.During a tour of R11's room on 05/02/2026 at 12:11 PM with the DON confirmed that R11's flow rate was set at 1.5 LPM instead of 2 LPM per physician order. The DON adjusted the oxygen flow rate to 2 LPM prior to exiting the resident's room. She reported that R11 had no known history of self adjusting the dial meter on his oxygen concentrator.During an observation of R10 and R11's shared room (room [ROOM NUMBER], a two bed unit) on 05/02/2026 at 12:18 PM, the DON confirmed that oxygen signage was not posted on the exterior or interior walls of the residents' room to alert staff and visitors that oxygen therapy was being provided. She reported that having oxygen signage posted was part of the facility's Safety/Risk Protocol to ensure resident safety while receiving oxygen. In addition, the DON reported that her expectations were for licensed nursing staff to check each resident's physician orders to ensure each resident's oxygen setting was at the correct flow rate.

Based on observations, staff interviews, and review of the facility policy titled, Medication Storage, the facility failed to ensure one of three medication carts was locked and secured.This deficient practice increased the risk of misuse, diversion, and potential harm to residents. Findings include:Review of the facility policy titled Medication Storage with a date of 01/05/2018 documented Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, lights, ventilation, moisture control, segregation, and security .Policy Explanation and Compliance Guidelines (1) General Guidelines (a) all drugs and biologicals will be stored in locked compartments (i.e, medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature control.During an observation and interview on 05/01/2026 at 10:06 AM, a medication cart was observed to be unlocked in between resident rooms 103-107 on the South Hall. At approximately 10:08 AM, Licensed Practical Nurse (LPN) AA exited room [ROOM NUMBER] and went to the unlocked medication cart and locked it while the surveyor was standing there. She confirmed she had left the cart unlocked while providing care to residents and stated that the medication cart should always be locked while unattended.An interview on 05/01/2026 at 10:36 AM with the Director of Nursing (DON) revealed that medication carts should always be locked when left unattended.

Based on observation, staff interview, and review of the facility's policy titled Storage of Records, the facility failed to ensure confidential medical, financial, and legal records were stored in a manner to prevent unauthorized access to the records. This deficient practice had the potential to compromise the confidentiality of resident records. Findings include: Review of the facility's policy titled Storage of Records, reviewed 11/2024, revealed the Purpose section included, .Resident-purged paper records are placed in filing cabinets located in the locked [NAME] Hall storage room. Observation on 4/24/2025 at 4:25 pm, in the copy room across from the Nurse's Station, revealed a bin for storage of medical records to be destroyed that was unlocked, and the door to the copy room was unlocked. Observation on 4/24/2025 at 4:24 pm revealed a shred bin behind the Nurse's Station that was unlocked with the door slightly ajar. The Nurse's Station had an open floor plan with no doors or gates to restrict access to the items behind it. At the time of the observation, multiple staff members were both behind and in front of the nursing station. Observation on 4/24/2025 at 7:20 am revealed that the [NAME] Hall Storage Room used the same entry code as the restroom. Observation of the storage room revealed two two-drawer file cabinets and five four-drawer filing cabinets next to a scale for weighing residents. One of the two-drawer filing cabinets had a label that stated Jan - [DATE] Financial. Another drawer was labeled as COVID-19 2020 - 2022. Another drawer was labeled Social Service Files, and another was labeled Business Office Files. Three cabinets were labeled Resident Files and had unlocked hasps attached. In an interview on 4/25/2025 at 4:37 pm, the Administrator stated that medical and financial records should be stored securely to limit access based on a need-to-know. The Administrator confirmed that locks were being ordered and would be installed to secure the records in the [NAME] Hall Storage Room.

Based on observations, staff interviews, record review, and review of the facility's policy titled Food: Preparation, the facility failed to ensure sanitary practices were followed during food preparation. This deficient practice had the potential to place the 62 residents who received food from the kitchen at risk of foodborne illness. Findings included: Review of the facility's policy titled Food: Preparation, dated 9/2017, revealed the Procedures section included, .2. Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. Observation on 4/22/2055 at 11:50 am revealed the Dietary Manager (DM) measuring food temperatures of 11 food items on the steam table. The DM used a paper napkin to wipe the residue from the probe thermometer between each food item tested without sanitizing the probe. He then used the probe thermometer to measure the temperature of a bowl of fruit and a bowl of applesauce. When asked about sanitizing the temperature probe, the DM placed the probe in a cup of sanitizing solution and said the same solution used in the sanitization buckets was used in the probe thermometer cup. In an interview on 4/23/2025 at 11:55 am, the DM stated he tried to sanitize the food thermometer probe between each food in a sanitizing solution and provided a box of food probe wipes. The box was tattered and had an illegible date ending in 2025. In an interview on 4/23/2025 at 2:15 pm, the District Manager acknowledged that using a paper napkin to wipe the food thermometer probe between food types was not acceptable, and the expectation was that staff should use a clean probe wipe to sanitize the temperature probe between each food type to prevent cross-contamination. In an interview on 4/25/2025 at 3:32 pm, the Registered Dietitian stated there were probe wipes available to sanitize the probe thermometer between food types, and the expectation was for dietary staff to sanitize the probe between each food type with a new wipe.

Based on observations, resident interviews, and staff interviews, the facility failed to serve food to residents that was palatable, attractive, and appetizing. This deficient practice had the potential to adversely affect 62 residents who received meals from the kitchen. Findings include: In a Resident Council meeting on 4/23/2025 at 9:30 am, residents expressed dietary concerns, including that meals were often cold and the food was bland and without flavor. On 4/25/2025 at 5:30 pm, the Administrator ordered a test tray to be brought to the Activity Room. The test tray was carried by a staff member from the Kitchen to the Activity Room and was delivered at 5:32 pm. The dinner plate was covered with a dome lid, and an insulated bowl, and all beverage cups were covered with disposable plastic lids. Two surveyors participated with the Administrator in sampling the test tray. The tray contained the following food items: - One prepackaged bag of barbeque potato chips (one and one-half ounces) - One bowl of broccoli and cheese soup - One chicken salad sandwich on white bread and one serving of green pea salad, which were served on the same plate. Observation revealed that the green pea salad was in a liquid that had spread across the plate and came into contact with the bottom slice of the sandwich's bread, causing the bread to become soggy. The sandwich was cut into four quarters and tasted by all three participants. All participants agreed that the chicken salad was bland and lacked salt and/or seasoning. The soup was found to be lumpy. The temperature of the soup was neither hot nor cold. The soup, when tasted, was bland and of the consistency of condensed soup, as if no water had been added to a concentrated pre-packaged product. The pea salad, when sampled, was neither hot nor cold and tasted like peas without any additional seasoning. The sauce also lacked any seasoning. The Administrator speculated that the sauce was mayonnaise-based and remarked that this salad should have been served cold. All three people who sampled the test tray agreed that the pea salad should have been served in a bowl or with a thicker sauce to prevent the sauce from running across the plate into the sandwich. All three people sampling the test tray agreed with the above findings, and the Administrator stated that most of the residents' complaints were about the supper [evening] meal.

Based on observation, staff interviews, record review, and review of the facility policie titled Dignity and Routine Resident Checks, the facility failed to provide care in a manner to promote dignity and respect for five of seven residents (R) (R3, R9, R57, R60, and R54) who were noted to have food spills on their clothing or dirty, jagged fingernails. This failure had the potential to diminish R3, R9, R57, R60, and R54's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: A review of the facility policy titled Dignity, last reviewed and revised on 6/19/2024, revealed the following: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances hir or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. A review of the facility policy titled Routine Resident Checks, last reviewed and revised on 4/2025, revealed the following: Staff shall make routine resident checks to maintain resident safety and well-being . Policy Interpretation and Implementation 1. To ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each unit at least once per each 8-hour shift. 2. Routine resident checks should occur more frequently for residents that are not able to call for assistance based on their individual needs. Residents that are able may call for assistance as needed for any care needs to be performed. This involves entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. 1. Review of R57's medical record revealed he was admitted to the facility on [DATE], and diagnoses included diabetes mellitus with diabetic neuropathy, age-related nuclear cataract, and bilateral vitreous degeneration. Review of his most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/27/2025, R57 achieved a score of 13 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. The assessor also documented on this MDS that R57 had impaired vision and impairments in functional range of motion in both upper and lower extremities. During the seven-day look-back period established by the ARD of 2/27/2025, the resident did not exhibit any rejection of care. Under Section GG (Functional Abilities and Goals), the assessor documented that R57 required set-up or clean-up assistance with eating. (Set-up or clean up assistance was defined as: Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.). The assessor also documented that R57 was dependent with personal hygiene (defined as: The ability to maintain personal hygiene, including combing hair, shaving, applying make-up, washing/drying face and hands (excludes baths, showers, and oral hygiene. Dependent was defined as Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.) Review of the resident's Comprehensive Care Plan revealed a Problem, dated 12/17/2024, which noted, [Name of R57] requires partial/dependent assistance from staff for ADLS [activities of daily living] R/T [related to] immobility. The goal associated with the problem was: [Name of R57]'s ADLs will be met per staff as needed. Review of a quarterly Registered Dietitian Progress Note recorded, dated 3/5/2025 at 2:05 pm, found: . He [R57] will not sit up to eat but is able to feed himself, using a divided plate. Observation on 4/22/2025 at 11:58 am revealed R57 in his room, wearing a hospital gown while lying in bed. Some food was observed on the front of his hospital gown, although he was not actively eating at the time of observation. No meal tray was present on his overbed table, indicating that someone had removed his meal tray from his room after he finished eating his breakfast that morning. 2. Review of R3's medical record revealed he was readmitted to the facility on [DATE], and diagnoses included: multiple sclerosis, muscle spasms, other specified disorders of muscle, encounter for attention to gastrostomy. Review of his most recent MDS assessment, with an ARD of 2/19/2025, R3 achieved a score of 15 out of 15 on the BIMS, which indicated the resident was cognitively intact. The assessor also documented on this MDS that R3 had impairments in functional range of motion in both upper and lower extremities. During the seven-day look-back period established by the ARD of 2/19/2025, the resident did not exhibit any rejection of care. Under Section GG (Functional Abilities and Goals), the assessor documented that R3 was dependent with eating. The assessor also documented that R3 was dependent with personal hygiene. Review of the resident's Comprehensive Care Plan revealed a Problem, dated 4/2/2019, which noted, [Name of R3] is dependent on staff for ADLs R/T MS (Multiple Sclerosis). He will reject care at times. The goal associated with the problem was: [Name of R3]'s ADLs [sic] will be met per staff. A review of the resident's Physician Orders noted the following active orders: Oral Meals Only When Out Of Bed And Seated At 90 Degrees, Dated 4/9/2025. Regular, Dys Adv [Dysphagia Advanced] Special Instructions: Add Ice Cream To Tray No Liquids, Dated 4/4/2025. May Have Pleasure Snacks By Mouth If Requested, He May Have Sherbert Or Ice cream Along With Solid Snacks Three Times A Day [Sic], Dated 3/20/2025. Observation on 4/22/2025 at 10:17 am revealed R3 in his room, wearing street clothes, seated in his wheelchair beside his overbed table, operating his computer tablet. Some food was observed on the front of his shirt and on his overbed table, although he was not actively eating at the time of observation. No meal tray was present on his overbed table, indicating that someone had removed his meal tray from his room after he finished eating his breakfast that morning. 3. Record review revealed R60 was readmitted to the facility on [DATE], and diagnoses included vascular dementia with behavioral disturbance, disorganized schizophrenia, and moderate intellectual disabilities. Review of his most recent MDS assessment, with an ARD of 4/3/2025, R60 achieved a score of zero out of 15 on the BIMS, which indicated the resident was severely cognitively impaired. During the seven-day look-back period established by the ARD of 4/3/2025, the resident rejected care one to three days during the look-back period. Under Section GG (Functional Abilities and Goals), the assessor documented that R60 required setup or clean-up assistance with both eating and personal hygiene. Review of the resident's Comprehensive Care Plan revealed a Problem, dated 1/17/2025, which noted, [Name of R60] requires assistance with ADLS R/T ID [intellectual disability] & Dementia. The goal associated with the problem was: [Name of R60] will receive adequate assistance with hygiene on a daily basis, AEB [as evidenced by] clean, neat appearance. [sic] Observation on 4/22/2025 at 11:06 am revealed R60 in the lounge area on South Hall, wearing a bright green T-shirt with orange stains down the front. Observation on 4/22/2025 at 11:58 am revealed R60 in the dining room, seated at a table, and wearing a bright green T-shirt with orange stains down the front. Observation on 4/22/2025 at 12:30 pm revealed R60 found him walking independently from the South Hall to the lobby after lunch at 12:30 pm on 4/22/2025, wearing a bright green T-shirt with orange stains down front. Observation at 7:08 am on 4/24/2025 revealed R60 independently propelling himself in a manual wheelchair down South Hall wearing a white T-shirt with orange stains down the front. During an interview at 8:10 am on 4/24/2025, the Activity Director (AD) was asked if R60 dressed himself. The AD replied, Yes and no . He does dress himself. When told he was wearing a white T-shirt with an orange stain on it, the AD stated, That's probably cocoa . He will change it if you ask him to. Observation on 4/24/2025 at 9:22 am revealed R60 standing at the nursing station. He was wearing a bright green T-shirt under a camouflage jacket. The green T-shirt had an orange stain down the front. Observation on 4/24/2025 at 1:14 pm revealed R60 found him sitting in a recliner in the lobby. He was wearing a bright green T-shirt under a camouflage jacket. The green T-shirt had an orange stain down the front. In an interview on 4/24/2025 at 1:15 pm, Certified Nursing Assistant (CNA) EE, who was also in the lobby, stated the stain on R60's shirt was probably from cocoa or a chocolate drink. 4. Record review revealed R9 was readmitted to the facility on [DATE] and was admitted to Hospice services on 9/3/2024 for congestive heart failure. Review of the most recent MDS, with an ARD of 1/30/2025, R9 achieved a score of 14 out of 15 on the BIMS, which indicated the resident was cognitively intact. During the seven-day look-back period established by the ARD of 1/30/2025, the resident had no documented episodes of rejecting care. Under Section GG (Functional Abilities and Goals), the assessor documented that R9 was dependent with personal hygiene. Review of the resident's Comprehensive Care Plan revealed a Problem, dated 3/11/2019, which noted, [Name of R9] requires limited assistance with ADLS R/T debility. The goal associated with the problem was: [Name of R9] will receive adequate assistance with hygiene on a daily basis AEB clean, neat, appearance. [sic] Observation on 4/24/2025 at 7:22 am revealed R9 lying in bed wearing a hospital gown with the covers pulled over his right arm. An observation of his left hand found the fingernails to be dirty and jagged. 5. Record review of R54 showed an admitted [DATE] for hospice care related to a diagnosis of lung cancer. The Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Observation on 4/22/2025 at 2:22 pm revealed R54's fingernails were dirty and untrimmed. Further observation revealed R54 had dried food on her hands, face, and clothing. She did not answer when asked about her fingernails and the dried food. During an interview beginning at 4:38 pm on 4/25/2025, the Administrator was asked about her expectations for staff rounding and providing residents with assistance with personal hygiene. The Administrator stated she would expect that staff would round every two hours. The Administrator also stated that, depending on where the resident was when found soiled, she would expect different staff to assist the resident to clean up. Regarding fingernail care, the Administrator stated each resident's assigned aide was responsible for the care of a resident's fingernails, including cleaning and clipping or shaping them. 45143 46565

Based on observations, staff interviews, record review, and review of the facility's policies titled Pharmacy Services For Medications and Multi-Dose Vials, the facility failed to ensure routine medications were available for two of four residents (R) (R8 and R62) observed during medication administration. The deficient practice had the potential to place R8 and R62 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility policy titled Pharmacy Services For Medications, review date 4/2025, revealed the Policy Statement included, The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. The Policy Interpretation and Implementation section included . 3. Pharmacy services are available to residents 24 hours a day, seven days a week. 4. Residents have a sufficient supply of their prescribed medications and receive medications (routine, emergency, or as needed) in a timely manner. 5. Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. Borrowing medications from other residents or from the emergency medication supply because of a failure to order or reorder a medication in time for a resident to receive a scheduled medication is not acceptable practice. 7. Medications are received, labeled, stored, administered and disposed of according to applicable state and federal laws and consistent with standards of practice. Review of the facility policy titled Multi-Dose Vials, review date 8/2024, revealed the Policy section included, It is the policy of [name of facility] to date all vials as they are opened during administration. Medication in multi-dose vials can be used for administration within 28 days of when the vial was opened. 1. Observation on 4/23/2025 at 7:47 am, during medication administration, revealed Licensed Practical Nurse (LPN) DD administering R8's medications. Observation revealed that a scheduled dose of Vitamin D3 1000 units was not in the resident's medication supply. LPN DD checked the medication storage room and stated the medication was not available and she would order it from the pharmacy. 2. Observation on 4/23/2025 at 7:57 am, during medication administration, revealed LPN BB administering R62's medications. Review of R62's Medication Administration Record (MAR) revealed an order for Lantus (insulin glargine) 100 units per milliliter, 15 units subcutaneous once daily at 8:00 am. LPN BB removed a multidose vial of Lantus, which was in its original box. Neither the box nor the vial was labeled with an open date. Observation revealed a pink sticker on the box reading Discard after 28 Days. LPN BB confirmed there was no open date on the insulin, and there was no way to determine the opened date. She checked the medication storage room and confirmed there was no back-up supply of the insulin. LPN BB re-ordered the insulin from the pharmacy. In an interview on 4/25/2025 at 4:38 pm, the Administrator stated her expectation was for a back-up container of insulin to be available for each resident prescribed insulin, and for medications to be available as ordered. The Administrator further stated that medications should be reordered prior to the current supply being exhausted.

Based on observations, staff interviews, and review of the facility's policy titled Medication Storage And Labeling, the facility failed to ensure one of three medication carts was locked and secured when unattended and out of the sight of authorized personnel, failed to ensure expired medications and medical supplies were discarded from the storage room and treatment cart, and failed to ensure a multi-dose vial of insulin was dated when opened. These deficient practices created the potential for residents, unauthorized staff, and visitors to have access to medications and biologicals stored on the medication cart and placed residents at risk of receiving medications with altered effectiveness. The facility's census was 64 residents. Findings include: A review of the facility policy titled Medication Storage And Labeling, review date 4/22/2025, revealed the Policy included, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. The Policy Interpretation and Implementation section included, Medication Storage . 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others . Medication Labeling 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices . 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. 1. Observation on 4/22/2025 at 12:09 pm revealed one medication cart parked in front of the nursing station under a sign delineating the room numbers for South Hall (Rooms 96 through 111). The cart's key lock was popped out, indicating the cart was unlocked, and the surveyor was successful in accessing a drawer full of medications. [NAME] Clerk (WC) CC was sitting at the nursing station and stated Licensed Practical Nurse (LPN) BB was responsible for the unlocked medication cart. Observation revealed LPN BB sitting at a desk behind the nursing station, located in an area without direct line of sight of the cart. At 12:11 pm, LPN BB verified the cart was unlocked, out of her sight, and locked the cart. In an interview on 4/22/2025 at 2:23 pm, the Director of Nursing (DON) stated the medication cart should not be unlocked when out of sight of the nurse. She stated anyone could access its contents, including residents, if left unlocked and unattended. 2. Observation on 4/22/2025 at 11:37 am with the DON of the contents of the storeroom housing central supply revealed the following: One gastrostomy feeding tube - expired 9/23/2022 One dressing change tray - expired 1/31/2025 One infusion set - expired 9/2016 20 IV [intravenous] start kits - expired 3/1/2023 One box of 50 suction catheters - expired 10/31/2024 two bottles of packing strip dressing - expired 3/20/2025 One box of 10 electrocardiogram tab electrodes - expired 9/2017 One skin staple extractor - expired 3/31/2025 Multiple boxes of absorbent, permeable adhesive film dressings - expired 2/2025 20 male external catheters - expired 3/1/2023 The DON verified the findings. Observation on 4/22/2025 at 1:20 pm with the DON of the treatment cart and supplies stored in the treatment room revealed: One eight-ounce bottle of Hibiclens Chlorhexidine Gluconate - expired 9/2024 One tube of Clotrimazole Cream 1 percent - expired 2/2025 One tube of Clotrimazole Antifungal Cream - expired 9/2024 One bottle of packing strip dressing - expired 3/20/2025 One bottle of packing strip dressing - open with expiration date rubbed off Two multiple-use drawing needles - expired 2/26/2025 Four tuberculin syringes - expired 8/2021 39 packages of skin closures - expired 11/2023 Six occlusive bandage strips - expired 11/30/2024 One 0.9% sodium chloride injection, 20 milliliters (ml) - expired 1/1/2025 One 0.9% sodium chloride injection, 20 ml - expired 11/11/2024 One 12 ml syringe with luer-lock tip - expired 11/16/2024 Six buffered sodium citrate - expired 3/31/2025 Observation of the treatment care revealed the following items were opened, compromising the cleanliness of the items: Two antibacterial foam dressings Two foam dressing One adhesive island dressing One non-adherent pad prepack One wound dressing Three occlusive gauze patch Four occlusive gauze strip One honey impregnated wound dressing Two open packages of non-sterile cotton-tipped applicators, containing a combined total of 84 applicators. The applicators were seen spilling from the open packaging into the cart and would not be considered clean for use in applying anything to an open wound. In an interview on 4/22/2025 at 2:00 pm, the DON confirmed that all items observed were kept past their expiration dates and/or were opened and should not have been available for use. 3. During medication pass observation on 4/23/2025 at 7:47 am, observation revealed LPN DD left a prepared cup of MiraLax on top of the medication cart, parked in the area of a resident's room, when she went to the medication storage room. The medication was left out of her direct line of sight. Upon her return to the medication cart at 7:56 am, LPN DD confirmed she had left the cup of MiraLax unsecured and unattended on top of her cart when she walked to the medication room. 4. During medication pass observation on 4/23/2025 at 7:57 am, observation of LPN BB preparing one resident's (R) (R62) medications revealed one opened multi-use vial of Lantus insulin (a medication used to treat high blood sugar) without an open or discard date. LPN BB confirmed that neither the multi-dose vial nor the box was dated to indicate when the vial was opened. In an interview on 4/23/2025 at 3:24 pm, the DON stated her expectations were for expired medications and medical supplies to be removed from use, and multi-dose vials were to be dated when opened and discarded 28 days after opening. In an interview on 4/25/2025 at 4:38 pm, the Administrator stated her expectations were for medication carts to be locked and secured when unattended, medications to be secured and not left on top of medication carts when unattended, and expired medications and supplies to be discarded upon expiration dates.

Based on observation, staff interviews, record review, and review of the facility's policy titled Pharmacy Services For Medications, the facility failed to ensure the medication error rate was less than 5 percent. A total of 30 opportunities were observed with two errors for two residents (R8 and R62), resulting in an error rate of 6.67 percent. This failure had the potential to place R8 and R62 at risk of medication not being given in accordance with the physician's orders and had the potential to adversely affect the residents' clinical conditions. Findings include: A review of the facility policy titled Pharmacy Services For Medications, reviewed 4/2025, revealed the Policy Statement included, The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. The Policy Interpretation and Implementation section included, . 3. Pharmacy services are available to residents 24 hours a day, seven [7] days a week. 4. Residents have a sufficient supply of their prescribed medications and receive medications (routine, emergency, or as needed) in a timely manner. 1. Observation on 4/23/2025 at 7:47 am, during medication administration, revealed Licensed Practical Nurse (LPN) DD administering R8's medications. Observation revealed that a scheduled dose of Vitamin D3 1000 units was not in the resident's medication supply or the back-up medication supply. The medication was not administered. LPN DD verified the medication was not administered and would be an omitted dose. 2. Observation on 4/23/2025 at 7:57 am, during medication administration, revealed LPN BB administering R62's medications. Review of R62's Medication Administration Record (MAR) revealed an order for Lantus (insulin glargine) 100 units per milliliter, 15 units subcutaneous once daily at 8:00 am. LPN BB removed a multidose vial of Lantus, which was in its original box. Neither the box nor the vial was labeled with an open date. Observation revealed a pink sticker on the box reading Discard after 28 Days. LPN BB confirmed there was no open date on the insulin, and there was no way to determine the opened date. There was no back-up or emergency supply of the medication, and the medication was not administered. LPN BB verified the medication was not administered and would be an omitted dose. In an interview on 4/25/2025 at 4:38 pm, the Administrator stated her expectation was for medications to be available for each resident, and medications should be re-ordered before the supply was exhausted.

Based on observation and staff interview, the facility failed to ensure four of 42 sampled residents (R) diagnoses were kept private and confidential. This failure had the potential to affect all residents with a diagnosis of diabetes living in the facility. Observation on 4/22/2025 at 9:30 am revealed that an undated handwritten list titled Diabetics was seen posted on the wall in the activity room. There was a window between the lobby and the activity room that allowed clear visibility of the list to anyone visiting the facility. The activity room was used daily by residents and staff. During an interview with the Activities Director on 4/24/2025 at 2:35 pm, she stated that the list was used to ensure residents with diabetes received snacks appropriate for them and acknowledged that she was unaware that posting that sign was a privacy and confidentiality issue.

Based on observation, staff interviews, record review, and review of the facility policies titled Nebulizer Equipment and Oxygen Equipment, the facility failed to maintain respiratory equipment in a sanitary manner for four residents (R) (R9, R14, R28, and R37) of 41 sampled residents. Findings include: Review of the facility policy titled Nebulizer Equipment, with a review date of 11/2024, revealed the Purpose section stated, It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using the proper technique and standard precautions. The Procedure section included Care of the Equipment 1. Clean after each use. 2. Wash hands before handling equipment. 3. Disassemble parts after every treatment. 4. Rinse the nebulizer cup and mouthpiece with water. 5. Shake off excess water. 6. Air-dry on an absorbent towel. 7. Once dry, store the nebulizer cup and mouthpiece in provided storage container. 8. Routinely change nebulizer tubing every 14 days, and as needed before. 9. Periodically disinfect the unit per the manufacturer's recommendations. Review of the facility policy titled Oxygen Equipment, with a review date of 11/2024, revealed the Purpose section included, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The Procedure section included Care of the Equipment 1. Care of the Concentrator: . c. Nurse responsibilities: i. Change oxygen tubing and mask/cannula every 14 days with date label, and as needed if it becomes soiled, contaminated, or damaged. 1. Review of R28's Comprehensive Care Plan revealed a Problem, dated 2/26/2025, which noted: [Name of R28] has scheduled nebulizer treatments R/T [related to] SOB [shortness of breath]. Approaches associated with this problem included: Change tubing and mask as directed by MAR [Medication Administration Record]. Clean Nebulizer mask with water, rinse after each use. Review of R28's Physician Orders revealed an order dated 1/28/2025 for administration of ipratropium-albuterol solution, one three milliliter (ml) vial for inhalation via nebulization twice daily. Review of R28's MAR dated April 2025 revealed that, between 8:00 am on 4/1/2025 and 8:00 am on 4/24/2025, R28 was to receive a total of 47 doses of the nebulizer treatment. Further review of the MAR revealed she refused 27 nebulizer treatments and accepted and received 20 nebulizer treatments during this same period. The last scheduled nebulizer treatment she received was at 8:00 pm on 4/23/2025. Further review of the MAR revealed no documentation of changing the nebulizer tubing, cup, or mask. Review of R28's Physician Orders revealed no order to change the nebulizer tubing, cup, or mask. Observation on 4/24/2025 at 7:13 am in R28's room revealed a nebulizer compressor on the floor against the wall under the head of R28's bed. The tubing, mask, and nebulizer cup were attached to the compressor. The tubing, nebulizer cup, and mask were not dated. 2. Review of R14's Comprehensive Care Plan revealed a Problem, dated 3/2/2025, which noted: [Name of R14] requires nebulizer treatments 5 [five] times a day R/T COPD [Chronic Obstructive Pulmonary Disease]. Approaches associated with this problem included: Change tubing and mask as directed by MAR. Clean Nebulizer mask with water, rinse after each use. Review of R4's Physician Orders revealed an active order, dated 4/13/2022, for ipratropium-albuterol solution, one three ml vial for inhalation via nebulization to be administered five times per day. The order also contained the following Special Instructions: Clean After Each Use. Rinse With Warm Water & Dry & Store In Container @ [at] Bedside. Review of R14's MAR dated April 2025 revealed the administration times for scheduled doses of ipratropium-albuterol were at 12:00 am, 5:00 am, 9:30 am, 3:30 pm, and 7:30 pm. Further review of the MAR revealed the resident received a dose of ipratropium-albuterol at 5:00 am on 4/24/2025, indicating the nebulizer cup was not disassembled and allowed to air-dry after it was last used. Review of the MAR revealed no documentation of changing the nebulizer tubing, cup, or mask. Review of R28's Physician Orders revealed no order to change the nebulizer tubing, cup, or mask. Observation on 4/24/2025 at 7:16 am of R14's room revealed a nebulizer device in the seat of a chair placed at the bedside. Observation of the nebulizer compressor found tubing connected to the device with the mask connected to an assembled nebulizer cup, both of which were resting on folded white paper towels. Observation of the nebulizer cup revealed droplets of moisture inside the cup, indicating the nebulizer cup had not been disassembled and allowed to air-dry. Further observation revealed no dates on the tubing, cup, or mask. 3. Review of R9's medical record revealed he was readmitted to the facility on [DATE] and was admitted to Hospice services on 9/3/2024 for congestive heart failure. Review Of R9's Comprehensive Care Plan Revealed A Problem, Dated 8/22/2019, Which Noted: [Name Of R9] Requires O2 [Oxygen] @ two lpm [Liters Per Minute] via N/C [Nasal Cannula] As Needed R/T Effects Of COPD With Chronic Bronchitis. Approaches Associated With This Problem Include: Change O2 Tubing Twice Monthly When In Use. Humidify O2 With Sterile Or Distilled Water When In Use And PRN [As Needed] To Prevent Drying Of The Mucous Membranes Review of R9's Physician Orders revealed an order dated 10/1/2024, for O2 at two LPM PRN SOB. Further review revealed there was no order to indicate what days staff should change the oxygen tubing. Observation on 4/24/2025 at 7:16 am revealed R9 receiving O2 at two LPM via a NC, connected to an O2 concentrator. Observation reveled the tubing was undated. During an observation and interview on 4/24/2025 at 7:46 am, Licensed Practical Nurse (LPN) BB confirmed R9's O2 tubing was undated. When asked how often staff were to change the tubing, LPN BB stated, It's set up in the computer for each resident. I think it's weekly. 4. Review of R37's medical record revealed the resident was readmitted to the facility on [DATE], and diagnoses included COPD. Review of R37's Comprehensive Care Plan revealed a Problem, Dated 7/2/2024, which noted: Resident Requires O2 @ 2 Lpm Prn Via N/C R/T Shortness Of Breath And/or Decreased O2 Sats [Oxygen Saturation Levels, Which Refers To The Percentage Of Red Blood Cells That Are Carrying Oxygen In The Blood]. Approaches Associated With This Problem Include: Administer O2 Per MD Order. Change Nasal Canula [Sic] Bubble Humidifier On The 2nd & 4th Wed [Wednesday] Of Each Month When In Use And As Needed. Humidify O2 With Steril [Sic] Or Distilled Water When In Use As Needed To Prevent Drying Of The Mucous Membranes. Review of R37's Physician Orders revealed an order dated 7/2/2024 for O2 at two LPM via NC PRN. Review of R37's MAR for April 2025 revealed the resident had used the O2 14 times in April, with the last use documented as having occurred at 11:17 pm on 4/18/2025. Observation on 4/24/2025 at 7:40 am of R37's room revealed an O2 concentrator set up beside the unoccupied bed next to R37's bed. R37 was not present at the time of the observation. The O2 concentrator was not in use, and the NC tubing, which was connected directly to the O2 concentrator, was rolled up and stuck under the elastic strap intended to secure a bubble humidifier bottle on the front of the concentrator. A section of tubing dangled from the concentrator and was in direct contact with the floor. There was no date on the tubing to indicate when it had been put into service. In an interview on 4/24/2025 at 8:03 am, LPN BB stated R37 normally used his O2 at night, and she would have the tubing changed. In an interview on 4/25/2025 at 4:38 pm, the Administrator stated that after the nebulizer treatments, the nebulizer cup should be taken apart, and the cup and mask were to be rinsed with water and stored on a paper towel inside a plastic container and allowed to air-dry. The Administrator further stated that staff should change the O2 tubing, nebulizer mask, and nebulizer cup every 14 days, and date the tubing when changed. 46565

Based on staff interviews, record review, and review of the facility policy titled Psychotropic Medications, the facility failed to ensure that as-needed (PRN) orders for psychotropic medications were limited to 14 days for one of six residents (R) (R29) reviewed for the use of unnecessary medications. Findings include: Review of the facility's policy titled Psychotropic Medications, reviewed 6/2024, directed that PRN orders for psychotropic medications should be limited to no more than 14 days. Review of R29's clinical record revealed diagnoses that included schizophrenia, anxiety disorder, and delusional disorders. Review of R29's Physician's Order revealed an order dated 3/20/2025 for lorazepam 0.5 milligrams (mg) twice daily as needed (PRN) for anxiety disorder, and the end date was listed as open-ended. Review of R29's Medication Administration Records (MARs) revealed the lorazepam was administered on 4/24/2025, 4/23/2025, 4/21/2025, 4/14/2025, 4/13/2025, 4/11/2025, 4/7/2025, 4/3/2025, 4/2/2025, 4/1/2025, 3/28/2025, 3/27/2025, 3/25/2025, 3/22/2025, and 3/20/2025. In an interview on 4/25/2025 at 4:10 pm, the Pharmacist stated that PRN orders for psychotropics should be limited to 14 days, and he would increase vigilance and step up encouraging compliance from the physicians. In an interview on 4/25/2025 at 4:37 pm, the Administrator stated that her expectation was for the nurse who entered the order for a PRN psychotropic medication to put an end date on the order of 14 days.

46565 Based on observation, staff interview, record review, and review of the facility policy titled Call System, Resident, the facility failed to ensure one of 41 sampled residents (R) (R9) call devices was within reach. Findings include: Review of the facility policy titled Call System, Resident, last reviewed and revised on 4/22/25, revealed the following: Policy Heading: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Policy Interpretation and Implementation: 1. Each resident is provided with a means to call staff directly for assistance from his/her bed by push button cord, from toileting/bathing facilities and from the floor . 3. The resident call system remains functional at all times . Cords are to be placed easily in reach of resident. 4. If a resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan. [sic] Record review revealed R9 was readmitted to the facility on [DATE] and was admitted to Hospice services on 9/3/2024 for congestive heart failure. Review of the MDS, with an ARD of 1/30/2025, R9 achieved a score of 14 out of 15 on the BIMS, which indicated the resident was cognitively intact. During the seven-day look-back period established by the ARD of 1/30/2025, the resident had no documented episodes of rejecting care. Under Section GG (Functional Abilities and Goals), the assessor documented that R9 required partial to moderate assistance with eating and substantial to moderate assistance with activities of daily living. Review of the resident's Comprehensive Care Plan revealed a Problem, dated 3/11/19, which noted, [Name of R9] requires limited assistance with ADLS R/T debility. The goal associated with the problem was: [Name of R9] will receive adequate assistance with hygiene on a daily basis AEB [as evidenced by] clean, neat appearance. [sic] Observation on 4/24/2025 at 7:22 am revealed R9 lying in bed wearing a hospital gown with the covers pulled up, covering his right hand. The resident's left hand was free. Observation revealed the call bell cord was wrapped around the right upper half bed rail, with the pendant dangling down below the half rail and not within the resident's reach. In an interview on 4/24/2025 at 7:29 am, Licensed practical Nurse (LPN) BB verified that R9's call device was not within his reach and placed it within his reach. During an interview beginning at 4:38 pm on 4/25/2025, the Administrator stated her expectation was that the call light should be readily accessible to the resident at all times.

Based on interview and review of policy titled Infection Preventionist, the facility failed to employ a qualified Infection Preventionist who had completed the required specialized training in infection prevention and control. This deficient practice had the potential for creating an ineffective infection prevention program that may contribute to the spread of COVID-19 for all residents in the facility. The census was 55 residents. Findings include: Review of the facility policies titled, Infection Preventionist (revised September 2022) revealed: Specialized Training - 1. The infection preventionist has obtained specialized IPC training beyond initial professional training . 2. Evidence of training is provided through a certificate(s) of completion or equivalent documentation. During an interview on 2/28/23 at 9:37 a.m. with the Director of Nursing (DON) revealed the facility recently hired Infection Preventionist (IP) CC after the previous IP FF resigned. The DON also revealed that she is fully aware the newly hired IP CC was not currently certified but reported that IP CC was enrolled in the necessary classes to become certified. The DON acknowledged there has been no certified ICP in the facility on a full time or part time basis, since January 2023 when IP FF resigned. An interview on 2/28/23 at 2:24 p.m. with the Administrator revealed she was aware of IP CC not having an Infection Control & Preventionist (ICP) certification. However, she was under the assumption that time would be allotted for IP CC to obtain the certification. During an interview on 3/1/23 at 2:34 p.m. with IP CC it was revealed the facility did not have a certified Infection Control & Prevention Nurse. She revealed they have not had a Certified IP since the middle of January. IP CC acknowledged that she had been carrying out the responsibilities of the IP, but she does not have an Infection Control & Preventionist certification.

Based on observation, record review, staff interviews, and review of the facility policy titled, Administering Medications, the facility failed to ensure a Physician's Order for oxygen therapy was followed for one of 12 residents (R) (#29) with orders for oxygen therapy. Findings include: Review of the policy titled Administering Medications (revised April 2019) revealed: Policy heading: Medications are administered in a safe and timely manner, and as prescribed. Review of the medical record for R#29 revealed a diagnosis not all inclusive of acute upper respiratory infection, Edema, Anemia, and Dementia. Further review of the medical record revealed a Physician Order for oxygen (O2) at 2 LPM (liters per minute) via nasal cannula every shift, day, evening, night. with a start date of 7/2/2022. Observations on 2/28/2023 at 11:23 a.m. and 3/1/2023 at 8:41 a.m. revealed R#29 receiving oxygen therapy via nasal cannula at 1.5 LPM. During an interview and observation on 3/1/2023 at 1:20 p.m. with the Director of Nursing (DON) confirmed O2 setting was infusing at 1.5 LPM via nasal cannula. DON reported that her expectations were for staff to follow physician orders. During an interview on 3/1/2023 at 2:00 p.m. with LPN AA it was reported she was the nurse assigned to R#29 on 2/28/2023 and 3/1/2023. She confirmed oxygen orders were on the Medication Administration Record (MAR) and reported she had not checked R#29 oxygen settings during her shifts. She confirmed O2 setting was at 1.5 LPM and reported she had changed it to the correct setting of 2 LPM per physician orders.

Based on observations, record reviews, staff observations, and review of policy titled, Care Plans, Comprehensive Person-Centered, the facility failed to follow the care plans related providing oxygen as ordered for one resident (R) (R#29) and failed to follow care plan related to cleaning or storage of nebulizer mask after each use for one resident (R#30) for 30 sampled residents. Findings Include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered revised date March 2022 revealed the following: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. Review of the medical record for R#29 revealed a diagnosis not all inclusive of acute upper respiratory infection, Edema, Anemia, and Dementia. Further review of the medical record revealed a Physician Order for oxygen (O2) at 2 LPM (liters per minute) via nasal cannula every shift, day, evening, night. with a start date of 7/2/2022. Review of Care Plan revealed R#29 required O2 (oxygen) at 2/LPM (liters per minute) via nasal cannula for comfort care with an intervention (with a created date of 3/1/2023) that included to Administer O2 per Medical Director (MD) order. Observations on 2/28/2023 at 11:23 a.m. and 3/1/2023 at 8:41 a.m. revealed R#29 receiving oxygen therapy via nasal cannula at 1.5 LPM. During an interview and observation on 3/1/2023 at 1:20 p.m. with the Director of Nursing (DON), she confirmed O2 setting was infusing at 1.5 LPM via nasal cannula. DON reported that her expectations are for staff to follow the care plan. 2. Review of the medical record for R#30 revealed a diagnosis not all inclusive of acute upper and lower respiratory infection, chronic sinusitis, and Nasal congestion. Further review of the medical record revealed a Physician Order for Ipratropium-Albuterol solution for nebulization; 0.5 mg-3 mg (2.5 mg base)/3 mL; amt: 1; inhalation with special instructions: 1 vial via jet nebulizer four times a day. Chart minutes. Clean nebulizer equipment after each use; Rinse with warm water and store in container at bedside four times a day at 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. with a start date of 2/2/2023. Review of Care Plan dated 2/28/2023 revealed R#30 requires PRN (as needed) nebulizer treatments related to wheezing with interventions clean nebulizer mask with soap and water, rinse after each use. Observations on 2/28/2023 at 9:38 a.m. and 3/1/2023 at 8:33 a.m. revealed R#30 nebulizer mask lying on bedside table not cleaned, unbagged, or stored in a container. During an interview on 3/2/2023 at 10:05 a.m. with RN MDS Coordinator revealed she is responsible for making sure each resident has a comprehensive care plan in place. She confirmed there was a care plan in place to administer O2 (oxygen) at 2/LPM (liters per minute) via nasal cannula for R#29 and to clean nebulizer mask with soap and water, rinse after each use for R#30. Her expectations of staff to follow the care plans.