Every finding on record at Serenity Transitional Care

Based on observations, resident and staff interviews, and document review, it was determined that the facility failed to treat each resident with respect and dignity. This was true for 3 of 3 residents (#73, #77, and #79) observed for dignity. This deficient practice had the potential for residents to experience embarrassment and low feelings of self-worth. Findings include: The facility's Nursing Facility Services and admission Agreement dated 5/14/24, documented on page 24, to protect your right to be treated with dignity and respect include, it is our policy to provide the kind of care to our residents that will maintain and enhance their dignity, individuality, and quality of life. Resident #73 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including multiple fractured ribs and diabetes. On 6/22/26 at 12:07 PM, observed Resident #73 with his hospital name band on his wrist. Resident #73 stated he had recently been at the hospital before coming to this facility, and no one had removed the name band. Resident #77 was admitted to the facility on [DATE], with multiple diagnoses including sepsis (the body's extreme, life-threatening response to an infection), respiratory failure, and diabetes. On 6/22/26 at 1:52 PM, observed Resident #77 with his hospital name band on his wrist. Resident #77 stated he had recently been at the hospital before coming to this facility a few days ago and no one had removed the name band. Resident #79 was admitted to the facility on [DATE], with multiple diagnoses including stroke and diabetes. On 6/22/26 at 2:02 PM, observed resident #79 with a hospital wrist band still on her wrist. Resident #79 stated the nursing staff use it each time they come into the room to identify her before they give her medications. On 6/23/26 at 9:02 AM, the DON stated the facility's practice was to leave the hospital ID bands on until the first care conference and she did not think about it being a dignity issue.

Based on record review and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 4 of 4 residents (#4, #10, #19, and #44) reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when their medications were not administered according to the physician's order. Findings include:a) Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including post-laminectomy syndrome (PLS) (a condition where a patient experiences persistent, new, or recurring back and/or leg pain following spinal surgery) and diabetes.On 6/22/26 at 11:52 AM, Resident #4's medical record documented the following related to bowel care within the last 45 days.- No documented BM from 5/29/26 to 6/7/26- No documented BM from 6/8/26 to 6/11/26- No documented BM from 6/19/26 to 6/23/26Resident #4's medication administration record had no documentation of nursing intervention for BM related issues for the dates listed.Resident #4's physician order related to bowel care are documented as follows:- Bisacodyl Suppository Insert 10 mg rectally as needed for constipation If no results within 24 hours from Bisacodyl tablet, may give Bisacodyl Suppository per rectum- Bisacodyl Tablet Delayed Release Give 10 mg by mouth as needed for constipation Take one tablet PRN for no bowel movement in 3 consecutive days. FYI do not crush or chew. Do not give within 1 hour of antacids or milk ingestion- Fleet Naturals Cleansing Enema (Rectal Cleansers) Insert 1 dose rectally as needed for constipation If no results from Bisacodyl Suppository within 24 hours, may give one fleet type cleansing enema. If there is still no results contact/notify MD for further instructionsb) Resident #10 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including cervical fracture and diabetes.On 6/22/26 at 11:36 AM, Resident #10's medication administration record documented the following related to bowel care within the last 30 days. - No documented BM from 6/10/26 to 6/22/26Resident #10's medication administration records documented Bisacodyl being given on June 12, 2026.- Bisacodyl Suppository Insert 10 mg rectally as needed for constipation If no results within 24 hours from Bisacodyl tablet, may give Bisacodyl Suppository per rectum- Bisacodyl Tablet Delayed Release Give 10 mg by mouth as needed for constipation Take one tablet PRN for no bowel movement in 3 consecutive days. FYI do not crush or chew. Do not give within 1 hour of antacids or milk ingestion- Fleet Naturals Cleansing Enema (Rectal Cleansers) Insert 1 dose rectally as needed for constipation If no results from Bisacodyl Suppository within 24 hours, may give one fleet type cleansing enema. If there is still no results contact/notify MD for further instructions - Senna-Docusate Sodium Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium) Give 1 tablet by mouth at bedtime for constipationc) Resident #19 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including centrilobular emphysema (type of chronic obstructive pulmonary disease (COPD), characterized by the destruction of the tiny air sacs (alveoli) in the center of the lung's functional units) and sepsis.On 6/22/26 at 2:07 PM, Resident #19's medication administration record documented the following related to bowel care within the last 30 days.- No documented BM from 6/17/26 to 6/21/26Resident #19's medication administration record had no documentation of nursing intervention for BM related issues for the dates listed.- Bisacodyl Suppository Insert 10 mg rectally as needed for constipation If no results within 24 hours from Bisacodyl tablet, may give Bisacodyl Suppository per rectum- Bisacodyl Tablet Delayed Release Give 10 mg by mouth as needed for constipation Take one tablet PRN for no bowel movement in 3 consecutive days. FYI do not crush or chew. Do not give within 1 hour of antacids or milk ingestion- Fleet Naturals Cleansing Enema (Rectal Cleansers) Insert 1 dose rectally as needed for constipation If no results from Bisacodyl Suppository within 24 hours, may give one fleet type cleansing enema. If there is still no results contact/notify MD for further instructions - Senna-Docusate Sodium Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium) Give 1 tablet by mouth at bedtime for constipation - MiraLax Oral Powder 17 GM/SCOOP (Polyethylene Glycol 3350) Give 1 scoop by mouth one time a day for constipationd) Resident #44 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE], with multiple diagnoses including myocardial infarction (occurs when blood flow to a section of the heart muscle is severely reduced or blocked) and interstitial pulmonary disease (progressive inflammation and scarring (fibrosis) in the tissue between the air sacs of your lungs).On 6/22/26 at 2:39 PM, Resident #44's medication administration record documented the following related to bowel care within the last 30 days.- Last documented BM was 6/17/26 and not again until 6/22/26Resident #44's medication administration record had no documentation of nursing intervention for BM related issues for the dates listed.- Bisacodyl Suppository Insert 10 mg rectally as needed for constipation If no results within 24 hours from Bisacodyl tablet, may give Bisacodyl Suppository per rectum- Bisacodyl Tablet Delayed Release Give 10 mg by mouth as needed for constipation Take one tablet PRN for no bowel movement in 3 consecutive days. FYI do not crush or chew. Do not give within 1 hour of antacids or milk ingestion- Fleet Naturals Cleansing Enema (Rectal Cleansers) Insert 1 dose rectally as needed for constipation If no results from Bisacodyl Suppository within 24 hours, may give one fleet type cleansing enema. If there is still no results contact/notify MD for further instructions- Polyethylene Glycol 3350 Oral Powder 17 GM/SCOOP (Polyethylene Glycol 3350) Give 17 gram by mouth one time a day for constipationOn 6/23/26 at 1:19 PM, the DON stated they did not have any documentation of nurse intervention for BM care for Residents #4, #10, #19, and #44 for the dates listed and should have.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not offer or encourage residents hand hygiene prior to meals and follow proper cleaning of medical equipment and handling of linens. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: The facility's Hand Hygiene policy dated 12/11/25, documented wash hands with soap and water whenever they are visible dirty, before eating, and after using the restroom. The facility's Glucometer Disinfection policy, revision date 12/11/25, documented the glucometers will be cleaned and disinfected after each used and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. The Quintet AC Blood Glucose Meter Owner's Manual documented: Cleaning and Disinfecting frequency: after each use. 1. Thoroughly wipe the entire surface of the meter with disinfecting wipes listed to clean any possible dirt, dust, blood, and other body fluids. 2. Take another disinfecting wipe and wipe the meter thoroughly (Note: All blood and body fluids should be cleaned from surface before step 2). 3. Allow the surface to remain wet for 2 minutes. 4. Allow to air dry.The facility's Oxygen Administration policy, dated 12/30/25, documented 5. Infection Control measures include: d. Keep delivery devices covered in plastic bag when not in use.The facility's Handling Clean Linen policy, reviewed date 12/11/25, documented: 4. Clean linens must be transported by methods that ensure cleanliness and protect from dust and soil during intra or inter-facility loading, transport and unloading, such as: b. Placing clean linen in a properly cleaned cart and covering the cart with disposable material or a properly cleaned reusable textile material that can be secured to the cart. 5. a. Clean linen shall be delivered to resident units on covered linen carts with covers down. The following was observed for oxygen supplies storage: On 6/22/26 at 11:14 AM, Resident #73's nebulizer mask, tubing, and machine was observed sitting on his windowsill, not covered. On 6/23/26 at 4:12 PM, the CRN stated the nebulizer equipment should have been covered when not being used and had not been. The following was observed for proper laundry handling: On 6/23/26 at 11:51 AM, observed the laundry staff transporting resident linens from the laundry room to the resident unit with the cart's front cover pulled up and lying on top of the cart. On 6/23/26 at 2:01 PM, the laundry staff stated he was transporting the clean resident linens to the unit and should have pulled the top down to cover the items during transport and had not. The following was observed regarding personal protective equipment (PPE): On 6/23/26 at 1:54 PM, observed in the designated dirty side of the laundry room a hopper (a clinical fixture used to safely rinse deeply soiled linens) with several boxes of gloves available nearby but did not observe protective gowns or eyewear. On 6/23/26 at 1:56 PM, the laundry staff stated there were no goggles or protective gowns used or available in the laundry area. On 6/23/26 at 3:28 PM, observed in the East Hall soiled utility room a hopper used for soiled linens. On 6/23/26 at 3:31 PM, RN #2 stated gloves are used but personally she had not used goggles or a protective gown when using the hopper for soiled linens. On 6/24/26 at 8:49 AM, the DON stated staff should be wearing appropriate PPE when using the hopper and had not been. The following was observed for hand hygiene: On 6/22/26 at 12:50 PM, observed CNA #1 delivered and set up Resident #37's food tray on his overbed table. Resident #37 requested two glasses of orange juice. CNA #1 went to the kitchen to get the orange juice. CNA #1 did not offer or encourage Resident #37 to perform hand hygiene when she delivered and set up his tray or when she delivered the orange juice. On 6/22/26 at 12:55 PM, CNA #1 stated she did not offer hand hygiene to Resident #37 and she should have. The following was observed for proper cleaning of medical equipment: On 6/24/26 at 7:37 AM, RN #1 used the glucometer (a device used to measure the amount of glucose in your blood) to check Resident #79's blood sugar. RN #1 placed the glucometer in his shirt pocket after checking her blood sugar. RN #1 returned to the medication cart and removed the glucometer from his pocket and placed the glucometer in a baggie. RN #1 was asked if he had cleaned the glucometer before storing it and he stated he had wiped it down with hand sanitizer. On 6/24/26 at 9:30 AM, the DON stated the glucometer should be cleaned after each use with the disinfected wipes following the dry time of 3-5 minutes. On 6/24/26 at 10:52 AM, observed LPN #2 return to the [NAME] side medication cart after checking Resident #18's blood sugar. LPN #2 removed the glucometer from his shirt pocket and placed it in a baggie. LPN #2 was asked if he had cleaned the glucometer before storing it in the baggie and he stated he had wiped the glucometer off with an alcohol swab like he always does. On 6/24/26 at 1:23 PM, the CRN stated the nurses should have cleaned the glucometers with the Sani-wipe (a pre-moistened, disposable germicidal wipe) after each use.

Based on resident and staff interviews, record review, and policy review it was determined the facility failed to ensure resident's preference for bathing schedule was honored. This was true for 1 of 23 residents (Resident #5) reviewed for choices. This deficient practice had the potential for residents to experience a decreased sense of well-being, lack of self-worth, and frustration when their preference for bathing was not accommodated. Findings include:The facility's Resident Shower policy revision date 12/31/25, documented residents would be provided showers as per request or as per facility schedule protocols and based upon resident safety.Resident #5 was admitted to the facility 7/22/25, with multiple diagnoses including pneumonia and chronic kidney disease.Resident #5's care plan documented that she required partial/moderate assistance with shower/bathing.Resident #5's task form documented she was to receive showers on Tuesdays and Fridays on the day shift.On 6/22/26 at 9:40 AM, Resident #5 stated she usually only gets one shower a week, and would like two showers a week. Resident #5 stated she had requested two showers a week, but the staff are too busy to give her a shower. On 6/23/26, a review of Resident #5's shower sheet and tasks documentation form documented she received showers on the following days:For the month of May 2026:5/12/26 (Tuesday)5/24/26 (Sunday)5/26/26 (Tuesday)Resident #5 refused a shower on 5/15/26 and 5/19/26. Resident #5 should have received nine showers in the month of May and only received three.For the month of June 2026:6/6/26 (Saturday)6/16/26 (Tuesday)6/20/26 (Saturday)Refused 6/9/26 (Tuesday)Resident #5 should have received six showers in the month of June and only received three.On 6/23/26 at 11:23 AM, the DON stated residents should get two showers a week but for Resident #5 it depends because she goes to dialysis.On 6/23/26 at 3:41 PM, the DON stated Resident #5 should have been offered a shower on Fridays and Tuesdays and she could not account for the missed showers.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure as needed (PRN) psychotropic drugs were limited to 14 day use. This was true for 1 of 1 Resident (Resident #4) reviewed for psychotropic medication use. This failure created the potential for residents to be subjected to unnecessary psychotropic medication use. Findings include:The facility's Nursing Facility Services and admission Agreement dated 5/14/24, documented on page 24, to protect your right to be treated with dignity and respect include, we will avoid using physical restraints or psychoactive drugs (chemical restraints) except as required to treat a resident's medical symptoms on a temporary basis.The facility's Use of Psychotropic Medication(s) policy dated 3/3/25, documented psychotropic medications used on a PRN basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record and is subject to the limitations as noted: PRN orders for psychotropic medications, excluding antipsychotic, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration.Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including post-laminectomy syndrome (PLS) (a condition where a patient experiences persistent, new, or recurring back and/or leg pain following spinal surgery) and diabetes.On 6/23/26 at 11:52 AM, Resident #4's medical record documented she had psychotropic medication, Lorazepam, ordered on 11/4/25 as needed (PRN). Resident #4's medication administration records documented the following related to Lorazepam administration. - 2025- November given 0 times- December given 6 times- 2026- January given 3 times- February given 0 times- March given 4 times- April given 2 times- May given 4 times- June given 2 timesA pharmacy consultation report dated 11/12/25, for Resident #4 documented please consider adding a stop date to Lorazepam 0.5 mg PO q4h PRN for anxiety/agitation. The provider declined the recommendation by documenting On Hospice.A pharmacy consultation report dated 5/10/26, for Resident #4 documented please consider adding a stop date to Lorazepam 0.5 mg PO q4h PRN for anxiety/agitation. The provider declined the recommendation by documenting Resident is on hospice and hospice provider declines do change.On 6/23/26 at 3:10 PM, the DON stated the lorazepam should have had a stop date and not have been used passed the 14 days for Resident #4 but was.

Based on record review and staff interview, it was determined the facility failed to ensure a written notice of transfer and bed hold policy was provided to the resident or their representative when residents were transferred to the hospital. This was true for 1 of 2 residents (Resident #12) reviewed for transfers. This deficient practice created the potential for psychosocial distress if residents and their representatives were not made aware of or able to exercise their rights related to transfers from the facility. Findings include:The facility's Bed Hold Notice policy dated 3/3/25, documented in the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident representative within 24 hours or next business day. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file and/or medical record.Resident #12 was initially admitted to the facility on [DATE], and readmitted to the facility on [DATE], with multiple diagnoses including acute cystitis without hematuria (a common bladder infection (UTI) characterized by painful urination, urinary frequency, urgency, and pelvic discomfort) and chronic obstructive pulmonary disease (progressive lung disease characterized by increasing breathlessness).On 6/22/26 at 12:37 PM, Resident #12's medical record had no documentation of a bed hold for the recent 4/17/26 hospitalization.On 6/23/26 at 12:56 PM, the DON stated she could not find any bed hold data for Resident #12 for the 4/17/26 hospitalization.

Based on document review, staff interview, and policy review it was determined the facility failed to provide a resident's baseline care plan to the resident or his/her representative for 1 of 1 resident (Resident #73) reviewed for baseline care plan. This failure placed residents and their representatives at risk of not being informed and having input in their care plan. Findings include:The facility's Baseline Care Plan policy, dated 12/24/25, documented 5. A supervising nurse or MDS nurse/designee is responsible for providing the written summary of the baseline care plan to the resident and representative. This will be provided by completion of the comprehensive care plan. 6. The person providing the written summary of the baseline care plan shall: a. Obtain a signature from the resident/representative to verify that the summary was provided.Resident #73 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including multiple fractured ribs and diabetes.Resident #73's medical record had not documented that a baseline care plan had been provided and discussed with him or his representative.On 6/24/26 at 8:57 AM, the Social Worker stated Resident #73's medical record had not documented a signature from the resident or resident representative indicating a copy of the baseline care plan had been discussed or offered to the resident or his representative and should have been.On 6/24/26 at 8:58 AM, the DON stated Resident #73's medical record should have documented that a copy of the baseline care plan had been offered to him or his representative and had not.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents maintained a person-centered comprehensive care plan. This was true for 1 of 1 resident (Resident #76) whose record was reviewed for comprehensive care plans. This created the potential for harm when staff were not informed of person-centered care and treatment interventions. Findings include: The facility's Comprehensive Care Plans policy, date reviewed 12/24/25, documented 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Resident #76 was admitted to the facility on [DATE], with multiple diagnoses including spinal stenosis (the narrowing of the spaces within the spine), anxiety, and acute respiratory failure. On 6/22/26 at 2:06 PM, Resident #76's care plan had not documented his oxygen interventions. On 6/22/26 at 2:07 PM, review of Resident #76's medical record had documented a Provider's order for oxygen at 0-1 L/M via NC continuous to keep sats equal or greater than 88%. Check O2 sats every shift. On 6/24/26 at 8:46 AM, the DON stated Resident #76's care plan should have addressed his oxygen interventions and had not.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure residents were given treatment and services to maintain or improve their ability to carry out activities of daily living (ADLs). This was true for 1 of 1 resident (Resident #12) reviewed for decline in ADLs without services. This failure placed residents at risk for decreased range of motion, functional ability, and decreased quality of life. Findings include:The facility's Restorative Nursing Programs dated 12/20/24, documented restorative aides will implement the plan for a designated length of time, performing the activities, and documenting on the Restorative Aide Documentation Form.On 6/23/26 at 12:33 PM, Resident #12's care plan documented Restorative Nursing Program to provide cues for me to move through tolerated ROM of ALL MAJOR JOINTS. Sci-fit exercise x15 minutes on level 1-2 resistance. x6 to 7 days per week. On 6/23/26 at 11:01 AM, Resident #12's medical record documented restorative services were only provided on 6/15/26, 6/20/26 and 6/21/26, with no documentation of resident refusals on 6/16/26, 6/17/26, 6/18/26, 6/19/26, or 6/22/26.On 6/23/26 at 11:05 AM, the DON stated restorative services for Resident #12 were only provided on 6/15/26 and 6/20/26 and 6/21/26 and should have been done at least 6 times each week and were not.

Based on observation, interview, policy review, and record review, the facility failed to ensure that parenteral/IV fluids were administered consistently with professional standards of practice. This occurred for 1 of 2 residents (Resident #42) reviewed for IV therapy. Findings include:The facility's Intravenous Therapy policy revision date 12/29/25, documented:12. A doctor's order is obtained before starting IV therapy.13. IV sites are checked every shift or as per facility protocol and PRN for sign and symptoms of infection or inflammation.15. IV documentation is recorded in the nurse's notes and/or Medication Administration Record.Resident #42 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's Disease and acute respiratory failure.Resident #42's physician's order dated 6/19/26 at 8:45 AM, documented Normal Saline Flush Intravenous Solution 0.9 % (Sodium Chloride Flush). Use 1 liter intravenously one time only for acute chronic kidney injury for 1 Day infuse over 1 hour.Resident #42's physician's order dated 6/19/26 at 9:26 AM, documented Ceftriaxone Sodium (antibiotic) Injection Solution Reconstituted 1 GM (Ceftriaxone Sodium). Use 1 gram intravenously one time only for UTI for 1 Day.Resident #42's physician order dated 6/20/26 at 10:30 AM, documented Sodium Chloride Intravenous Solution 0.9 % (Sodium Chloride). Use 1 liter intravenously one time only for AKI for 1 Day.Resident #42's physician order dated 6/22/26 at 11:15 AM, documented IV/PICC line: Inspect intravenous catheter/site for any signs/symptoms of infection or any other IV related complications. Every day and night shift if any complications identified, make progress note and update MD as indicated.On 6/22/26 at 10:07 AM, observed Resident #42 with an IV in her right arm. The IV dressing had a dark red, dry substance on it. The edges of the IV dressing were loose and the IV line was not secured. The IV dressing was not dated.On 6/22/26 at 11:12 AM, LPN #1 stated Resident #42 had received a bag of fluids so the IV was just left in to see if they needed to give her more. The IV dressing should be changed every three days and should have been dated.On 6/22/26 at 3:26 PM, a Review of Resident #42's care plan did not document that she had an IV. Review of Resident #42's medical record documented a Nurses Note dated 6/19/26 at 17:11, Resident continues with hypotension, confusion and weakness. Resident #42's medical record did not have documentation regarding her IV for 6/19/26 through 6/21/26. A progress note was documented in Resident #42's medical record on 6/22/26 at 11:26 AM, documenting IV/PICC line: Inspect intravenous catheter/site for any signs/symptoms of infection or any other IV related complications every day and night shift If any complications identified, make progress note and update MD as indicated. IV was removed due to infiltration. NP aware. On 6/24/26 at 9:34 AM, the DON stated the IV was started on 6/19/26, for IV fluids. LPN #2 removed the IV because he thought Resident #42 was done using it. On 6/20/26, the IV needed to be restarted for more fluids so LPN #2 asked RN #1 to restart the IV. RN #1 started an IV in Resident #42's LFA using a 20 gauge needle. The IV clotted off so RN #1 put another IV in Resident #42's RFA. The DON stated there was no order for dressing changes or monitoring for the IV site because the original IV put in on the 19th was removed after the bag of fluid. The DON stated Resident #42 should have had orders to monitor the IV site and the orders were put in on 6/22/26.On 6/24/26 at 9:39 AM, RN #1 stated he did not document the IV insertion on June 20th, and he should have. He stated he did a late entry today June 24, 2026. On 6/24/26 at 12:01 PM, LPN #2 stated he removed Resident #42's IV on Friday June 19th because he thought they were done using it. He stated he did not document the IV removal and should have. LPN #2 stated on June 20th IV fluids were ordered for Resident #42, so he attempted to restart the IV and could not get it, so he asked RN #1, to try. He did not document the attempt to restart an IV and should have.

Based on observation and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate and posted daily for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels. Findings include:On 6/23/26 at 3:47 PM, during review of the daily staffing sheets, the surveyor observed the facility's name was missing on all of the daily staffing sheets.On 6/23/26 at 4:10 PM, the Chief Clinical Officer stated the facility name should have been on the daily staffing sheets and was not.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents were monitored appropriately for medication. This was true for 1 of 2 residents (Resident #4) reviewed for unnecessary medications. This failure created the potential for residents to experience adverse reactions due to the lack of appropriate monitoring. Findings include:The facility's Unnecessary Drugs policy dated 12/30/25, documented under Policy Explanation and Compliance Guidelines, documentation will be provided in the resident's medical record to show adequate indications for the medication's use and the diagnosed condition for which it was prescribed.Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including post-laminectomy syndrome (PLS) (a condition where a patient experiences persistent, new, or recurring back and/or leg pain following spinal surgery) and diabetes.Resident #4's physician's orders for psychotropic medications follow: - DULoxetine HCl Oral Capsule Delayed Release Sprinkle 60 MG (Duloxetine HCl) Give 1 capsule by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE, start date 7/8/25.- LORazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 4 hours as needed for anxiety/agitation start date 11/4/25.- QUEtiapine Fumarate Oral Tablet (Quetiapine Fumarate) Give 25 mg by mouth at bedtime for BRIEF PSYCHOTIC DISORDER, start date 3/6/26.Resident #4's medical record on Hospice Outside Agency Resident Reports documented the following:- 12/1/25, Aide on shift reports decreased behaviors since last visit.- 1/2/26, Staff report decreased behaviors and hallucinations.A pharmacy Psychotropic Review report dated 12/16/25, for Resident #4 documented your patient is receiving the following psychotropic medications(s): duloxetine 60 mg PO daily for MDD; lorazepam 0.5 mg PO q4h PRN for anxiety/agitation; quetiapine 25 mg PO nightly for behavior. Review the patient's current behavioral updates and determine if a gradual dose reduction would be clinically indicated at this time. The provider declined the recommendation by documenting defer to hospice.A pharmacy Psychotropic Review report dated 3/17/26, for Resident #4 documented your patient is receiving the following psychotropic medications(s): ativan 2 mg/ml 0.5 PO q6h PRN for hallucinations; duloxetine 60 mg PO daily for MDD; lorazepam 0.5 mg PO q4h PRN for anxiety/agitation; quetiapine 25 mg PO nightly for brief psychotic disorder. Review the patient's current behavioral updates and determine if a gradual dose reduction would be clinically indicated at this time. The provider declined the recommendation by documenting defer to hospice.Resident #4's TAR for May 2026 and June 2026 documented the following related to monitoring for anxiety and hallucinations:- May 2026, four occurrences of anxiety/hallucinations documented- June 2026, two occurrences of anxiety/hallucinations documented On 6/23/26 at 3:40 PM, the DON stated she would need to visit with the Medical Director and the Hospice MD about Resident #4's psychotropic medication.

Based on observation, policy review, and staff interviews, it was determined the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents and were destroyed in a timely manner when they were discontinued to prevent unauthorized access and potential diversion. This was true for 1 of 2 medication storage rooms inspected and 1 of 4 medication carts observed. Findings include: The facility's Storage of Medication policy dated [DATE], documented:- During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.- Schedule II drugs and back-up stock III, IV, and V medications are stored under double-lock and key. The facility's Destruction of Unused Drugs policy dated [DATE], documented all unused, contaminated, or expired prescriptions drugs shall be disposed of in accordance with state laws and regulations. On [DATE] at 6:30 AM, the [NAME] side medication storage room was audited with the DON present. Observed in the medication storage refrigerator an open bottle of Ativan Injection Solution for Resident #4. The bottle of Ativan was lying on top of the narcotic lock box. The medication storage refrigerator did not have a lock on it. On [DATE] at 6:33 AM, the DON stated the Ativan should have been in the narcotic lock box in the medication storage refrigerator since there was no lock on the refrigerator. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including post-laminectomy syndrome (PLS) (a condition where a patient experiences persistent, new, or recurring back and/or leg pain following spinal surgery) and diabetes. Review of Resident #4's medical record documented a physician's order dated [DATE], Ativan Injection Solution 2 MG/ML (antianxiety). Inject 0.5 ml intramuscularly every 6 hours as needed for hallucinations. The order was discontinued on [DATE]. On [DATE] at 9:44 AM, the DON stated discontinued medications should be removed as soon as they are discontinued. On [DATE] at 2:50 PM, observed the East Hall medication cart unlocked and unattended by staff. On [DATE] at 2:51 PM, observed LPN #3 walking around the corner from another hallway towards the East Hall medication cart and locked it. On [DATE] at 2:53 PM, LPN #3 stated the medication cart should not have been left unlocked when leaving the cart unattended. On [DATE] at 8:31 AM, the DON stated the medication cart should not have been left unlocked when the nurse left the cart unattended.

Based on observation, interview, policy review, and review of the FDA Food Code, the facility failed to ensure food items were dated and labeled. These deficient practices had the potential to impact all residents who received food brought in by family or visitors. This placed residents at risk for potential use of spoiled foods and adverse health outcomes including food-borne illnesses. Findings include:The FDA Food Code Section 3-501.17 stated, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, states refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded. Review of the facility's Date Marking for Food Safety policy dated 12/8/25, documented, the food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. On 6/23/26 at 11:51 AM, observed in the resident unit refrigerator with RN #2 present: - A container of watermelon chunks not dated or labeled. On 6/23/26 at 12:09 PM, RN #2 stated the container should have been dated and labeled or discarded and had not been.

Based on observation, review of the Food and Drug Administration (FDA) Food Code, and staff interview it was determined the facility failed to ensure trash was contained in the facility's dumpsters with closed lids for two of two outside trash dumpsters and the kitchen garbage cans were properly closed with tight fitting lids.This failed practice created the potential for insect and pest infestation. Findings include:The FDA Food Code Section 5-501.113 Covering Receptacles - receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (A) Inside the food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the food establishment.The FDA Food Code Section 5-501.115 Maintaining Refuse Areas and Enclosures - Areas to be free of: (A) Items that are unnecessary to the operation or maintenance of the establishment such as equipment that is nonfunctional or no longer used; and (B) Litter.On 6/24/26 at 6:55 AM, observed the kitchen's large garbage can with a hole cut out of the lid. The garbage can was not in use at the time.On 6/24/26 at 7:25 AM, the facility's dumpster area was observed. Two of two dumpsters had the lids open. One dumpster had cardboard trash overflowing onto the ground surrounding the dumpster and the other dumpster had weed vegetation and paper trash on the ground near the dumpster and along the surrounding fence line.On 6/24/26 at 7:27 AM, the Dietary Manager stated she was not aware the kitchen garbage cans had to have tight-fitting lids on them and the dumpster lids should have been closed and had not been.

Based on staff interview, record review, and policy review, it was determined the facility failed to ensure accurate and complete clinical records were maintained for each resident. This was true for 3 of 3 Residents (#76, #77, and #79) reviewed for oxygen administration orders. This deficient practice created the potential for harm should inappropriate care and/or treatment be provided based on inaccurate information in the residents' clinical record. Findings include: The facility's Oxygen Administration policy, dated 12/30/25, documented .Oxygen is administered under orders of a physician.The facility's Documentation in Medical Record policy, dated 12/31/25, documented 4. Principles of documentation include, but are not limited to: b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. Resident #76 was admitted to the facility on [DATE], with multiple diagnoses including spinal stenosis (the narrowing of the spaces within the spine), anxiety, and acute respiratory failure. On 6/22/26 at 11:12 AM, observed Resident #76 wearing an oxygen nasal cannula with oxygen set at 2L/minute. On 6/22/26 at 1:25 PM, Resident #76's medical record documented an Oxygen order: O2 at 0-1 L/M via NC continuous to keep sats equal or greater than 88%. Check O2 sats every shift, dated 6/16/26 with an end date of 6/18/26. On 6/24/26 at 8:47 AM, the DON stated Resident #76's oxygen had been discontinued on 6/18/26 but had been re-ordered and the new order had not been documented in the medical record and should have been. Resident #77 was admitted to the facility on [DATE], with multiple diagnoses including sepsis (the body's extreme, life-threatening response to an infection), respiratory failure, and diabetes. On 6/22/26 at 1:42 PM, observed Resident #77 wearing an oxygen nasal cannula with oxygen set at 2L/minute. On 6/22/26 at 1:52 PM, Resident #77's medical record had not documented an oxygen order. On 6/24/26 at 8:47 AM, the DON stated an oxygen order should have been written for Resident #77 and had not been. Resident #79 was admitted to the facility on [DATE], with multiple diagnoses including stroke and diabetes. On 6/22/26 at 9:58 AM, observed Resident #79 using supplemental oxygen at 2 lpm via NC. On 6/23/26 at 1:40 PM, observed Resident #79 using supplemental oxygen at 2 lpm via NC. On 6/24/26 at 10:05 AM, observed Resident #79 using supplemental oxygen at 2 lpm via NC. On 6/24/26, Resident #79's medical record had not contained any physician order for oxygen therapy. On 6/24/26 at 11:58 AM, the DON stated an oxygen order should have been written for Resident #79 and had not been.

Based on record review, Hoyer lift manual review, interview, and review of the facility's investigation report, it was determined the facility failed to ensure resident safety during Hoyer lift transfers. This was true for 1 of 8 residents (Resident #174) whose record was reviewed for falls. This resulted in harm to Resident #174 when a proper Hoyer lift transfer was not provided. Findings include: Joerns Hoyer User Instruction Manual undated, documented under Warnings, always plan your lifting operations before commencing. Resident #174 was admitted to the facility on [DATE], with multiple diagnoses including dementia and anxiety. On 7/21/24 at 6:26 PM, Resident #174 fell out of a Hoyer lift during transfer resulting in left superior and inferior pubic fractures. On 4/30/25 at 2:15 PM, the DON stated during the Hoyer lift process with Resident #174 on 7/21/24, one of the Hoyer lift legs became stuck under the closet door causing a sling strap webbing loop to slip off one of the Hoyer lift 6 point loop connections. The DON also stated the CNA's should have moved furniture and planned better before starting the Hoyer lift transfer with Resident #174 and did not. These findings represent past non-compliance with this regulatory requirement. The facility did the following: -Resident representative was notified. -DON conducted a Hoyer lift training with the staff on duty the day of the incident. -All staff were given an in-service training Hoyer lift safety procedures, proper transfer procedures, the need to rearrange furniture to allow for safe transfer. Training completed on 7/25/24. -Plan put in place to make sure all new transfer slings were washed prior to first usage. There was sufficient evidence the facility corrected the non-compliance as of 7/25/24 as there were no further Hoyer lift incidents reported after this date. At the time of the survey, the facility was in substantial compliance and therefore does not require a plan of correction.

Based on review of the FDA Food Code, observation, and interview, the facility failed to appropriately store, distribute, and label foods. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include: The FDA Food Code revised 2022, documents Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. On 4/28/25 at 9:45 AM, observed the following in the walk-in refrigerator with the CDM present: - Ham with use by date of 4/25/25. - Roll of sausage with a use by date of 4/19/25. - Open bag of lettuce not properly sealed. - Sliced cheese was not properly sealed. The CDM stated the ham and sausage should have been used or discarded by the use by date and the lettuce and cheese should have been properly sealed. On 4/28/25 at 9:50 AM, observed the following in the dry food storage area with CDM present: - Granola in a plastic container with a use by date of 3/31/25. - Corn Flakes in a plastic container with a use by date of 4/20/25. On 4/28/25 at 9:52 AM, the CDM stated the granola and corn flakes should have been used or discarded by the use by date.

Based on observations and interviews, it was determined that the facility failed to treat each resident with respect and dignity. This was true for a) 2 of 5 residents (#22 and #45) who had uncovered urinary drainage bags and b) 1 of 19 Residents (Resident #50) who was addressed by a room number not her name. This deficient practice had the potential for residents to experience embarrassment, and low feelings of self-worth. Findings include: a) The following was observed for uncovered urinary drainage bags. Resident #22 was admitted on [DATE], with multiple diagnoses including pneumonia and urinary tract infection. On 4/29/25 at 9:34 AM, Resident #22's urinary drainage bag was uncovered and visible from the open doorway of his room. On 5/1/25 at 8:26 AM, the DON stated the urinary drainage bag should have been covered and was not. Resident #45 was admitted on [DATE], and readmitted on [DATE], with multiple diagnoses to include sepsis (a life-threatening condition that occurs when the body's response to an infection injures its own tissues and organs). On 4/29/25 at 10:58 AM, Resident #45's urinary drainage bag was uncovered and visible from the open doorway of his room. On 5/1/25 at 8:26 AM, the DON stated the urinary drainage bag should have been covered and was not. b) The following was observed for addressing resident by room number and not her name. Resident #50 was admitted to the facility on [DATE] with multiple diagnoses including diabetes and major depressive disorder. On 4/30/25 at 7:30 AM, observed Resident #50 in the hallway with LPN #2 who stated, take 21 back in her room so meds can be given. On 5/1/25 at 9:34 AM, the ADON stated all residents should be addressed by their name not their room number and was not.

Based on policy review, observation, record review, and interviews, it was determined the facility failed to ensure 1 of 1 resident (Resident #28), was assessed and evaluated for cognitive and physical ability to self-administer medications. This failure created the potential for adverse outcomes if Resident #28 self-administered medication inappropriately. Findings include: The facility's policy, Resident Self-Administration of Medication dated 12/16/24, documented a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Resident #28 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease, COPD (a progressive lung disease making it hard to breath), and immunodeficiency (when a body's immune system is more susceptible to infections). On 4/29/25 at 10:38 AM, observed an open, uncapped bottle of Icy Hot (a topical pain relief medication) on Resident #28's bedside table. Resident #28 stated he uses the Icy Hot for the pain in his shoulder. Resident #28's medical record did not document a self-administration assessment for the Icy Hot. On 4/29/25 at 4:30 PM, the CCO stated there should be a self-administration assessment for the Icy Hot and there was not.