Every finding on record at Seymour Rehabilitation and Healthcare

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: The water temperature was cold in the kitchen handwashing sink.Stainless steel counters were soiled with food crumbs.Kitchen appliances interior and exterior surfaces were soiled with grease, food particles, and dust.Mesh shelf liner and parchment paper were used on shelves and had food crumbs and dust under them on the shelves.The residential-style snack refrigerator contained beverage glasses filled with juice and a clear plastic bag filled with individually wrapped luncheon meat sandwiches that were not labeled and was dated on 6/08/2026.The residential-style refrigerator contained 12 individual 8-ounce cartons of whole milk with a manufacturer's best by date of 6/09/2026 stored in the door compartment on 6/10/2026.Bulk storage bins used to store salt, corn meal, rice, and dry oats had lids soiled with food particles and the lids were not securely in place for the dry oats and rice, which was open to the air.The walk-in refrigerator had a red tomato on the floor under the shelf unit and a non-pasteurized shell egg in a one-dozen sized carton stored on the second shelf above fresh produce.The walk-in freezer had an open 3-gallon carton of vanilla ice cream with the lid not securely in place with the ice cream exposed to the air.The kitchen storage room contained cardboard cases with bottled water that were stored directly on the floor and had sustained water damage.The low temperature dish machine wash and rinse cycle water temperatures did not consistently reach 120 degrees F when operated according to the manufacturer's recommendations for minimum water temperatures.A live fly was observed moving throughout the food preparation area on 6/10/2026.The lunch meal pudding dessert was not maintained at 41 degrees F prior to serving on 6/10/2026.The kitchen water heater was not set at a temperature level to maintain hot water for use throughout the day.Resident #29 was hand fed lunch meal on 06/08/26 by CNA D with ungloved hands. These failures placed the residents at risk for foodborne illness and compromised health status. The findings included: Record review of the Resident Diet / Consistency Report, dated 6/08/2026, indicated the names of 36 residents were on the list. All current facility residents had diet orders for oral nutrition. Observations and interviews on 6/08/2026 between 9:43 AM and 10:30 AM, during the initial tour of dietary department revealed the following:- The DM stated the dietary staff were employed by the culinary service agency that was contracted with the facility.- DA A stated she had been employed for about 1-1/2 months in the facility, since the end of April 2026, and she washed the dishes.- [NAME] B stated she had been employed for 1 year in the facility.- Observation of the dish room revealed a low temperature dish machine with chlorine sanitizer. DA A stated the water temperatures and sanitizer level were checked 3 times daily and recorded on dish machine sanitizer log. She stated the 3-compartment sink was used to rinse pots and pans and all dishes and pans were washed in the dish machine.- Observation revealed there was no handwashing sink in the dish room. DA A stated she washed her hands in the 3-compartment sink or went into the kitchen to wash her hands. She stated she washed her hands between handling soiled and clean dishes. DA A stated she did not use disposable gloves when she washed the dishes. - Observation revealed a water heater in the dish room to the left of the 3-compartment sink.- 6 cracked and broken floor tiles were observed in the dish room and one broken floor tile had a broken piece missing.- The water from the hot water faucet in the kitchen handwashing sink was cold. The DM stated the kitchen water heater was located in the dish room and provided water for the dish machine. She stated she did not think there was a water line connecting the hot water from the water heater to the handwashing sink in the kitchen.- The counter beneath the electric steam table was soiled with food crumbs.- The interior surface of gas oven was soiled with dried food particles.- The open end of the convection oven vent pipe was positioned under the vent-hood and the pipe was suspended and held in place with wires from the vent-hood.- The top surface of the convection oven was soiled with dust.- The top surface of the stainless steel plate warmer was soiled with food crumbs.- The inside door surface of the microwave oven was soiled with grease.- The wooden shelf units mounted to the wall and wooden drawers had scraped and gouged paint surfaces with areas of wood exposed. 4 shelves had plastic shelf liner used to cover the wooden surface and 1 shelf had parchment paper used to cover the shelf's surface. There were spilled spices on the shelves and food crumbs on the shelves under the shelf liners.- Mesh shelf liner was used on the shelf beneath the tray line counter and plate covers were stored on mesh liner. The shelf was soiled with food particles beneath the mesh shelf liner.- The floor tiles were soiled with white-colored water mineral deposits beneath and behind the ice machine.- The coffee maker counter was soiled with food particles and a smeared clear substance on the edge of the counter.- The residential style refrigerator contained a large clear plastic bag that had been knotted closed and held individually wrapped 1/2 sandwiches with wheat bread and lunch meat in sandwich sized storage bags with fold over closures - the large bag and the individually wrapped sandwiches were not labeled and dated; 10 beverage glasses with plastic covers were filled with juice that were not labeled and dated; 15 individual 1/2 pint (8 ounce) sized cartons of whole milk were stored in the door shelf compartment with a best by date of 6/09/26.- In an interview, [NAME] B stated she had been off duty during the weekend and the sandwiches and glasses with juice were in the refrigerator when she arrived at work that morning. She stated they were for snacks that were given at 10 AM, 2 PM, and 8 PM. She stated sandwiches were usually given at 8 PM, unless a resident asked for one at some other time.- The non-perishable food storage room had wire rack shelf units that held bulk storage bins containing salt, corn meal, dry oats, and white rice. The container lids were soiled with dry food particles. The container lid for the rice was not secured in place and there was an approximate 1-inch gap of open space between the lid with the container contents exposed to the open air. The container lid for the dry oats was not secured tightly in place and loosely covered the container and pieces of dry oats were on the outer rim of the container and on top of the lid.- The walk-in refrigerator had a raw red tomato on the floor beneath the shelf unit; a one-dozen count egg carton with one shell egg in it was stored on the second shelf. The DM stated they ran out of eggs and had bought a dozen eggs at the local grocery store for a resident who wanted fried eggs for breakfast.- The walk-in freezer had a 3-gallon container with vanilla ice cream stored on a shelf. The lid to the container was not secured in place and the ice cream was exposed to the air. The DM removed the container from freezer and stated there was not much ice cream left and she would throw it away.- The service delivery door to the outside of the building had a self-closing device at the top of the door. The door was opened and allowed to swing closed. It did not close completely and was pulled to close securely.Record review for Resident #29's electronic Face Sheet dated 06/11/26 revealed she was a [AGE] year-old female, whose most recent admission date was on 1/16/2026. She had the following diagnoses: Hypertension (elevated blood pressure), Quadriplegia (partial or total loss of feeling or movement in all extremities and torso), Dysphagia (difficulty in swallowing), and dehydration. Record review for Resident #29's MDS assessment revealed a BIMS score of 15 indicating the resident was cognitively intact. She requires a wheelchair for mobility. Record review for Resident #29's Care Plan dated 06/11/26 revealed: had goals and interventions for nutritional status to include regular and at nutritional & hydration risk related to being quadriplegia and needing assistance at meals. She will let staff know what she wants to eat In an observation on 6/8/2026 at approximately 12:10PM during lunch meal, CNA-D was seated with Resident #29. CNA-D was observed using bare hands to break apart a grilled cheese sandwich and a cookie, and placing food in the resident's mouth without the use of eating utensils. In an interview on 6/9/2026 at 07:10am with the ADON, she stated she was aware of the failure during the lunch service on 6/8/2026. She stated Resident #29's preference was for staff not to use gloves when feeding her. She also stated facility staff should have used a fork when feeding this resident. This failure could result in an infection risk to the resident and staff members. In an interview on 6/9/2026 at 4:20pm with ADMN he stated his expectation of all staff was to follow policy and procedures for hand hygiene with every interaction with residents. He stated not following hand hygiene procedures could result in infection. When feeding a resident, he stated he felt gloves are unacceptable to ensure residents were treated with dignity. The alternative to wearing gloves would have been to use proper eating utensils. In an interview on 6/9/2026 at 5:30pm with CNA-D, she stated she was told by the ADON not to wear gloves while feeding residents. She stated the reasoning was because it could be an issue with residents being treated with dignity. She stated hand hygiene policy was to use hand sanitizer between interactions with residents and trays and wash hands with soap and water before feeding a resident. A negative outcome of poor hand hygiene or proper use of gloves was possible cross contamination, infection, spreading of virus or bacteria. During an observation and interview on 6/10/2026 at 10:25 AM, the room [ROOM NUMBER] Kitchen Storage , the DM stated she had ordered cases of bottled water earlier this year in the event of a storm and inclement weather. Observation revealed 9-1/2 cardboard cases, containing 6 one-gallon sized bottled water each, were stored directly on the floor near the wall and to the right of one of the water storage tanks. The cases were stacked 3 boxes high and the bottom case of one stack appeared to be collapsing under the weight of the cases stacked on top of it. During an observation and interview on 6/10/2026 at 10:30 AM, the Maintenance Supervisor entered the kitchen storage room. He stated he had recently drained the water storage tanks, cleaned them with bleach water, and then rinsed and drained them, which he did every 3 months. He stated when he was refilling the tanks one of them had over-flowed and spilled water onto the floor. He stated the bottom case of bottled water had got wet. The Maintenance Supervisor stated he had a lot of pallets and could place pallets on the floor to put the cases of bottled water on and store them off of the floor. During an interview and observations on 6/10/2026 at 10:35 AM, DA C stated he had finished washing the morning dishes. DA C stated he had checked the dish machine water temperature and sanitizer level that morning at 6:00 AM and the water temperature was 130 degrees F and chlorine sanitizer was 100 ppm. He had written the water temperature and sanitizer level on the dish machine log for that morning, 6/10/26 at 6 AM. The Manufacturer's recommendation plate on the dish machine indicated a minimum of 120 degrees F for wash and rinse cycle water temperatures and a minimum of 50 ppm sanitizer. DA C operated the dish machine per request. He ran the dish machine 3 times before checking the water temperatures and sanitizer level, due to the dish machine not being used for a few hours. The wash cycle water temperature was 110 degrees F, the rinse cycle water temperature was 114 degrees F, and the chlorine sanitizer level was measured at 100 ppm by DA C using a chlorine test strip. DA C stated the water was hotter in the morning. Observation on 6/10/2026 at 11:15 AM revealed the water heater in the dish room had a 75-gallon capacity tank and the temperature level was set on B, the mid-point setting for the water temperature. Observation on 6/10/2026 at 11:17 AM revealed the hot water temperature in the 3-compartment sink in the dish room was measured at 122.7 degrees F using a digital thermometer. During an observation and interview on 6/10/2026 11:24 AM, the hot water faucet was turned on and was allowed to run for 4 minutes prior to measuring the hot water temperature. The hot water temperature was measured at 94.8 degrees F using a digital thermometer. The DM stated the Maintenance Director was getting bids on a separate water heater for the kitchen handwashing sink. [NAME] B stated the water was hotter in the morning and got cooler during the day. During an observation and interview on 6/10/2026 at 11:25 AM, the residential style refrigerator used for beverages and snacks revealed the 12 individual 1/2-pint (8 oz) sized cartons of whole milk, dated best by 6/09/26, continued to be stored in the door shelf compartment. Interview with the DM revealed she did not know the milk cartons were being stored in the door shelf. She stated she could have returned them when the dairy was delivered and received credit for them. The DM removed the 12 cartons of whole milk and threw them in the trash can. The DM stated the bag containing sandwiches that had been in the refrigerator (on 6/08/26) had been thrown away because they were not dated and she did not know how long they had been in the refrigerator. Observation on 6/10/2026 at 11:30 AM revealed a live fly was moving throughout the kitchen and food preparation area. The fly landed on the wall and started crawling. Assorted knives in stainless steel holders and 3 knives with their blades stuck to a magnetic wooden cutting board were observed positioned on the food preparation counter. The knife blades were exposed to the air. The DM removed the knives and cutting board and placed them in the dish room. Observation on 6/10/2026 at 11:36 AM revealed dietary cleaning schedules dated June 2026 were posted on a bulletin board on the wall in the kitchen near the door to the hallway. The schedules included: Weekly cleaning schedule with specific staff assigned; Daily cleaning schedules for Morning Aides, Evening Aides; Daily cleaning schedule for Morning Cooks and Evening Cooks; and typed task list pages for PM Dish Aide and PM Cook. In an interview on 6/10/2026 at 11:40 AM, DA C stated he followed the morning dietary aide cleaning list. In an interview on 6/10/2026 at 12:13 PM, [NAME] B stated everyone had cleaning tasks. She stated she followed the cleaning schedules posted on the bulletin board. During an observation and interview on 6/10/2026 at 12:15 PM, [NAME] B used a digital thermometer to measure the holding temperatures for the lunch meal food items. The pudding for dessert had already been measured into individual dessert bowls and had been placed on a tray and covered. The pudding temperature was measured at 51.6 degrees F. DA C stated he had removed the tray with the pudding in bowls from the walk-in refrigerator and placed it on the serving counter around noon. DA C stated he had taken the tray with pudding out too soon. [NAME] B stated preparing the pureed diets had taken longer than she thought it would and they were late serving the lunch meal, which usually started at 12:00 PM. In an interview on 6/10/2026 at 12:24 PM, the DM stated the expectations for the dietary staff were to follow the facility's policies and procedures for food storage and cleaning schedules. The DM stated the staff were expected to complete daily cleaning tasks according to the cleaning schedule and were to label and date prepared food items stored in the refrigerators. She stated oatmeal had not been served on Monday morning, 6/08/2026. She stated oatmeal was served on Sunday morning (6/07/26) and rice was served during the weekend. She stated she knew who had been on duty and who had not put the covers securely on the containers for the oatmeal and rice in the storage room. The DM stated an outcome of not cleaning would be unsanitary conditions in the kitchen. She stated not properly storing dry food items could attract insects, and bugs could get into the containers. She stated not dating foods in the refrigerator could cause the residents to be sick. In an interview on 6/10/2026 at 12:37 PM, the Maintenance Supervisor stated he was getting a bid from a plumber on a 5-gallon water heater for the kitchen handwashing sink. He stated a small electric water heater could be placed in the cabinet under the sink and an electric outlet could be placed in the wall to the side of the cabinet. He stated the water heater in the dish room was only set on B, which was the mid-point temperature and it could go hotter. He said he could turn up the water heater temperature. He stated the dish machine pulled off a lot of hot water when it was used. In an interview on 6/11/2026 at 10:35 AM, the DM stated she could print and provide a facility policy and procedure for ware washing for review. She stated the staff were expected to tell her if the dish machine water temperature was low or not reaching 120 degrees F. The DM stated she had been employed in the facility right at one year and she did not know how long the water heater had been in the dish room. She stated the Maintenance Supervisor would have to be asked. The DM stated she and the Maintenance Supervisor had discussed the kitchen water heater temperature setting and had determined it needed to be set higher between C and very hot. During an observation and interview on 6/11/2026 at 10:39 AM, the temperature setting on the kitchen water heater was observed to be set on B - mid-point. The DM stated it had been turned up last night and had been set between C and very hot. She stated that was where the temperature setting should stay and the staff needed to leave it alone. Record review of the facility's Food and Nutrition Services Policy for Dry Food and Supplies Storage, dated as revised 11/15/2017, indicated [in part]: PolicyDry storage my be in a room or area designated for the storage of dry goods, such as single service items, canned goods, and packaged or containerized bulk food that is not PHF/TCS (potentially hazardous food/time temperature control for safety). The focus of protection for dry storage is to keep non-refrigerated foods, disposable dishware, and napkins in a clean, dry area, which is free from contamination. Dry foods and goods should be handled and stored in a manner that maintains the integrity of packaging until they are ready to use. It is recommended that foods stored in bins (e.g. flour, sugar) be removed from their original packaging. Food and food products should always be kept off the floor and clear of ceiling sprinklers, sewers/waste, disposal pipes, and vents to maintain food quality and prevent contamination.Fundamental InformationAll bulk food items (i.e. flour, sugar) that are removed from original containers into food grade containers must have tight fitting lids, and must be properly labeled with the common name of the product.Procedure1. Shelving is to be clean and free of rust and chipped, peeling paint.7. Bulk food products that are removed from original containers must be placed in plastic or metal food grade containers with tight fitting lids. Each container must be labeled with the common name of the food. Plastic food grade storage bags are also acceptable for storage. All storage bags must also be sealed and labeled with the common name of the food.9. All opened products must be resealed effectively and properly labeled, dated, and rotated for use.10. Use by, Best by, and Sell by dates should routinely be checked to ensure that items which have expired are discarded appropriately. Record review of the facility's Food and Nutrition Services Policy for Frozen and Refrigerated Foods Storage, dated as revised 12/05/2017, indicated [in part]: PolicyPHF/TCS (potentially hazardous/time temperature control for safety) foods will be properly refrigerated or frozen to reduce the potential for food borne illness and maintain product integrity.Fundamental InformationRefrigerated storage is essential to hold PHF/TCS food and most perishable foods as it slows down microbial growth and helps to control food quality.Procedure7.Refrigerated products that are opened must be labeled with an opened on date. The use by date is 7 days from when the product was opened, unless there is a manufacturer's use by, expiration or sell by date. For all foods that have a manufacturer use by, sell by or expiration dates this date will be used.10. Packaged frozen items that are opened and not used in their entirety must be properly sealed, labeled and dated for continued storage.13. On a daily basis the Cooks will:b. Check labeling and dating, use any items that are close to their use by date and discard any items that are past their use by date. Record review of the facility's Food and Nutrition Services Policy for Ware Washing, dated as revised 12/11/2027, indicated [in part]:PolicyThe purpose of ware washing is to clean and sanitize utensils and equipment during the preparation and service of food from the food and nutrition services department. Proper ware washing is an essential component in the prevention of food borne illness.Fundamental InformationThe purpose of ware washing is to clean and sanitize equipment and utensils. This process consists of two phases:1. cleaning phase: all visible soil is removed from items through washing and rinsing;2. sanitizing phase: process by which the number of disease-causing organisms on a cleaned surface is reduced to safe levels.Note: Cleaning and Sanitizing operations can be performed manually or mechanically.It is also important to protect equipment from recontamination via splash, dust, grease, etc.Dishwashing machines use either heat or chemical sanitization methods. Manufacturer's instructions must always be followed.Low Temperature Dishwasher (chemical sanitization):Wash 120 degrees F; andFinal Rinse 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse. Record review of the Food and Drug Administration Food Code 2022 specified [in part]: Chapter 3 Food3-202.15 Package Integrity.FOOD packages shall be in good condition and protect the integrity of thecontents so that the FOOD is not exposed to ADULTERATION or potentialcontaminants. Chapter 4. Equipment, Utensils, and Linens4-501.15 Warewashing Machines, Manufacturers' Operating Instructions.(A)A WAREWASHING machine and its auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions. Chapter 4 Equipment, Utensils, and Linens4-602.13 Nonfood-Contact Surfaces.The presence of food debris or dirt on nonfood contact surfaces may provide a suitableenvironment for the growth of microorganisms which employees may inadvertentlytransfer to food. If these areas are not kept clean, they may also provide harborage forinsects, rodents, and other pests. Record review of the facility's policy titled Infection Prevention and Control Program dated 10/24/2022 revised on 3/26/2024 states [in part]: This facility had established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of communicable diseases and infections as per accepted national standards.Section 4B: Handy hygiene shall be performed in accordance with our facility's established hand hygiene procedures.C: All staff shall use personal protective equipment (PPE) according to established facility policySection 16A: All staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job functionsB: All staff are expected to provide care consistent with infection control practices.

Based on record reviews and interviews, the facility failed to maintain a general training program to ensure staff were trained for 16 of 16 staff (ADMN, DON, ADON, RN-F, RN-G,, RN-H, LVN-I, LVN-H CNA-D, CNA-K, BOM, HSKP-J, AD, DES, SS, DM) reviewed. 1. The facility failed to ensure DM, RN-F, RN-G, LVN-H, and AD were trained for communication.2.The facility failed to ensure RN-F, RN-G, and AD were trained for Resident Rights.3. The facility failed to ensure RN-F was trained for Infection Control.4. The facility failed to ensure that DON, ADON, DM, MS, SS, RN-F, RN-G, LVN-H, LVN-I, CNA-D, CNA-K, BOM, HSKP-J, AD, and DES were trained for Compliance and Ethics.5. The facility failed to ensure that RN-F was trained for Abuse, Neglect and Exploitation.6. The facility failed to ensure ADMN, DON, DM, RN-F, RN-G, LVN-H, LVN-I, and AD were trained for QAPI.7. The facility failed to ensure DON, ADON, DM, SS, RN-F, RN-G, LVN-H, LVN-I, CNA-D, CNA-K and AD were trained for Behavioral Health.8. The facility failed to ensure DON, DM, RN-F, RN-G, LVN-H, and AD were trained for HIV.9. The facility failed to ensure ADMN, DON, DM, RN-F, RN-G, LVN-H, LVN-I, and AD were trained for Restraint Reduction.10. The facility failed to ensure DON, DM. RN-F, RN-G, LVN-H and AD were trained for Prevention of Falls. These failures could place residents at risk of receiving care from incompetent/untrained staff.Findings included:Record reviews of personnel files revealed the following staff did not receive the following training: ADMN hired on 9/9/2025 -QAPI, Restraint reduction DON hired 12/24/2025-Compliance and Ethics, QAPI, Behavioral Health, HIV, Restraint Reduction, Prevention of Falls. ADON hired 4/17/2023-Compliance and Ethics, Behavioral Health AD hired 12/1/2025-Communication, Compliance and Ethics, QAPI, Behavioral Health, HIV, Restraint Reduction, Prevention of Falls. DM hired 4/5/2021-Communication, Compliance and Ethics, QAPI, Behavioral Health, HIV, Restraint Reduction, Prevention of Falls. MS hired 8/6/2014-Compliance and Ethics SS hired 8/15/2023-Compliance and Ethics, Behavioral Health RN- F Hired 4/20/2026-Compliance and Ethics, Resident Rights, Infection control, Communication, Abuse, Neglect and Exploitation, QAPI, Behavioral Health, HIV, Restraint Reduction, Prevention of Falls. RN-G Hired 4/29/2026-Communication, Resident Rights, Compliance and Ethics, QAPI, Behavioral Health, HIV, Restraint Reduction, Prevention of Falls. LVN- H Hired 3/18/2026-Communication, Compliance and Ethics, QAPI, Behavioral Health, HIV, Restraint Reduction, Prevention of Falls. LVN-I Hired 8/12/2025-Compliance and Ethics, QAPI, Behavioral Health, Restraint Reduction, CNA-D hired 10/2/2024-Compliance and Ethics, Behavioral Health CNA- K hired 10/9/2018-Compliance and Ethics, Behavioral Health BOM hired on 4/4/2016-Compliance and Ethics HSKP J hired 2/28/2022Compliance and Ethics DES hired on 4/1/2021Compliance and Ethics. In an interview on 6/11/2026 at 3:00PM with the ADON, she stated some trainings were completed in computer system and others are completed as in-service training during staff meetings. She stated she was responsible for assigning trainings to the staff to complete. The ADON stated when a staff member did not complete a training, she received an alert at the beginning of the next month that it had not been completed. The staff were given a 3-month time frame to complete trainings before disciplinary action would be considered. She stated a negative outcome of employees not completing training could result in residents not receiving the best care. In an interview on 6/11/2026 at 3:15PM with the ADMN, he stated the ADON was responsible for assigning and following staff training for timely completion. He stated staff were expected to attend staff meetings for in-service training, and there were computer module trainings available for employees to complete. All employees were expected to complete all training assigned to them and attend meetings to had the most up to date information. A negative outcome to residents would be employees not having the knowledge to provide proper care. Record review of the facility's policy titled Training Requirements dated on 11/29/2022 stated [in part]: It was the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers consistent with their expected roles.Policy Explanation and Compliance Guidelines: 2. The amount and types of training necessary are based on a facility assessment, state and federal requirements.4. All facility staff are trained to interact in a manner that enhances the resident's quality of life, quality of care and demonstrates competency in the topic of areas of the training program.5. Training requirements should be met prior to staff and volunteers independently providing services to residents, annually and as necessary based on the facility assessment.6. Training content includes, at a minimum:a. Effective communication for direct care staff.b. Resident rights and facility responsibilities for caring of residentsc. Elements and goals of the QAPI programd. Written standards, policies and procedures for the facility's infection prevention and control program.e. Written standards, policies and procedures for the facility's compliance and ethics programf. Behavioral health including trauma informed careg. Restraintsh. HIVi. Dementia management and care of the cognitively impairedj. Abuse, Neglect and exploitation preventionk. Safety and emergency proceduresl. Cultural competencem. Emergency Response7. It was the responsibility of each employee, volunteer or contract staff to complete required training.a. The facility offers a variety of training methods and times to accommodate individuals.

Based on observation, interview and record review, the facility failed to implement the facility's established policy, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents in 1 of 1 outdoor designated smoking areas.1. The red metal can with the foot operated self-closing lid was positioned on a bench in the corner of the designated smoking building. The lid was locked with a padlock and could not be opened to empty the ashtrays used for extinguishing cigarettes.2. A metal ashtray canister was missing the flip-top closure lid and was being used to extinguish cigarettes.3. Cigarette butts and ashes were emptied into the 2 dome trash cans of non-metal construction located inside the smoking building.4. A cigarette tower of non-metal construction used for extinguishing cigarettes was located inside the smoking building.These failures could placed residents at risk for potential injury from fire and/or smoke inhalation from smoldering papers resulting from improper extinguishing and disposal of cigarettes in the designated smoking building.The findings included: Record review of the Resident scheduled smoking times, effective 12/16/2024, indicated there were 6 scheduled times for smoking at 9:30 AM, 11:00 AM, 1:30 PM, 4:00 PM, 7:00 PM, and 9:00 PM. The scheduled times had staff members designated to supervise the residents while they smoked. Record review of the facility's current list of residents who smoke indicated the names of 4 residents. Observation on 6/09/2026 at 2:57 PM revealed the facility's designated outdoor smoking area was in an enclosed smoking gazebo with an open entrance. The building was painted red and was located inside the enclosed courtyard. Signage for the designated smoking area was posted on the outside and interior walls of the building. There were 2 screened windows open and 2 electric fans mounted on walls near the ceiling for ventilation and air circulation inside the building. A red metal can with a foot operated lid was positioned on a bench in a corner of the room. The lid of the metal can was secured with a padlock and could not be opened. A tower cigarette ash tray of non-metal construction was positioned on the floor in a corner of the room. An open metal ashtray missing the flip-top cover was on a bench. A metal ash tray canister was on the floor near a bench. 2 dome covered trash cans of non-metal construction were positioned on the benches in 2 corners of the building. Observation of the contents of the 2 dome trash cans revealed they contained cigarette butts and ashes (from the ashtrays that had been emptied into them), paper, plastic beverage bottles, and other trash. Observation on 6/10/2026 at 9:55 AM, of the outdoor designated smoking building, revealed the covered red metal can lid continued to be secured with a padlock and the dome trash can liners containing cigarette butts and ashes and paper trash had not been emptied. The metal ashtray canister missing the flip-top closure lid had been removed from the building. In an interview on 6/10/2026 at 10:15 AM, the BOM stated there were quite a few staff who smoked and went outside to the smoking building. She stated there were more than 12 staff who smoked. An interview and observations were conducted on 6/10/2026 at 12:49 PM, during an observation of outdoor designated smoking area building accompanied by the Maintenance Supervisor. The Maintenance Supervisor stated he had been employed in the facility for the past 13 years and had taken the position as the Maintenance Supervisor during 2019. The Maintenance Supervisor observed the 2 dome covered trash cans inside the building. He stated he did not know what the cans were made out of and did not know if they were fire resistant. The red metal covered can lid continued to be secured closed with the padlock and the red can was positioned on the bench in the corner. He stated there was a key for the can padlock by the box containing the residents' cigarettes at the nurse's station. The Maintenance Supervisor removed the lids to the 2 dome covered trash cans and observed the ashes and cigarette butts that had been emptied into the 2 cans. He removed the plastic trash bag liners from each trash can and said he would throw them into the dumpster. The Maintenance Supervisor stated the expectation was for the staff to empty the metal ashtrays with ashes and cigarette butts into the red covered can after each resident scheduled smoking time. He stated a potential outcome of emptying the ashtrays into the domed trash cans with paper trash was it could cause a fire that could burn down the smoking shack and cause death. In an interview on 6/10/2026 at 1:07 PM, the ADON stated she had done an internet search, and the dome trash cans were made from non-combustible material. She stated the material was called HDPE - high density polyethylene. In an interview on 6/10/2026 at 1:35 PM, the Maintenance Supervisor stated he had ordered the cigarette smoking tower about 3 years ago from the supply company used by the facility. He stated it had a metal pan in the base to collect the cigarette butts that were dropped into it. The Maintenance Supervisor stated, It probably just needs to go away. He stated it was lighter weight than the dome trash cans and he did not think it was made out of the same material as the dome trash cans. During an observation and interview on 6/11/2026 at 4:09 PM, CNA E was seated on a park bench outside the entrance to the designated smoking building. CNA E stated she had supervised 2 residents during the 4:00 PM scheduled smoking time. Observation of the red metal covered can revealed it continued to be positioned on the bench in the corner of the building. The padlock was unlocked on the lid of the red metal covered can. CNA E entered the smoking building and proceeded to empty the metal ashtray into the red metal covered can and replaced the padlock. CNA E stated the staff emptied the ashtrays after every resident smoke break prior to the key missing. She said when the key became missing they could not be empty the ashtrays into the red can. She stated staff had been emptying the ashtrays into the trash cans. CNA E stated the key was kept in a compartment in the lid of the cigarette box (plastic tackle box). CNA E stated the key had been missing for 7 or 8 months, but the padlock was unlocked today. Observation on 6/11/2026 at 4:12 PM revealed 1 of 2 domed trash cans which contained cigarette butts and ashes with the paper trash that had been placed in it. During an observation and interview on 6/11/2026 at 4:15 PM, the BOM and ADON came outside to the smoking building. The BOM indicated where the key to the padlock for the red metal can was located and reached up and removed a small silver key from a ledge on the wall above the can. During an observation and interview on 6/11/2026 at 4:17 PM, with the Maintenance Supervisor at the smoking building. He stated he found an extra key for the padlock on the red metal can on his key ring and had unlock the can lid. He stated he would get a new padlock and keys. The Maintenance Supervisor looked in the domed trash can and observed cigarette butts and ashes, which had been emptied into the trash can since the prior day when he had removed the trash can liners and thrown them in the dumpster. The Maintenance Supervisor stated the domed trash cans were going to be removed from the smoking building. Observations throughout the survey time frame revealed the facility staff exited the facility to go to the designated smoking building and visitors periodically smoked in the building. Record review of the facility Smoking Policy, dated as revised 1/23/26, indicated [in part]:PolicyIt is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees as related to smoking Fundamental InformationTo establish guidelines for patients that desire to smoke or use smokeless tobacco products in the center.Procedure2. Facilities will have designated non-smoking areas for the patient, family members, or responsible party.3. Facilities will have a designated Smoking/Tobacco use area. Signs will be prominently posted. Smoking is prohibited in all other areas. Safety measures for the designated smoking area will include, but not limited to:a. Protection from weather conditions (i.e. covered)b. Ashtrays made of noncombustible material and safe designc. Accessible metal container(s) with self-closing covers into which ashtrays can be emptied.d. Accessible fire extinguishere. Sign prohibiting use of oxygen in the smoke areaf. Type A fire extinguisher or fire blanket

Based on interviews and record review, the facility failed to ensure pharmacist recommendations were reviewed, and/or acted upon to meet residents needs for 3 of 5 residents (Resident #4, Resident #16, and #37) reviewed for pharmacy recommendations. The facility failed to act upon pharmacist recommendations identified during medication reconciliation for Resident #4, #16 and #37. These failures place residents at risk of treatments and/or medications outside of therapeutic doses.Findings included:Resident #4Review of Resident #4 face sheet revealed he was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnosis included adjustment disorder with mixed anxiety and depressed mood-dated 12/29/2025; unspecified psychosis not due to substance or known physiological condition; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety dated - 01/02/2024; dementia in other diseased classified elsewhere, mild, with other behavioral disturbances-dated 10/27/2023. Reviewed most recent MDS quarterly dated 5/1/26 and modification of quarterly dated 5/1/26 revealed active diagnosis of non-Alzheimer's dementia; section N - Medications revealed that a gradual dose reduction had not been attempted and a GDR has not been documented by a physician as clinically contraindicated. The remainder of the section of the antipsychotic medication review is left unanswered. BIMS score of 14. Reviewed resident #4 care plan dated 04/09/26 that revealed focus, goals and interventions for cognitive impairment. Review of active order summary for resident #4 reveals an order on 11/11/2025 for Quetiapine fumarate 200mg one tablet by mouth at bedtime for hallucination Record review of orders indicated Quetiapine fumarate started on 09.08.25 at 50mg then discontinued on 9/25/25. Then Quetiapine fumarate 100mg started on 9/25/25 and increased to Quetiapine fumarate 200mg on 11/11/2025, which is the current dose. Reviewed consent form 3713 dated 9/8/25 for resident #4 for medication Quetiapine fumarate but the form was not signed by the doctor. Record review of Resident #4's Consultant Pharmacist's Medication Reconciliation Report did not show documentation for review of the medication Quetiapine. Resident #16Record review for resident #16 electronic Face Sheet dated 06/10/26 indicated she was a [AGE] year old female. She was admitted to the facility on [DATE]. She had the following diagnoses of: Type 2 Diabetes, PTSD (post- traumatic stress disorder), Fracture of the upper end humerus left, adjustment disorder with mixed anxiety and depressed mood, schizoaffective disorder and bipolar disorder. Record review for Resident #16's Annual MDS completed on 5/20/2026 indicates PASSR Level 2 for serious mental illness. BIMS 15 (high cognitive function) with inattention and disorganized thinking. She ambulates without assistive devices. Independent with ALDs. She had a fall resulting in a Major injury (fracture). GDR did not recommend changes in medications on 5/8/2026. Record review for Resident #16's Care plan dated 6/9/2025 has appropriate goals and interventions for Residents diagnoses, treatments, and preferences. Including monitoring for side effects/effectiveness of treatments. Careplan addresses fall risk and use of anticoagulants related to recent falls. Record review for Resident #16's electronic Physician Orders dated 06/11/26 included: Divalproex Sodium Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 250 mg by mouth three times a day for mood, Sertraline HCl Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth in the morning related to major depressive disorder, TraZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime related to Schizoaffective disorder, Bipolar type, Tramadol HCl Tablet 50 MG Controlled Drug Give 1 tablet by mouth every 4 hours as needed for Pain and Quetiapine Fumarate Tablet 100 MG Give 1 tablet by mouth at bedtime related to bipolar disorder. Record review for Resident #16's Consultant Pharmacist's Medication Reconciliation Report revealed:-dated 6/13/2025 identified recommendations including PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order for resident #16. Documentation failed to evidence physician notification, clinical review, implementation of recommended interventions, or documented rationale for declining the recommendations.-dated 9/23/2025 identified recommendation to decrease Divalproex 250mg three times a day to Divalproex 250mg in AM, 125mg at noon, 250mg QHS (each night at bedtime), for resident #16. Documentation failed to evidence physician notification, clinical review, implementation of recommended interventions, or documented rationale for declining the recommendations.-dated 4/30/2026 identified recommendations including This resident has been taking Pantoprazole 40mg QD (every day) since 07/22/2025 without a dose reduction. Please consider a trial doses reduction to Pantoprazole 20mg QD (every day) for resident #16. Documentation failed to evidence physician notification, clinical review, implementation of recommended interventions, or documented rationale for declining the recommendations. This resident has been taking sertraline 25mg QAM (every morning) since 11/04/2025 without a GDR. Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? for resident #16. Documentation failed to evidence physician notification, clinical review, implementation of recommended interventions, or documented rationale for declining the recommendations.-dated 5/31/2026 identified recommendations including This resident has been taking Trazodone 50mg QHS (every night) since 11/08/2025 without a GDR. Could we attempt to dose reduction at this time to perhaps Trazodone 25mg QHS (every night) to verify this resident is on the lowest possible dose? for resident #16. Documentation failed to evidence physician notification, clinical review, implementation of recommended interventions, or documented rationale for declining the recommendations.-Further review of subsequent medical records revealed the recommendations remained unresolved for following identification by the pharmacist. Resident#37Record review for Resident #37's electronic Face sheet dated 06/10/26 indicated resident was a 72- year- old female. She was admitted to the facility on [DATE] with other admission dates of 3/21/2022 and 5/7/2025. She had the following diagnoses: Type 2 Diabetes, Chronic pain syndrome, Chronic kidney disease, Major depressive disorder, anxiety disorder, insomnia, repeated falls, Obstructive sleep apnea, Chronic obstructive sleep apnea, Hypertensive heart failure, Alzheimer's with late onset, Congestive heart failure. \ Record review for Resident #37's Quarterly MDS completed on 3/25/2026. BIMS 12 (mild cognitive impairment). She required wheelchair for mobility. She needed assistance with showering/bathing. Record review for Resident #37's electronic Physician Orders dated 06/11/26 included: Levothyroxine Sodium Oral Tablet 25 MCG (Levothyroxine Sodium) Give 50 mcg by mouth one time a day for thyroid take 2 tablets to equal 50mcg. trazodone HCl Oral Tablet 100 MG (Trazodone HCl) Give 2 tablet by mouth at bedtime related to major depressive disorder. Record review for Resident #37's consultant pharmacist's Medication Reconciliation Report revealed:-dated 7/8/2025 identified recommendations including Per CMS regulations, please evaluate resident for trial dose reduction Trazodone 100mg QHS (at bedtime) Insomnia (difficulty sleeping) to Trazodone 75mg QHS (each night at bedtime) insomnia (difficulty sleeping) for resident #37 Documentation failed to evidence physician notification, clinical review, implementation of recommended interventions, or documented rationale for declining the recommendations.-dated 4/30/2026 identified recommendations including This resident has been taking Aricept 5mg QD (every day) for over 6 weeks. The manufacturer recommends increasing the dose to 10mg HS (at bedtime) after 6 weeks of therapy as the increased dose has been found helpful to most patient's for resident #37. Documentation failed to evidence physician notification, clinical review, implementation of recommended interventions, or documented rationale for declining the recommendations. The current order for Aricept 10mg was not increased until 6/8/2026.-Further review of subsequent medical records revealed the recommendations remained unresolved for following identification by the pharmacist. In an interview on 6/10/2026 at 2:30pm, the RN DON stated her expectation was for the Pharmacist's recommendations to be presented to the facility provider in a timely manner for consideration of the recommendations. The DON stated there had been a recent change in the DON and the current facility DON was not aware if the recommendations were presented to the physician(s) for review. A negative outcome of Pharmacists recommendations not being presented to the physician was residents could be receiving an unnecessary dose of medication or a medication that was not needed. In an interview on 6/10/2026 at 2:40pm, the Administrator stated when the Pharmacist makes a recommendation the nurse should present the recommendation to the physician for a decision. He stated a negative outcome of the physician not being given the pharmacists recommendation was the resident would not have a needed dose reduction, and a medication could continue to be given and worsen the resident condition. Record review of facility policy titled Drug Regimen Review Process dated 6/9/17, reviewed on 1/13/2019 states [in part]ProcedureDrug regimen reviews are automated and are conducted when medications are entered into Pharmacy software.The Consultant Pharmacist for the facility receives the alert, reviews and contacts the Director of Nurses with recommendations.The director of Nurses oversees that the Pharmacy Recommendation is completed timely (up to 12 midnight the next night)Monthly Drug Regimen ReviewThe consultant Pharmacist reviews the medication regimen of each resident at least monthly and more frequently if deemed necessary.The DON (Director of Nurses) or designee reviews, tracks and completes follow up to recommendations that do not require a physicians intervention within 5 days of receipt.Recommendations that require physician response are sent to the physician timely for follow up or the physician is contacted by phone as indicated.The DON will maintain a system to review and track all recommendations sent to the physician to validate timely response by physician.The DON will validate that all recommendations sent to Physician, once returned ae acted upon timely.

Based on observation and interview the facility failed to ensure that drugs and biologicals used in the facility were properly stored and or disposed of according to professional standards in 1 of 2 (Medication room [ROOM NUMBER]) reviewed for medication storage. The facility failed to ensure 18 doses of expired hydrocortisone suppositories stored in the refrigerator were disposed of properly. This failure could place residents receiving medication that is expired at risk of not receiving the intended therapeutic benefit of their medication, or other adverse side effects.The findings include: During an observation on 6/9/2026 at 0815am of Medication room [ROOM NUMBER] it was revealed 1 resident had 18 doses of Hydrocortisone 25mg suppositories with an expiration date of 3/2026. In an interview with the DON on 6/9/2026 at 8:25am, she stated the nurses are responsible for checking medications and supplies in the medication rooms and medication carts for expiration dates. She stated if a medication was expired or damaged, it was to be placed in the box located inside the medication storage room for destruction. She said her expectation was for nurses to audit carts, check medications for expiration dates and rotate medications based on expiration dates. She stated that administering an expired medication would be considered a medication error. In an interview with the ADMN on 6/9/2026 at 4:15PM, he stated the nurses were to check the medication cart and medication storage rooms weekly and remove any expired medications from the area and secure them in a locked area for destruction. He said administering expired medications to residents would not be an effective treatment. Policy titled Medication Storage dated 1/20/2021 states [in part]Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored, dated, and labeled according to the manufacturers' recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.8. Medication carts are routinely inspected for discontinued, outdated, defective or deteriorated medications with worn, illegible or missing labels. These medications are removed and destroyed in accordance with the facility policy.9. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with the facility policy.

Based on interview and record review, the facility failed to ensure the Minimum Data Set assessments were transmitted for 2 of 13 residents (Residents #1 and Resident #25) reviewed for assessment completion and transmission. 1. Resident #1 had an Entry MDS Assessment with an Assessment Reference Date of 4/06/2026 and was still export ready.2. Resident #25 had an Annual MDS Assessment with an Assessment Reference Date of 5/07/2026 was still export ready. This failure could place resident at risk for a delay in MDS transmittal and delay in care needs based on MDS.The findings included: Review of Resident #1's admission Record, dated 6/11/2026, indicated a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included congestive heart failure (chronic condition where the heart cannot pump enough blood to meet the body's needs for blood and oxygen), major depressive disorder (mood disorder characterized by severe and persistent low mood, profound sadness, or a sense of despair), type 2 diabetes mellitus (chronic condition characterized by insulin resistance and high blood sugar levels), dementia (decline in cognitive function affecting memory, thinking, and behavior), chronic obstructive pulmonary disease (progressive lung disease with difficulty breathing), and peripheral vascular disease (narrowed arteries reduce blood flow to the arms and legs - poor circulation). Record review of Resident #1's MDS Assessment history indicated:- Discharge Return Anticipated assessment dated [DATE] had been completed and Accepted for transmission.- Entry assessment, dated 4/06/2026 was Export Ready and had not been transmitted.- RN signature was not completed until 06/09/26 for accuracy and completion of assessment. Review of Resident #25's admission Record, dated 6/11/2026, indicated a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included hypertension (high blood pressure), congestive heart failure (chronic condition where the heart cannot pump enough blood to meet the body's needs for blood and oxygen), major depressive disorder (mood disorder characterized by severe and persistent low mood, profound sadness, or a sense of despair), type 2 diabetes mellitus (chronic condition characterized by insulin resistance and high blood sugar levels), chronic obstructive pulmonary disease (progressive lung disease with difficulty breathing), hypothyroidism (thyroid disorder), gastro-esophageal reflux disease (back-up of stomach acid into the esophagus), and end stage renal disease (the kidneys no longer function normally and lose their ability to filter waste). Record review of Resident #25's MDS Assessment history indicated:- Annual assessment with an ARD of 5/07/2026 was Export Ready.- RN signature was not completed until 06/04/26 regarding accuracy and completion of assessment. In an interview of 6/11/2026 at 11:43 AM, the facility's MDS Coordinator stated she had been employed in the facility for 3 years and had started in the position as MDS Coordinator during December 2025. She stated each staff member who completed parts of the MDS assessment was responsible for e-signing and listing the sections they completed. She stated electronic signatures were date and time stamped when the staff digitally signed assessment. The MDS Coordinator stated she exported/transmitted MDS assessments 1 time weekly either at the beginning or the end of the week. She stated she had exported yesterday (Wednesday - the middle of the week) because she had quite a few MDS assessments to export so went ahead and did it. The MDS Coordinator stated she took vacation time off 5/25/26 - 5/29/26. She stated the LVN Corporate Reimbursement Coordinator had exported/transmitted 3 MDS assessments for facility residents during her absence. During an interview and record review on 6/11/2026 at 11:55 AM, the MDS Coordinator printed an MDS transmission batch report, for batch accepted date 6/10/2026. Review of the printed batch report, dated 6/10/2026, indicated 8 resident assessments were exported, including Resident #25's Annual MDS Assessment, dated 5/07/2026. The MDS Coordinator stated she did not know why the annual assessment, dated 5/07/2026, for Resident #25 had not been exported in a prior batch. She reviewed Resident #25's Annual MDS assessment and stated it was signed as completed by the RN on 6/04/2026. She stated the annual assessment with an ARD 5/07/2026 had been revised by the RN Corporate Reimbursement Coordinator. The MDS Coordinator stated she had created Resident #25's MDS assessment as a quarterly with an ARD of 5/23/2026, which was incorrect, and the RN Corporate Reimbursement Coordinator had changed it to an annual assessment with an ARD of 5/07/2026 that was actually due, and not a quarterly assessment. The MDS Coordinator stated she completed Resident #25's MDS assessment on 6/03/2026 when she returned from vacation. She stated she thought the assessment needed to be completed by the 14th day from the ARD. She stated she did not know if there was a written policy for completing and transmitting MDS assessments. The MDS Coordinator stated she went by what the LVN Corporate Reimbursement Coordinator had taught her. She stated the chart in the computer program generated the MDS completion date. The MDS Coordinator stated she had started a Significant Change MDS Assessment for Resident #25 with an ARD of 6/09/2026 which would make it due on 6/23/2026. In an interview on 6/11/2026 at 12:30 PM, the facility's MDS Coordinator called the LVN Corporate Reimbursement Coordinator and put her on speaker phone. The LVN Corporate Reimbursement Coordinator reviewed Resident #25's MDS assessment history and stated an Annual MDS assessment was due on 5/07/2026 and should have been completed by 5/20/2026 and exported within 14 days of the signature date of the RN. She stated it would have been exported by 6/04/2026. She stated the Annual MDS Assessment was not completed timely, but the exportation was timely based on the completion date of 6/04/2026. The LVN Corporate Reimbursement Coordinator stated there was not a written facility or company policy and procedure for completing and exporting the MDS assessments. She stated the MDS Coordinators went by the instructions of the RAI Manual. In an interview on 6/11/2026 at 12:40 PM, the facility's MDS Coordinator stated the prior RN-DON should have completed Resident #25's Annual MDS with the ARD of 5/07/2026. The MDS Coordinator stated the prior RN-DON had left in of May 2026. The MDS Coordinator stated she had completed the Resident #25's Annual MDS assessment and the current RN-DON signed the MDS as completed on 6/04/26. The MDS Coordinator stated when the MDS was signed by the RN, she locked the assessment and a submit by date was generated in the computer program used for the residents' electronic health records. She stated the current RAI Manual was dated October 2025. During a record review and interview on 6/11/2026 at 12:57 PM, the MDS Coordinator reviewed Resident #1's MDS assessment history. She stated an entry MDS dated [DATE] was completed. She stated it was signed as completed 6/09/2026 by the RN - DON. The MDS Coordinator stated the assessment had not been exported, and it should have been submitted by 4/20/2026. Record review of the facility policy and procedure for MDS Completion, dated as reviewed 11/05/2024, indicated [in part]:Anticipated OutcomeResidents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan Process1.According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State.2. Types of OBRA Assessments:a. Entry Trackingi. Complete and submit every entry into the facility no later than entry date + 7 calendar days c. Annual Assessment - a comprehensive assessment completed using an ARD no > 366 days from the most recent prior comprehensive assessment and no > 92 days from the most recent quarterly assessment (counting ARD to ARD) .7. Transmission Requirements:a. All assessments shall be transmitted to the designated CMS system (QIES ASAP) within 14 days of completion.b. Each assessment must be accepted into the system, as verified by validation reports.c. Validation Edits:i. For each file submitted, the submitter will receive confirmation that the file was received for processing and editing by the MDS system (initial submission feedback).

Based on interview and record review, the facility failed to provide an activities program directed by a qualified professional for 1 of 1 (AD) reviewed for Activity Director. The facility Activity Director was not a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. This failure could place all residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident.Findings include: Record Review of the Activity Director's personnel file indicated the employee was hired for AD on 12/1/2025. No training for an activities program, therapeutic recreational specialist, or activities professional was noted in the file. In an interview on 06/08/2026 at 2:14pm, the AD stated that she had not taken her certification for AD. The AD stated she started in the role on 12/1/2025. The AD stated the previous corporation would not pay for the classes to get her certification as an AD. The AD stated she had not signed up for the class and needed help with paying for the class. The AD stated she was told she could work under another staff member at the facility that had the certification course. In an interview on 06/09/2026 at 3:15 pm, the BOM stated regarding her previous role was as AD and she had not kept up with her annual hours for AD certification, so it was no longer valid. In an interview on 06/09/2026 at 6:19 pm, the ADMN stated he thought the AD could work under the BOM that had a certification. He stated he would find out if the new corporation would pay for the course and it would be taken care of soon Review of AD job description signed by AD on 12/1/2025 reveals [in part]: to include qualifications of A high school diploma or equivalency certificate with two years of experience in social or recreational programs within the last 5 years, one year of which was full-time in a patient activities program in a healthcare setting. Successful completion on a State-approved and certified course of instruction in patient activities. Individuals who do not meet the above criteria may serve in that capacity of an activities director with consultation from a person meeting the above-described qualifications if he/she successfully completes the State-approved and Certified Activities Director's course within 9 months of the beginning of employment.

Based on interviews and record reviews, the facility failed to maintain medical records on each resident that were complete and accurately documented for 2 (Resident #1, and #3) of 5 residents reviewed for medical records. The facility failed to ensure Residents #1 and #3 had accurate daily BS assessments and insulin injection documented in the medical record. These failures could place residents at risk due to inaccurate assessments.Findings included: Record review of Resident #1's face sheet dated 12/30/2025 revealed a [AGE] year-old female, originally admitted to facility on 11/11/24 with most recent readmission on [DATE] and the following diagnoses: Dementia (mental decline caused by different diseases), type 2 diabetes (insulin resistance). Record review of Resident #1's MDS revealed, Section C-Cognitive Behavior BIMS score of 4 (severe cognitive impairment), Section N-Insulin Injections. Record review of Resident #1's Care Plan dated 9/4/25 revealed Resident #1 diabetes- monitor BS, diabetic diet. Record review of Resident #1's Medication order reflected: Lyumjev Kwik Pen 100 UNIT/ML Solution pen-injectorInject as per sliding scale: if 151 - 200 = 2 units ; 201 -250 = 4 units ; 251 - 300 = 6 units ; 301 -350 = 8 units; 351 - 400 = 10 units ; 401 - 450 = 12 units 451 and greater give 14 units and notify MD, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (too much sugar in blood) Hold if BS less than 90 and notify MD. Record review of Resident #1's MAR for insulin injection revealed that on 12/11/25 the 8:00PM Blood Sugar Check and insulin injection were not documented in the MAR. Record review of Resident #3's face sheet dated 01/02/2026 revealed a [AGE] year-old female, originally admitted to facility on 3/31/25 with most recent readmission on [DATE] and the following diagnoses: Type 2 diabetes (insulin resistance). Record review of Resident #3's MDS dated [DATE] revealed, Section C-Cognitive Behavior BIMS score of 15 (cognitively intact), Section N-Insulin Injections. Record review of Resident #3's Care Plan dated 10/3/25 revealed Resident #3 diabetes- monitor BS, diabetic diet. Record review of Resident #3's Medication order reflected: Lyumjev Kwik Pen 100 UNIT/ML Solution pen-injectorInject as per sliding scale: if 151 - 200 = 2 units ; 201 -250 = 4 units ; 251 - 300 = 6 units ; 301 -350 = 8 units; 351 - 400 = 10 units ; 401 - 450 = 12 units 451 and greater give 14 units and notify MD, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65) Hold if BS less than 90 and notify MD. Record review of Resident #3's MAR for insulin injection revealed that on 12/11/25 the 8:00PM Blood Sugar Check and insulin injection were not documented in the MAR. Record review of Resident #3 MAR revealed that on 12/11/25 LVN B was the nurse that was on duty and took BS and provided insulin injection. In an interview on 12/31/25 at 10:00am LVN B (by phone), stated she only works at facility part-time. LVN B recalled working at facility on 12/11/25, and stated she did check Resident #1 and #3's BS and administered Insulin. LVN B stated that Resident #1 had a BS of 189 and received 2 units of insulin, and Resident #3 had a BS of 146 and insulin was withheld at that time. LVN B stated she wrote the BS and insulin dosage on paper but forgot to document in the MAR. LVN B stated that she only works PRN, and it is hectic for her to chart as she goes so, she writes notes on paper and charts later. LVN B stated that charting needs to be done once the task is completed and stated most the time she is able to chart right after the task but at times gets behind and charting is done later during the shift. At an interview on 1/2/26 at 2:40pm, DON stated that it is the facility's expectation that charting be completed after a task and or assessment has been completed or soon afterwards as to not forget documenting.

Based on interview, and record review, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 6 residents (Resident #6), reviewed for activities of daily living. The facility failed to provide timely incontinence care for Resident #6. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, skin breakdown, and a decreased quality of life. Findings included: Resident #6 Review of Resident #6's Face Sheet, not dated, revealed a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included: Obesity, abdominal hernia (a condition where a portion of an organ or tissue protrudes through a weak spot in the abdominal wall, often appearing as a bulge or lump), attention to colostomy (describes care for a surgical incised stoma through the abdomen and into the bowel to allow stool to exit the body to a colostomy bag instead of the rectum). Review of the Quarterly Minimum Data Set (MDS) for Resident #6 dated 4/22/25 reflected a BIMS score of 15 which indicated the resident was cognitively intact. Resident #6 was assessed to be frequently incontinent of bladder and had a colostomy. She required extensive assist of 1 for personal hygiene. Record review of Resident #6's care plan revealed the following: Focus: Resident is incontinent of bladder at night only related to impaired mobility, and activity impairment Goal: Resident will be clean, dry and odor free. Interventions: briefs or incontinence products as needed for protection, Incontinent at night check frequently for wetness and soiling and change as needed. Focus: Resident has ADL self-care deficit related to impaired mobility related to functional limitations due to impaired mobility. Interventions: toileting - extensive assistance of one. Dated Initiated 5/3/25 and revised 5/16/25 In an interview on 5.15.25 at 1:30 PM, CNA B said she had concerns about the night shift aide that she relieved this morning. She stated Resident #6 was pulling her call light when she came on shift and that she was upset because she was soaked through to the mattress and was very wet. She stated she had told the nurse on duty about it, and she stated she said she would ask LVN A about it. She stated it has happened before and usually happens with this rotation of aides that she relieves (which was CNA D and CNA E). Stated she believes they neglect their duties because they are friends with the charge nurse, who was LVN A, and she would take up for them. In an interview on 5/15/25 at 1:45 PM CNA C stated she had concerns about the night shift aides that she relieved morning. She stated Resident #6 was pulling her call light when she came on shift on 5.15.25 and Resident #6 was upset because, she was soaked through to the mattress and was very wet when she went in to answer the light. She stated she believed this occurred because CNA E didn't like to do their job. She stated she had told the DON of her concerns. In an interview on 5/15/25 4:30 PM, the DON said it was her expectation for resident's to be changed when needed. She stated she was going to speak with the aides regarding the residents' concerns and. She stated she did not know why it happened. She stated she would look into it. In an interview with CNA D at 6:30 PM on 5.15.25 she said she did not check on Resident #6 that morning. She stated CNA E was supposed to check on her. She stated she and CNA E divided the incontinent residents up for last bed check on the morning of 5.15.25 that they make at about 5 am and CNA E did Resident #6. She stated she had never had concerns regarding her coworkers being neglectful. She stated not changing a resident could cause skin breakdown or infection. In an interview with CNA E at 6:45 PM on 5.15.25 she stated she did not check on Resident #6 that morning before she got off. She stated CNA D was supposed to check on her. She stated they divided the incontinent residents up and she checked on 11 residents but didn't check on Resident #6 . She stated she had never had concerns regarding her coworkers being neglectful. She stated they usually didn't check on Resident #6 unless she called, because Resident #6 had asked them not to wake her at night. In an interview with Resident #6 on 5.16.25 at 9:00 AM she stated that she called for assistance twice on 5.15.25 due to urinary incontinence and no one came until after 7: 00 AM. She stated she asked the nurse LVN A for someone to change her while LVN A was performing colostomy care. She stated LVN A told her she would get the Nurse. She stated nobody ever came and it was the day shift CNA's that changed her. She stated that she did not think that the girls did it on purpose to be neglectful. She stated she thinks they just overlooked her. Stated it has never happened before. She stated it made her feel uncomfortable physically, but it didn't hurt her emotionally. She stated she had been a nurse's aide herself and she knew how it was when you got busy. Sometimes people just forget what they are doing. She stated she did fall back asleep while she waited. She also stated she had never asked the aides not to check on her at night, which was when she needed them. During an interview on 5.16.25 at 9:30 AM the Administrator stated she would expect the nurse to change the resident if she had time or to ensure that an aide cared for the resident. She stated she believed the failure occurred because of the lack of monitoring on the nurses' part and the aides' lack of communication. She stated she had reported the alleged neglect to the state and had suspended the CNA's effective yesterday evening (5.15.25) until the completion of her investigation. She stated she had done an Inservice on abuse and neglect, and reporting and a one-on-one counseling with CNA B for not reporting to her immediately. Record Review of the facility policy Activities of Daily Living (ADLs) Guidelines revised 2.10.2020, revealed the following [in part] . Policy Statement Anticipated Outcome Residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene.' Residents participate in and receive the following person-centered care: Toileting/Continence: toileting or receiving assistance with toileting or receiving incontinence care.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to self-administer medications if the interdisciplinary team determined that this practice was clinically appropriate for 1 of 5 resident (Resident #12) reviewed for medication self-administration. The facility did not assess Resident #12 for self-administration safety. This failure could place residents at risk for not receiving medication as ordered and ingesting an incorrect amount of medication. Findings include: Record review of Resident #12's Admission MDS, dated [DATE], and revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #12 had diagnoses which included cancer, arthritis (joint inflammation), Alzheimer's disease (a disease that destroys memory and other mental functions), and rheumatoid arthritis (inflammatory disorder affecting joints). Her BIMS is 11. Scores between 0-7 indicate severe cognitive impairment, scores between 8 and 12 indicate moderate impairment, while scores above 13 indicate little to no impairment. Record review of Resident #12's Order Summary Report revealed an order for 10ml of Storm Wash (liquid oral medication used for sores in mouth and throat) for mouth before meals and at bedtime for throat cancer. Swish and swallow 10ml 5 minutes before meals and at bedtime. The start date for the medication was 03/29/2025 with no end date. Record review of Resident #12's Care Plan, dated 03/29/2025, did not indicate that self-administration of medications was care planned. In addition, the care plan did not address the medication. No documentation in the care plan was found regarding the medication. Record review of Resident #12's assessments and progress notes, dated from 03/28/2025 to 04/07/2025, did not reveal the resident had been instructed in the proper use of the bedside medication, which included demonstrating appropriate use of the medication, and documentation of this education in the medical record. Observations on 04/06/2025 at 9:30 AM revealed two unsecured prescription bottles of [NAME] Wash on Resident #12's nightstand. The label read, [NAME] Wash 1:1:1:1, swish and swallow 10 ml 5 minutes before meals and at bedtime. No medication measuring cups were noted in the room and no locked boxes or locked drawers were observed. In an interview on 04/15/2025 at 10:02 AM with the Pharmacy Technician revealed [NAME] Wash was a special compounded medication that consisted of Lidocaine (numbing agent) 2%, Nystatin (antifungal agent) 100,000 units/ml, anti-gas medication, and simple syrup. In an interview on 04/06/2025 at 9:30 AM with Resident #12, she reported she was allowed to keep the medication at her bedside because she took it several times a day. She did not measure the medication with a measuring cup. She took swigs before she ate. She continued to say she had not received any education on how to take the medication and stated, the instructions were on the bottle. It says to just drink it. In an interview on 04/06/2025 at 9:30 AM with LVN A, she reported Resident #12 had an order to keep the medication at her bedside. She stated, I've never seen her take it. When I give her medications, she can only sit up on her elbow to swallow her medication. I don't know if there was an assessment completed because I wasn't here when she was admitted . In an interview on 04/07/2025 at 9:22 AM with the DON, she stated Residents should be educated before self-administering medications. It appears she cannot do it herself. An adverse reaction could be diarrhea, maybe side effects. We will assess her now. The DON continued to state she did not know if the resident was assessed prior to allowing her to keep the medication at her bedside. In an interview on 04/07/2025 at 10:54 AM with the ADON, she stated they need to have a medication administration assessment. They need an order. We monitor and assess they are actually able to take the medication. The [NAME] Wash should at minimum be stored in the dresser so there is not easy access to other residents. Adverse reactions could include allergic reactions and decreased blood pressure if not stored or taken properly. In an interview on 04/07/2025 at 11:32 AM, with the Nurse Practitioner, she reported ideally residents should be following directions on the bottle and should have been assessed prior to ensure they were capable of taking the medication as prescribed. She felt harm from taking too much [NAME] Wash is minimal. Record review, on 04/07/2025, of the facilities policy titled Bedside Medication Storage, dated 09/2018, revealed in part: -Policy Bedside medication storage is permitted for residents who wish to self-administer medication, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team (or equivalent). -Procedures 1. A written order for the bedside storage of medication is present in the resident's medical record. 2. Bedside storage of medication is indicated on the resident Medication Administration Record (MAR) and in the care plan for the appropriate medications. 3. For residents who self-administer medications, the following conditions are met for bedside storage to occur. a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if unlocked storage is deemed appropriate. Facility management should have copy of the key in addition to the resident. 4. The resident is instructed in the proper use of bedside medication, including what the medication is for, how it is to be used, how often it may be used, properly cleaning of inhalers where applicable, and proper storage of the medication. The resident should be able to repeat the instructions or demonstrate appropriate use of the medication, and the necessity of reporting each dose used to then nursing staff. The completion of this instruction is documented in the resident's medical record. Periodic review of these instructions with the resident is undertaken by the nursing staff and deemed necessary.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for food and nutrition services. The facility failed to ensure the stainless-steel shelf units were not soiled with food particles and dried liquid. This failure could place residents at risk for foodborne illness and a decline in health status. The findings include: Observations on 04/06/2025 at 9:40 AM, during the initial tour of the facility kitchen, revealed the following: the floor behind the stove and stainless-steel shelf unit were soiled with food debris and dried liquid. Observations on 04/06/2025 at 9:50 AM revealed daily cleaning logs, dated April 2025, used for all the kitchen cleaning duties, revealed all cleaning duties for the morning had been completed and initialed by the kitchen staff who completed the cleaning task. In an interview on 04/07/2025 at 10:40 AM, the Dietary Manager stated her kitchen staff followed a daily cleaning schedule, but the dietary department was short staffed and she must have overlooked the cleaning of the stainless steel shelf unit and floor behind the stove. She said it's important that the kitchen stainless steel shelf unit, and the floor behind the stove be kept clean to prevent foodborne illness. In an interview on 04/07/2025 at 2:35 PM, the DON stated her expectation was for the dietary department to follow the dietary department cleaning policy. In an interview on 04/07/2025 at 2:40 PM, the Administrator stated his expectation was for the dietary department to follow their cleaning schedule per dietary department policy. Record review of the facility's policy titled Sanitation, dated October 2019, dated as revised 2008, revealed the following [in-part]: The food service area shall be maintained in a clean and sanitary manner. The Nutrition services staff maintains clean and sanitary kitchen facilities and equipment. Walls, floors, ceilings, equipment, and utensils are clean and/ or sanitized, and maintained in good working order . 12. For fixed equipment or utensils that do not fit in the dishwashing machine, washing shall consist of the following steps: a. Equipment will be disassembled as necessary to allow access of the detergent/solution to all parts. b. Removable components will be scraped to remove food particle accumulation and washed according to manual or dishwashing procedures throughout their work areas cleaning of the kitchen and dining areas. Food service staff will be trained to maintain cleanliness.

Based on interview and record review the facility failed to review the work of each Certified Nurse Assistant (CNA) at least once every 12 months, for 3 (CNA A, CNA B and CNA C) of 6 CNAs reviewed for annual competency evaluations. This deficient practice could affect residents and place them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs. Findings included: Record Review of Personnel Files revealed the following: - Employee record for CNA A revealed a hire date of 08/02/2022, with no evidence of a competency evaluation in the past 12 months. - Employee record for CNA B revealed a hire date of 10/07/2022, with no evidence of a competency evaluation in the past 12 months. - Employee record for CNA C revealed a hire date of 01/10/2022, with no evidence of a competency evaluation in the past 12 months. In an interview on 02/29/24 at 11:39 AM, the Administrator stated the previous DON quit at the end of January of this year and boxed everything up. Documentation cannot be found confirming evidence of a competency evaluation had been completed. Potential negative outcomes would be the DON would not be aware where the nurses would need further education. Record review of the facility policy titled Nursing Services and Sufficient Staff, dated 4/10/2022, revealed the following in part: Policy: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill set to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Policy Explanation and Compliance Guidelines: 6. The facility must ensure that nurse aids are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Based on observation, interview, and record review the facility failed to develop and implement care plans for necessary treatments and conditions for one of two residents (Resident #13) reviewed for Comprehensive Care Plans. The facility failed to develop Resident #13's care plan dated 12/04/2023 that addressed Resident 13's diagnosis of altered mental status and psychotic medication as ordered. This failure could place residents at risk of not receiving care that was thoughtful, planned, and relevant to their condition(s) which could lead to complications in resident health and quality of life and care. The findings included: Record review of Resident #13's face sheet, dated 02/28/24, revealed a [AGE] year-old female, admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Resident #13 had a diagnosis of altered mental status (a symptom of a brain malfunction that affects behavior and awareness). Record review of Resident #13's Annual MDS, dated [DATE], revealed in Section I diagnoses included Psychotic Disorder. Section N showed 7 days of antipsychotic medications given. Record review of Resident 13's Order Summary Report, dated 02/28/24, revealed an order for Abilify 10- at bedtime for psychosis. Record review of Resident #13's care plan, dated as revised on 12/04/23, failed to address Resident #13's diagnosis of altered mental status and failed to address the antipsychotic medication (Abilify) in the comprehensive care plan. In an interview and record review, on 02/28/24 at 2:24 PM, the Regional Nurse Consultant and the Regional MDS Consultant reviewed Resident #13's care plan. They said there was not a care plan that addressed Resident 13's diagnosis of altered mental status and psychotic medication as ordered. In a follow-up interview, on 02/29/24 at 11:56 AM, The Regional Nurse Consultant said the Social Worker was responsible for care plans and she was only at the facility two days a week. She said Resident #13 should have had a care plan addressing the diagnosis of altered mental status and psychotic medication the resident was receiving, it was missed. She said a potential negative outcome would be the resident might not receive the services or care they need. Record review of the facility policy Comprehensive Care Plans, dated 02/10/21, revealed the following [in part]: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 2 Residents (Resident #20) reviewed for respiratory care. The facility failed to ensure Resident #20's nasal cannula and nebulizer were kept in a bag while not in use . These failures could place residents at risk for infections and transmission of communicable diseases. Findings included: Record review of Resident # 20's Face Sheet dated 02/29/2024 revealed an [AGE] year-old male, who was admitted to the facility on [DATE]. Diagnosis included pain, Hypertension (high blood pressure), Muscle wasting, Shortness of breath, Depression, Anxiety, chronic obstructive pulmonary disease (a lung disease that block airflow and make it difficult to breathe). Record review of Resident #20's MDS admission assessment dated [DATE] revealed a BIMS score of 12 (moderate cognitive impairment). Section I: Active diagnosis revealed chronic pulmonary disease. Section O: Respiratory Treatments was marked for Oxygen Therapy. Record review of Resident #20's Physician Orders dated 2/29/2024 revealed an order for Oxygen at 2 liters per minute via nasal cannula continuous to maintain oxygen above 90%. Change oxygen tubing weekly on Sunday. Change out nebulizer tubing weekly on Sunday. Change oxygen water when empty. Record review of Resident #20's admission Care Plan, 01/15/2024, revealed a care plan for Resident #20 has COPD (obstructive pulmonary disease) - Oxygen to keep oxygen saturation above 90%. The Care Plan failed to have an intervention regarding when oxygen tubing needed to be changed. In an observation and interview on 02/26/2024 at 2:00 PM during rounds, Resident #20 was lying in his bed receiving oxygen by ia nasal cannula at 2 liters per minute. His nebulizer was sitting on his nightstand uncovered. He was unable to answer any questions regarding whether his oxygen tubing had been changed. In an observation on 02/28/2024 at 10:07 AM Resident #20 was sitting on side of his bed. His nebulizer was uncovered and hanging over the nightstand in his room with the nebulizer about an inch from the floor. His oxygen tubing was hanging from the straw in his cup. In an interview on 02/28/2024 at 10:25 AM with the DON stated oxygen tubing was changed weekly based on the resident's orders, or as needed if they become contaminated or occluded. The DON stated oxygen tubing and the humidifier bottle should be changed per doctor's orders. If they were not dated, she stated she would discard them and replace them with a new nasal cannula. She stated resident 20's tubing and the nebulizer should have been stored in a plastic bag when not in use to prevent cross contamination and infection. In an interview on 02/28/2024 at 10:40 AM with the Administrator stated, the resident care is handled by the nursing department. Record review of the facility policy Respiratory Therapy -Prevention of Infection, dated 2001 revised November 2011, revealed the following [in part]: Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Procedure: Product: Oxygen delivery devices (no-aerosol producing) Ex: venturi masks, nasal cannulas, oxygen supply tubing. Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 7. Store the circuit in plastic bag between uses. 9. Discard the administration set-up every seven (7) days as needed.

Based on interview, observation and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 2 residents (Resident #22) reviewed for accuracy of medical records. The facility failed to ensure Resident #22 medical record was complete and included physician orders for oxygen. This failure could place residents at risk of receiving inadequate care and services. Findings included: Record review of Resident #22's face sheet, dated 02/28/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnosis of Chronic Obstruction Pulmonary Disease (chronic lung disease characterized by air flow limitation). In an observation and interview on 02/26/24 at 2:28 PM, Resident #22 was receiving oxygen by nasal cannula said that she has been on oxygen since she was admitted to the facility. Record review of Resident #22's Order Summary Report dated 02/28/24 failed to reflect an order for oxygen. In a record review and interview on 02/28/24 at 3:32 PM, the Regional Nurse Consultant reviewed Resident #22's physical orders and said there was no order for oxygen administration. In an interview on 02/29/24 at 10:15 AM, the ADON said the resident came to the facility on oxygen. It was the responsibly of the admitting floor nurse to assure that all physician orders had been entered and are correct. The floor nurse missed it. She said a potential negative outcome would be the resident would not be provided the care they actually needed. Record review of the facility policy Orders Management, Transcribing or Noting and Discontinuing Orders, dated 3/2014, revealed the following [in part]: Guideline: When a physical order is completed, it is necessary to transcribe or note the information received onto the appropriate forms to ensure care provision.

Based on observation, interview and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections. This affected 1 (Resident #27) of 1 resident observed for incontinent care. The facility failed to ensure Resident #27 was provided incontinent care by staff who demonstrated correct infection control procedures on 2/29/2024. This failure could place residents at risk of the spread of infection. Findings included: Record review of Resident #27's Face Sheet dated, 2/29/24, indicated a [AGE] year-old male. He was admitted to the facility initially on 9/25/21 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, and Essential Hypertension. Record review of Resident #27's Admission MDS dated [DATE] indicated a BIMS of 12 or moderate cognitive impairment. Resident #27 required Extensive assist of one to two persons for ADLs and was always incontinent of bowel and bladder. Record review of Resident #27's Care Plan with a revision date of 2/21/24 indicated the following: Incontinent: check Resident #27 every 2 hours and as required for incontinence. Wash, rinse, and dry perineum. During an observation on 2/29/24 at 1:08 pm, CNA A provided incontinent care to Resident #27. The CNA washed her hands and donned gloves prior to starting care. CNA A then placed a trash bag in the resident's trash can, while placing the bag she touched the rim of the trash can and then began incontinent care without removing her gloves and washing her hands that had touched the trash can. CNA A unfastened Resident #27's brief and began incontinent care. CNA A then obtained a clean brief touching the inside of the brief where the brief would be in contact with the resident's perineum. She fastened the brief and assisted with replacing the resident's bed sheets and blanket. CNA A performed the entire incontinent care process on Resident #27 without washing or sanitizing her hands. During an interview with CNA A on 2/29/24 at 1:30 pm, she said that she did not wash or sanitize her hands in between changing gloves while performing incontinent care for Resident #27. She said that was how she usually performed incontinent care. She said gloves should be changed if they become soiled to prevent cross contamination. She was just so nervous with surveyor watching. During an interview with the DON on 2/29/24 at 2:00 pm, she said her expectations were that CNAs wash/sanitize their hands per policy when providing resident care. She further stated, not doing so would cause cross contamination. Record review of the facility's Handwashing/Hand Hygiene policy last revised September 2005 indicated the following: Policy Statement: This facility considers handwashing/hand hygiene as the primary means to prevent the spread of infection. 2. b. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; c. handling items potentially contaminated with blood, body fluids, or secretions . 3. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-90 % ethanol or isopropanol for all the following situations: g. After removing gloves Review of Hand Hygiene in Healthcare Settings from the Centers for Disease Control and Prevention (https://www.cdc.gov/handhygiene/providers/index.html) accessed 3/11/20 indicated the following: When to perform hand hygiene? -Before moving from work on a soiled body site to a clean body site on the same patient. -After touching a patient or the patient's immediate environment. -After contact with blood, body fluids or contaminated surfaces. - Immediately after glove removal. When and how to wear gloves -Wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. - Gloves are not a substitute for hand hygiene. - Perform hand hygiene immediately after removing gloves. Change gloves and perform hand hygiene during patient care, if - moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs.

Based on interview and record review the facility failed to provide both a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (Form CMS-10055) and a Notice of Medicare Non-coverage (Form CMS-10123 general notice) for 2 of 3 residents (Resident #6 and Resident #7) reviewed for Medicare Beneficiary Protection Notification when discharged from Medicare Part A Services with benefit days remaining. The facility failed to ensure Resident #6, and Resident #7 were given a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (Form CMS-10055) in addition to the Notice of Medicare Non-coverage (Form CMS-10123 general notice) when they were discharged from skilled services. These failures could place residents at risk of not being fully informed about services covered by Medicare. The findings included: Record review of Resident #6's Quarterly MDS, dated [DATE], revealed an [AGE] year-old female, admitted to the facility on [DATE]. The resident had a diagnosis of Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior). Review of the SNF Beneficiary Protection Notification Review (Form CMS-20052) completed for Resident #6 revealed the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The last day of Part A service was 08/11/23. The form reflected a SNF ABN, Form CMS-10055, was provided and acknowledged by the beneficiary or the beneficiary representative. The form reflected a NOMNC, Form CMS-10123) was provided and acknowledged by the beneficiary or the beneficiary's representative. Record review of the NOMNC form (Form CMS-10123) revealed notification was made to Resident #6 on 08/09/23. A SNF ABN form (Form CMS-10055) was not completed as the facility used the Advance Beneficiary Notice of Noncoverage (Form CMS-R-131) instead. Record review of Resident #7's Quarterly MDS, dated [DATE], revealed a [AGE] year-old male, admitted to the facility on [DATE]. The resident had a diagnosis of dementia (A group of symptoms that affects memory, thinking and interferes with daily life). Review of the SNF Beneficiary Protection Notification Review (Form CMS-20052) completed for Resident #7 revealed the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The last day of Part A service was 09/09/23. The form reflected a SNF ABN, Form CMS-10055, was provided and acknowledged by the beneficiary or the beneficiary representative. The form reflected a NOMNC, Form CMS-10123) was provided and acknowledged by the beneficiary or the beneficiary's representative. Record review of the NOMNC form (Form CMS-10123) revealed notification was made to Resident #7 on 09/07/23. A SNF ABN form (Form CMS-10055) was not completed as the facility used the Advance Beneficiary Notice of Noncoverage (Form CMS-R-131) instead. In an interview on 02/29/24 at 11:03 AM, the BOM and MDS Regional Consultant both stated they have been giving the resident's the wrong form. They stated the facility was giving the residents Form CMS-R-131 instead of the correct Form CMS-10055. Record review of the facility policy Resident Rights Under Federal Law, in the Admission Agreement, not dated revealed the following [in part]: The Resident has the right to be fully informed in advanced about care and treatment and any changes in that care or treatment that may affect the Resident's well-being.

Based on observation, interview and record review, the facility failed to provide the required minimum of 80 square feet of room space per resident in 1 of 40 double occupancy resident rooms by failing to provide a minimum of 160 square feet in resident room # 13. This deficient practice could place residents who may occupy double occupancy resident rooms at risk of not having the personal living space to meet their needs. The findings included: In an interview on 02/26/2024 at 11:30 AM, during entrance conference, the administrator stated the facility had a room size waiver for resident room [ROOM NUMBER] and wished to continue the waiver. In an observation on 02/26/2024 at 11:45 AM, room [ROOM NUMBER] was measured at 156 square feet and did not meet the required minimum of 160 square feet for a double occupancy resident room. Review of the facility's Bed Classifications Form 3762, signed and dated 02/29/2024 by the facility's administrator, documented resident room [ROOM NUMBER] was licensed and certified as a double occupancy resident room.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary drugs for 1 of 1 residents (Resident # 1) whose medications were reviewed for unnecessary meds. Resident #1 (a male) received a female hormone replacement drug (Provera) for a diagnosis of inappropriate sexual behavior without documented clinical rationale for the benefit or adequate monitoring of behaviors. This failure could place residents at risk of undesirable side effects and cause a physical or psychosocial decline in health. Findings include: Record review of Resident #1's Annual MDS, dated [DATE], indicated a [AGE] year-old male, who was initially admitted to the facility on [DATE] with diagnoses which included: Dementia, personal history of malignant neoplasm of the prostate (a cancer in a man's prostate, a small walnut-sized gland that produces seminal fluid) psychotic disorder, anxiety, and mood disturbance. Record review of Resident #1s Annual MDS dated [DATE], revealed Resident #1 was able to make himself understood and he had the ability to understand with clear comprehension. Section C revealed Resident #23 had a BIMS score of 3, which indicated he had severe cognitive impairment. Section G revealed Resident #23 required extensive assistance and 1-person physical assist with activities of daily living except for transfer, and dressing, and personal hygiene which required extensive assistance of 2. Resident #1 required the use of a wheelchair for a mobility device. Section N revealed Resident #1 took an antidepressant daily in the last 7 days Section Q indicated Resident #1 participated in the assessment. Record review of Resident #1's care plan revealed the following problem: Behavioral: The resident has a history of pleasuring himself and will be allowed to maintain dignity. Date Initiated: 09/01/2023. Interventions included: The resident's dignity will be maintained and respected while he is pleasuring himself. The curtain will be pulled to ensure privacy. Close resident's door if able. The resident will be allowed to pleasure himself in his room with the curtain pulled. Ensure he is taken to his room in order to provide privacy and not disturb other residents. Record review of Resident #1's Physician order report dated 11/01/2023, revealed the following orders: Start Date 10/14/2023 End Date Ongoing, for Provera (medroxyprogesterone acetate) 10 mg; amt: 1 tablet by mouth one time a day every day for inappropriate sexual behavior, ordered and electronically signed by [Physician A]. Record review of Resident #1s clinical record revealed there was No behavior monitoring nor side effect monitoring logs were found. Review of Resident #1s MAR sheets revealed The Provera was documented as administered on the medication administration sheet from 10/14/23 to 11/03/23. Record review of a consent witnessed by the DON and the ADON on revealed the consent did not inform the family of side effects of the Provera. Review of information from the Federal Drug Administration (FDA revealed the following in part: Provera is a progesterone derivative used to treat abnormal uterine bleeding, prevent pregnancy, paraphilia (a condition typically involving extreme or dangerous sexual activities) .The recommended dose is 5-10 mg daily. It lowers testosterone levels and sexual drive. It has been used in younger patients including pedophiles and individuals with mental illness and sexually inappropriate behaviors. Record review of a progress note written by the DON on 10/09/23 at 12:45 PM revealed the Resident was informed of an order for conjugated estrogen by Physician A on 10/09/2023 which documented the family was notified of the new order and told the resident would have to be discharged if the hormone did not eradicate Resident 31's sexually in appropriate behaviors. An interview on 11/02/2023 at 11:30 AM, with Resident #1's family member revealed she had consented to the Provera for her relative because she was afraid, he was going to be forced to move from the facility if he continued to have inappropriate sexual behaviors with staff and other residents. She stated he needed to stay at the facility because it was close, and his family could visit him. She stated she felt as if it was taking the medication or get kicked out of the facility. She stated she had not been informed of the side effects of Provera by the facility. An interview with Resident #1 on 11/03/2023 at 3:00 PM revealed he had no recollection of sexually inappropriate behaviors with staff or other residents. In an interview on 11/03/2023 at 1:30 PM, the DON said they had received a verbal consent for Provera from Resident #1's Family Member. She said that was who they received all the consents for Resident #1 from. She said they did not get consents for any type of treatments, medications, or care planning from Resident #213, they only received consents from Family Member. She stated there was no documentation for side effect monitoring believed she did not have to even get a consent for this type of medication. In an interview on 1103/32/20232 at 10:00 AM, the DON said they had not tried any non-pharmacological interventions for Resident #1 other than one on one after the incidents. The DON said the intended action of Provera to male residents was it would lower the testosterone levels which would lower their sex drive. In an interview on 1103/0325/20231 at 4:24 PM, Physician A said he treated Resident #1 for health conditions and behaviors, which included sexual behaviors. He said he was aware of orders given by Resident #1's Neurologist for the Provera and it was not intended for long term use. He stated eventually the residents dementia would progress, and the Provera would not be needed as he became less mobile. Record review of the facility's policy that was provided on unnecessary meds was titled, Psychotropic Meds, documented [in-part]: Each resident's drug regimen must be free from unnecessary drugs. Each residents drug regimen will be monitored for dosage, duration of use, indications for use, and presence of adverse effects. Each resident will receive the lowest dose for the shortest period of time to improve the target symptoms being monitored.

Based on interviews and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 3 (Resident #22,#24 and #30) who require glucometer checks for abnormal blood sugar on back hall (Zone 5). The glucometer used for checking resident blood sugars was not calibrated on 01/04/2023 and 01/05/2023 as recorded in the glucometer logbook. This failure could put residents at risk of inaccurate blood sugar levels potentially causing adverse reactions. The findings were: Review of facility glucometer log on 01/10/2023 at 12:05 AM revealed 2 days (01/04/2023 and 01/05/2023) calibration was not completed. During an interview on 01/11/2023 at 12:20 AM LVN A said she did not know why no one else calibrated the glucometer on 01/04/2023 or on 01/05/2023. She was not there on those days so apparently no one did the calibrations. She said she is aware the calibration for the glucometer needs to be accurate to ensure resident blood sugars are accurate. During observation on 01/12/2023 at 12:20 AM LVN A calibrated Assure(R) Platinum glucometer correctly calibrating the glucometer correctly. During an interview on 01/12/2023 at 10:35 AM the Corporate Regional Nurse said it is important to do the calibrations for glucometers but the need for calibration depends on the brand of the glucometer. She said some glucometers only require weekly calibration but depends on the brand of the glucometer and the manufacture recommendations. Her expectations were calibrations need to be done if it is recommended by the manufacture. Facility policy and procedure dated 03/28/2018 titled, Glucometer Use and Maintenance Fundamental Information Follow manufacture's instruction for calibration of glucometers. Review of the website https:// cdn.Boundtree.com on 01/12/2023 revealed the following: Assure(R) Platinum glucometer recommends: Your sensor needs to be calibrated at least 2 times a day (every 12 hours) or when you get a Calibrate now alert. Calibrating your sensor 2 or 3 times a day is a best practice and may help with sensor accuracy.

Based on observations, interviews, record review, and review of the facility's infection control policies, the facility failed to ensure that two of two newly admitted and unvaccinated residents (Resident (R) 9 and R10) out of 41 facility residents were placed on quarantine with transmission-based precautions. An Immediate Jeopardy (IJ) was identified on 8/30/21 at 9:27 PM. While the IJ was removed on 9/1/21, the facility remained out of compliance at a severity level of potential for harm that is not immediate jeopardy and a scope of widespread because the facility continued to train staff and monitor the effectiveness of the Plan of Removal. This failure had the potential to increase the risk of spread of COVID-19 among all 41 facility residents, putting all facility residents at risk of serious illness or death. Findings include: Review of R9's undated Face Sheet, found in the electronic medical record (EMR) under the Face Sheet tab, revealed R9 was admitted to the facility from a local hospital on 08/28/21 with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R9's EMR revealed no documentation of R9's COVID-19 vaccination status. During an interview on 08/30/21 at 6:05 PM, the Administrator provided a copy of a negative COVID-19 test for R9 that was completed on 08/28/21. Review of R10's undated Face Sheet revealed R10 was admitted to the facility from home on 08/26/21 with no diagnoses listed. Review of R10's EMR revealed no documentation of R10's COVID-19 vaccination status. During an interview on 08/30/21 at 6:05 PM, the Administrator provided a copy of a negative COVID-19 test for R10 that was completed at the facility on 08/26/21. During an interview on 08/30/21 at 3:35 PM with the Director of Nursing (DON), confirmed that R9 and R10 were newly admitted and had not received COVID-19 vaccinations. During an observation on 08/30/21 at 2:55 PM on the quarantine unit, there was no personal PPE available (gloves, face shield/goggles, or gowns) at or near R9's or R10's rooms. Also, there was no signage regarding what PPE to wear to enter the residents' rooms = or to alert the staff the residents were quarantined on transmission-based precautions. At this time, Social Services worker (SS) 1 entered R9's room with only a KN95 mask on: she did not don gown, gloves, or eye protection before entering. SS1 sat by the R9 on the bed, met with R9, and then left the room. On 08/30/21 at 3:00 PM, after SS1 left the room, the surveyor asked R9 if she had taken the COVID-19 vaccine and R9 clearly stated, No, but I am thinking about getting it. During an interview on 08/30/21 at 3:35 PM with the DON, stated when a resident was a new admission and was not vaccinated, they were admitted to the quarantine hall and staff was required to wear full PPE (mask, face shield/goggles, gown, and gloves) to enter the resident's room. The DON said there should be signage on the resident's door reviewing what PPE needed to be worn to enter the resident's room. The DON confirmed there was no signage on R9's and R10's room doors and no PPE available outside of the rooms. The DON said R9 and R10 tested negative for COVID-19 prior to admission. The DON also confirmed that R9 and R10 were not vaccinated against COVID-19. The DON confirmed the residents should have been on transmission-based precautions. The DON stated PPE should have been available near each resident's room and worn any time staff entered the rooms. During an interview on 08/30/21 at 5:10 PM with the Medical Director, she stated if a resident was admitted to the facility and was not vaccinated, the resident should be admitted to the quarantine unit for a 10 to 13 day stay, and staff was required to wear full PPE (mask, face shield, gown, and gloves) when going into those resident's rooms. During an interview on 08/30/21 at 6:40 PM with SS1, she stated R9 reported she had been vaccinated, so SS1 did not think she needed to wear additional PPE, other than a mask, to meet with R9. SS1 stated PPE was usually out by the resident's door when they were on quarantine, and there was no PPE available outside of R9's room, so she was not aware the resident was quarantined, and full PPE was required. During an interview on 08/30/21 at 9:00 PM with the Administrator, she stated R9 was admitted to the facility from the hospital. The Administrator said when she was talking with the hospital prior to admission regarding R9, she was informed R9 had recently tested negative for COVID-19 and had not received the COVID-19 vaccine, therefore R9 was admitted to the facility's quarantine unit. The Administrator stated R10 was admitted to the facility from home. The Administrator revealed she spoke to R10's son prior to R10's admission, and he stated R10 had not received a COVID-19 test, had no symptoms of COVID-19, and had not received a COVID-19 vaccination. The Administrator explained on the day of R10's admission, the DON met R10 and her son in the facility parking lot, administered a rapid COVID-19 test to R10, and after 15 minutes the test result read as negative, so R10 was admitted to the facility's quarantine unit. A review of the facility's policy, Surveillance Plan: Infection Control COVID-19 Response, dated 05/02/21, revealed, Unknown COVID-19 status - A person who is an unvaccinated new admission . will be immediately placed in Droplet/Contact Isolation Precautions [gown, gloves, eye protection, and N95 mask] and placed in a private room or cohorted with the door closed in the designated area . signage on the isolation precaution door use of specific PPE sequencing (for staff) and posted in appropriate locations in the facility e.g., outside of a resident's room. Review of the 03/29/21 CDC guidelines titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 [COVID-19] Spread in Nursing Homes, accessed on 08/24/21 at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, revealed, In general, all unvaccinated residents who are new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission . HCP [Health Care Professionals] caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). The Administrator was notified on 8/30/21 at 9:27 PM that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 9/1/21 at 12:00 PM.: Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address: DON immediately identified 2 residents who were in quarantine. Appropriate signage was placed on both resident's doors, and PPE was provided outside of both resident's rooms. DON on 8/30/2021 completed testing on all other residents in the facility to ensure no other residents tested positive and required Isolation. All other residents tested negative for COVID 19. Facility Medical Director was notified of the incident. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. In-Service education with Post-Test was started 8/31/2021 by DON/Designee on Isolation Precaution (type and PPE recommendations) for all department managers and license nurses which includes post-test to validate knowledge of staff of when and type of Isolation a resident required. 57% of Department managers and license nurses have completed this education. No department manager or license nurse will be allowed to work until this education has been completed. In-Service education on Admission check list was started on 8/31/2021 by DON/Designee with all department managers and license nurses to use to ensure room preparation for all new or readmissions requiring Isolation precautions. 57% of Department managers and license nurses have completed this education. No department manager or license nurse will be allowed to work until this education has been completed. In-Service education on Location/Storage of PPE/Isolation equipment in preparation for Admission of resident requiring Isolation was started on 8/31/2021 by DON/Designee to all licensed nurses and department managers. 57% of Department managers and license nurses have completed this education. No department manager or license nurse will be allowed to work until this education has been completed. Starting 8/31/2021 any new hire will receive the In-Service education on Isolation Precautions, (type and PPE recommendation,) Admission check list, and Location/Storage of PPE/Isolation equipment, DON designated night shift back hall nurse to be responsible daily to re-stock all PPE for each resident that is in Isolation beginning 8/31/2021 How the corrective action(s) will be monitored to ensure the practice will not recur: The DON/designee will use the Isolation Precaution QAPI monitoring to validate residents are in appropriate Isolation as applicable, that appropriate signage is on resident door(s), and that adequate supply of PPE is available at or near a resident(s) room that is in Isolation. Daily x2 weeks, 3 x week for 4 weeks, 2 x week for 2 weeks, and monthly x 2 months The DON/designee will complete Donning/Doffing PPE competency skill validation on staff (rotating shifts) began 8/31/2021 Three staff weekly for four weeks then; Two staff weekly for two weeks then; Two staff a month for two months. A Regional consultant will visit the facility weekly to provide general oversight and monitoring of the Plan of Removal. Administrator/Designee and DON/Designee to validate daily on rounds that all Infection Control Processes (including Isolation, signage, availability of PPE) are in place to sustain compliance If any issues are identified, re-education will be started immediately to maintain compliance Quality Assessment and Performance Improvement A QAPI meeting will be conducted by Administrator on August 31, 2021 to review Plan of removal. A QAPI meeting will be conducted monthly to validate that the facility's Infection Control System is in place. Dated 8/31/21 The survey team validated the POR through observations, interviews, and record review. Removed on 09/01/21 at 12:00 PM following the facility's implementation of the plan of removal. The Administrator was notified the IJ was removed on 9/1/21 at 12:00 PM. However, the facility remained out of compliance at a severity of level of potential for harm that is not immediate jeopardy and a scope of widespread due to the facility needing more time to monitor the plan of correction effectiveness.

Based on observation, interview and record review, the facility failed to ensure nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through the resident assessments, and described in the plan of care, for 1 of 4 sampled residents (ID #2), who required extensive assistance with 2 persons physically assisting with transfers, by failing to ensure: A. 2 staff assisted Resident ID #2 with transferring according to his assessed need, which resulted in Resident ID #2 falling and sustaining an avoidable right shoulder fracture; B. staff utilized a gait belt while assisting Resident ID #2 with transferring, C. staff followed facility policy and procedure for safe transfers. This facility failure could affect any of the current 17 residents who required 2 person physical assistance with transfers, by placing them at risk for avoidable injury. The findings included: Review of the Record of Admission (face sheet) for Resident ID #2 revealed he was [AGE] years old and had been initially admitted to the facility on [DATE]. Review of the monthly Physicians Orders, dated August 2010, revealed Resident ID #2's [DIAGNOSES REDACTED]. Review of the Occupational Therapy Plan of treatment for [REDACTED]. The resident was documented as being very weak, confused, and incontinent, and as needing Occupational Therapy to regain his ability to perform ADLs. Review of the nurse's notes, dated 8/25/10 at 2:00 PM, revealed documentation CNA "A" was transferring Resident ID #2, lost her balance, tripped, and both she and the resident fell to the floor. Resident ID #2 sustained a 3 cm X 3 cm skin tear on his right elbow area. The skin tear was cleansed, treated with TAO, and a dressing applied. The resident was transferred to bed with 2 staff members assisting him. The resident did not assist the staff with transferring him to the bed. The resident's physician and responsible family member were notified. The nurse's notes, dated 8/26/10 at 9 AM, documented Resident ID #2 had complained of right shoulder pain and he refused to move his arm. The physician was notified via telephone and an order was received to transfer the resident to the hospital ER for an x-ray, evaluation, and treatment. The resident's family was notified. Resident ID #2 was transferred to the ER in the facility's van. Review of the Radiology Report, dated 8/26/10 at 3:45 PM, revealed 2 views of Resident ID #2's right shoulder showed a comminuted fracture (pulverized/crushed) of the humeral head on the right. The nurse's notes, dated 8/26/10 at 5 PM, documented a new order was received from the physician for an immobilizer to be applied to Resident ID #2's right shoulder for 2 weeks, and to apply when available. The resident's family was notified. Review of the facility's Provider Investigation Report, dated 8/26/10, revealed documentation on 8/25/10 at 2 PM, CNA "A" was transferring Resident ID #2 from a shower chair to the resident's bed. The report documented the resident frequently supported his own weight during transfers, but was designated as needing 2 person assistance for transfers. The report documented CNA "A" stated she was unable to find an available CNA to assist her, and she attempted to transfer Resident ID #2 by herself. The report documented CNA "A" tripped and lost her balance, and she and Resident ID #2 both fell to the floor. Resident ID #2 sustained a skin tear on his right elbow. He made no further complaints until the next morning, on 8/26/10 at 9:00 AM, when he began to complain of right shoulder pain. The resident was taken to the emergency room for an x-ray. The investigation report documented the x-ray report from the radiologist, received 8/26/10 at 5:00 PM, indicated the resident's right shoulder was fractured. An immobilizer was applied to the resident's right shoulder on 8/26/10 at 6:30 PM. In an interview on 9/13/10 at 9:20 AM, the facility Administrator stated CNA "A" had stated she couldn't find her partner, and had transferred Resident ID #2 alone, rather than wait or ask the LVN for assistance. In the same interview, the ADON stated Resident ID #2 was cognitively impaired and had been assessed as requiring 2 people to safely transfer. Review of the Nurse Aide's Information Sheet, kept at the nurses station in the Cardex book, revealed documentation Resident ID #2 was to be transferred by 2 persons as of 3/28/10. Review of the MDS assessment, dated 6/23/10, revealed Resident ID #2 was assessed as having long and short term memory problems and moderately impaired decision making skills, requiring extensive assistance with 2 or more persons physically assisting with transfers, and having partial loss range of motion in both legs, wheelchair mobility, an unsteady gait, and impaired standing balance with physical help required to attempt standing. The MDS documented a height of 66 inches and a weight of 176 pounds. Review of the CNA ADL Flowsheet, dated August 2010, revealed the resident required 1:1 transfer assistance, with an origination date of 6/26/06. The ADL Flowsheet had not been updated to be consistent with the MDS assessment and Nurse Aide's Information Sheet as of 3/28/10. In an interview on 9/13/10 at 10:25 AM, CNA "A" stated she had been employed in the facility "off and on" since 1994, and had most recently been employed in the facility for the past 2 years. She stated on 8/25/10, CNA "B" had assisted her with transferring Resident ID #2 from his w/c into the shower chair in the shower room, located on the back hall. CNA "A" stated she had dressed the resident in the shower room and assisted him to his room in the shower chair. CNA "A" stated she did not see any other CNAs in the hallway and did not see the nurse at the nurses station desk. CNA "A" stated she did not activate the call light in the shower room, nor the call light in the resident's room, to request assistance from other nursing staff. CNA "A" stated she transferred Resident ID #2 alone, and did not use a gait belt. She stated she was not the only CNA who transferred the resident alone, and half the time the CNAs did not use gait belts. Review of the Nursing Services Procedure Manual dated 4/12/!0 revealed the policy for "Gait Belt Policy" documented (in part)": Policy: "It is the policy that all facility certified nursing assistants are to wear and use a gait belt during resident transfers. In-services will be provided periodically on the proper use of gait belts....Gait belts will be kept on your person or in a readily accessible area. Gait belts will be kept clean and laundered in accordance with the infection control policy." In an interview on 9/13/10 at 10:55 AM, the ADON stated the CNAs had care plans on a Cardex located at the nurses station. She stated Resident ID #2 had returned from the hospital during March 2010 and had shown a decline in his condition. She stated the CNAs were told that 2 staff were needed to transfer him. She stated the Cardex with the CNA care plan was updated and the CNAs knew to have 2 people assist the resident. In an interview on 9/13/10 at 11:10 AM, CNA "B" stated she had been employed in the facility since November 2009. She stated on 8/25/10 she had assisted CNA "A" with transferring Resident ID #2 from his w/c into the shower chair while in the shower room, located on the back hall near the resident's room. CNA "B" stated she then went on her break. She stated CNA "A" was supposed to turn on the shower room call light when finished with helping Resident ID #2 with his shower, and 1 of the other CNAs on duty would help transfer the resident into his w/c. CNA "B" stated all the aides (CNAs) were guilty of transferring the resident without assistance. During the interview on 9/13/10 at 11:10 AM, CNA "B" stated the CNA care plan book was at the nurses station, and she looked at it every day. Observation on 9/13/10 at 11:20 AM, accompanied by CNA "B", revealed the CNA care plan book she looked at daily was the ADL Flowsheet book, which the CNAs initialed every shift for the care they provided to individual residents. CNA "B" did not know where to find the Cardex care plan book, which was located on a shelf behind the desk at the back hall nurses station. In an interview on 9/13/10 at 11:30 AM, the ADON was notified that Resident ID #2's ADL Flowsheet dated September 2010 documented 1:1 assist for transfers, and had not been updated to be consistent with the Nurse Aide Information Sheet in the Cardex care plan book, which documented the resident was to have 2 persons assist him with transfers as of 3/28/10. The ADON stated the CNA ADL Flowsheets needed to be looked at and updated. In an interview on 9/13/10 at 1:25 PM, the ADON stated the facility's transfer policy included the use of gait belts during transfer assistance of residents. The ADON stated the staff (CNAs) had been assigned gait belts and signed receipt of being given gait belts. The ADON stated she had been keeping a log, but had not kept up with it. She stated the gait belts had been given to the CNAs. Review of the Gait Belt Assignment Log revealed CNA "A" had signed receipt of being given a gait belt on 6/09/09. Comparison of the log to the current CNA employee list revealed 10 of 20 CNAs currently employed had not signed receipt of being given a gait belt. In an interview on 9/13/10 at 1:30 PM, CNA "F" stated she had been employed in the facility for 9 years. She stated she had been given a gait belt 2 times. She stated the CNAs did not use gait belts, and she had not seen anyone use a gait belt so far that day. In an interview on 9/13/10 at 1:45 PM, LVN "C" stated she had been on duty on 8/25/10 and had assisted with assessing Resident ID #2 after he had fallen during the transfer with CNA "A". LVN "C" stated she had helped transfer Resident ID #2 with the CNAs (during the past). She stated CNA "A" had not used a gait belt, had not activated the call light, and had not requested assistance from her that day to transfer the resident. LVN "C" stated she would have answered the call light and assisted CNA "A" if she had asked. In an interview on 9/13/10 at 2:05 PM, LVN "E" stated she had been on duty on 8/25/10 when Resident ID #2's incident occurred. She stated CNA "A" knew to use a gait belt and to ask for help to transfer Resident ID #2. In an interview on 9/13/10 at 2:55 PM, CNA "G" stated she carried a gait belt in her pocket, but did not use it on "skinny residents", as "it hurts them". She stated when she worked with the other CNAS, CNA "A" did not use a gait belt, and CNA "B" and CNA "H" used gait belts, but not all the time. In an interview on 9/13/10 at 3:45 PM, LVN "I" stated the CNAs did not use gait belts all of the time, and they should. She stated the CNAs should ask the LVNs for help when needed. In an interview on 9/14/10 at 10:46 AM, the ADON stated the facility did not have an annual nurse aide proficiency evaluation. She stated training had been started for proficiency evaluation of individual tasks for the CNAs. The ADON stated the Occupational Therapist had done transfer training with the CNAs a few months ago, including use of gait belts and the hoyer lift, with return evaluation. The ADON stated the Occupational Therapist had "checked off" on all the CNAs trained. In an interview on 9/14/10 at 12:05 PM, the facility's DON stated CNA "A" had attempted an unsafe transfer with Resident ID #2, which had resulted in the incident of injury (on 8/25/10). The DON stated CNA "A" had stated she had transferred Resident ID #2 alone during the past. The DON stated CNA "A" did not make a wise choice, and should have had help from another staff member. In an interview on 9/14/10 at 2:55 PM, the Occupational Therapist stated she had given the CNAs inservice training regarding the use of gait belts, transfer assistance, and transfer technique during March 2010, and had provided 3 inservice trainings during the past year. She stated the CNAs did not use gait belts all of the time when assisting the residents. The Occupational Therapist stated she did not have a record of the inservice training provided during March 2010, but did have inservice attendance reports dated 9/29/08 and 10/01/08. Review of the inservice reports provided by the therapist revealed 5 of 6 CNAs who attended the inservice training dated 9/29/08, on correct positioning and the purpose of a gait belt, were currently employed in the facility. Review of the inservice training report dated 10/01/08, regarding gait belt use with residents, revealed 3 of 5 CNAs who attended were currently employed in the facility. Review of the facility's Nursing Services Procedure Manual revealed it was initially reviewed and approved 7/26/06, and most recently reviewed and approved 4/12/10. Review of the Procedure Manual revealed the policy for "Safety (General Guidelines for Resident Safety)" documented (in part): Purpose - "To create a safe environment for the resident." General Instructions - "...7) Support the resident's body well during all positioning, transferring and ambulation. Avoid pulling on the resident's extremities. Provide two or more persons to assist when necessary for resident and staff safety....14) Use assistive devices as necessary." Review of the Procedure Manual revealed the policy for "Transfer Activities" documented (in part): Purpose - "To transfer the resident from bed to chair, toilet or tub safely." Procedure - Transfer From Bed to Wheelchair - "...2) Obtain assistance of another individual if necessary for safe transfer....5)...Put on gait belt and shoes." "NOTE:...Support may be provided by use of a waist belt. Do not support the resident under the arms as this prevents the resident from using his/her unaffected extremity. Do not allow resident to put arms around your neck." The facility's Resident Transfer Status list, dated 8/27/10, documented 17 current residents required 2 person transfer assistance.

I # 7 Based on observation, interview,and record review, the facility failed to ensure adequate supervision and assistance to avoid injury during transfers was provided to 1 of 4 sampled residents (ID #2), who required extensive assistance with 2 persons physically assisting with transfers, by failing to ensure: A. 2 staff assisted Resident ID #2 with transferring according to his assessed need; Resident ID #2 fell and sustained an avoidable right shoulder fracture. B. CNA "A" utilized a gait belt while assisting Resident ID #2 with transferring; C. CNA "A" followed facility policy and procedure for safe transfers. This facility failure could affect any of the current 17 residents who required 2 person physical assistance with transfers, by placing them at risk for avoidable injury. The findings included: Review of the Record of Admission (face sheet) for Resident ID #2 revealed he was [AGE] years old and had been initially admitted to the facility on [DATE]. Review of the monthly Physicians Orders, dated August 2010, revealed Resident ID #2's [DIAGNOSES REDACTED]. Review of the Occupational Therapy Plan of treatment for [REDACTED]. The resident was documented as being very weak, confused, and incontinent, and as needing Occupational Therapy to regain his ability to perform ADLs. Review of the nurse's notes, dated 8/25/10 at 2:00 PM, revealed documentation CNA "A" was transferring Resident ID #2, lost her balance, tripped, and both she and the resident fell to the floor. Resident ID #2 sustained a 3 cm X 3 cm skin tear on his right elbow area. The skin tear was cleansed, treated with TAO, and a dressing applied. The resident was transferred to bed with 2 staff members assisting him. The resident did not assist the staff with transferring him to the bed. The resident's physician and responsible family member were notified. The nurse's notes, dated 8/26/10 at 9 AM, documented Resident ID #2 had complained of right shoulder pain and he refused to move his arm. The physician was notified via telephone and an order was received to transfer the resident to the hospital ER for an x-ray, evaluation, and treatment. The resident's family was notified. Resident ID #2 was transferred to the ER in the facility's van. Review of the Radiology Report, dated 8/26/10 at 3:45 PM, revealed 2 views of Resident ID #2's right shoulder showed a comminuted fracture (pulverized/crushed) of the humeral head on the right. The nurse's notes, dated 8/30/10 at 2:30 PM, documented a new order was received for Resident ID #2 to have a physical therapy evaluation and treatment. The nurse's notes, dated 9/09/10 at 3:45 PM, documented Resident ID #2's right elbow was "red, hot to touch, swollen with clear drainage, no smell, yellow color slough 3 cm". The physician was notified via telephone, and a new order was received for Doxycycline 100 mg by mouth 2 times daily for 10 days for right elbow wound infection. The physician gave an order for [REDACTED]. The resident's family was notified. Review of the facility's Provider Investigation Report, dated 8/26/10, revealed documentation on 8/25/10 at 2 PM, CNA "A" was transferring Resident ID #2 from a shower chair to the resident's bed. The report documented the resident frequently supported his own weight during transfers, but was designated as needing 2 person assistance for transfers. The report documented CNA "A" stated she was unable to find an available CNA to assist her, and she attempted to transfer Resident ID #2 by herself. The report documented CNA "A" tripped and lost her balance, and she and Resident ID #2 both fell to the floor. Resident ID #2 sustained a skin tear on his right elbow. He made no further complaints until the next morning, on 8/26/10 at 9:00 AM, when he began to complain of right shoulder pain. The resident was taken to the emergency room for an x-ray, where the local physician stated the shoulder did not appear to be fractured. The report documented the x-ray report from the radiologist, received 8/26/10 at 5:00 PM, indicated the resident's right shoulder was fractured. An immobilizer was applied to the resident's right shoulder on 8/26/10 at 6:30 PM. In an interview on 9/13/10 at 9:20 AM, the Administrator stated CNA "A" had stated she couldn't find her partner, and had transferred Resident ID #2 alone, rather than wait or ask the LVN for assistance. In the same interview, the ADON stated Resident ID #2 was cognitively impaired and had been assessed as requiring 2 people to safely transfer. Review of the Nurse Aide's Information Sheet, kept at the nurses station in the Cardex book, revealed documentation Resident ID #2 was to be transferred by 2 persons as of 3/28/10. Review of the MDS assessment, dated 6/23/10, revealed Resident ID #2 was assessed as having long and short term memory problems and moderately impaired decision making skills, requiring extensive assistance with 2 or more persons physically assisting with transfers, and having partial loss range of motion in both legs, wheelchair mobility, an unsteady gait, and impaired standing balance with physical help required to attempt standing. The MDS documented a height of 66 inches and a weight of 176 pounds. Review of the CNA ADL Flowsheet, dated August 2010, revealed documentation Resident ID #2 required 1:1 transfer assistance, with an origination date of 6/26/06. The ADL Flowsheet had not been updated to be consistent with the MDS assessment and Nurse Aide's Information Sheet as of 3/28/10. In an interview on 9/13/10 at 10:25 AM, CNA "A" stated she had been employed in the facility "off and on" since 1994, and had most recently been employed in the facility for the past 2 years. She stated on 8/25/10, CNA "B" had assisted her with transferring Resident ID #2 from his w/c into the shower chair in the shower room, located on the back hall. CNA "A" stated she had dressed the resident in the shower room and assisted him to his room in the shower chair. CNA "A" stated she did not see any other CNAs in the hallway and did not see the nurse at the nurses station desk. CNA "A" stated she did not activate the call light in the shower room, nor the call light in the resident's room, to request assistance from other nursing staff. CNA "A" stated she transferred Resident ID #2 alone, and did not use a gait belt. She stated she was not the only CNA who transferred the resident alone, and half the time the CNAs did not use gait belts. CNA "A" stated she transferred Resident ID #2 by facing him and lifting him under his arms. She stated the resident stood up and then she and the resident fell to the floor. She stated she did not move the resident, and went to the room door to the hallway to get help. She stated the 2 LVN charge nurses on duty went to the room and assessed Resident ID #2, determined he was not hurt, and helped him to bed. Review of the Nursing Services Procedure Manual, dated 04/12/10, revealed the policy for "Gait Belt Policy" documented (in part)": Policy: "It is the policy that all facility certified nursing assistants are to wear and use a gait belt during resident transfers. In-services will be provided periodically on the proper use of gait belts....Gait belts will be kept on your person or in a readily accessible area. Gait belts will be kept clean and laundered in accordance with the infection control policy." Observation on 9/13/10 at 10:45 AM, of Resident ID #2, accompanied by CNA "A", revealed the resident was lying on his back in bed, with half side rails raised on both sides at the head of the bed. Resident ID #2 had the immobilizer on his right arm/shoulder, on the outside of his sweat shirt. In an interview on 9/13/10 at 10:45 AM, Resident ID #2 stated his shoulder did not hurt as long as he laid in bed. He stated he was given a pain pill. In an interview on 9/13/10 at 10:55 AM, the ADON stated the CNAs had care plans on a Cardex located at the nurses station. She stated Resident ID #2 had returned from the hospital during March 2010 and had shown a decline in his condition. She stated the CNAs were told that 2 staff were needed to transfer him. She stated the Cardex with the CNA care plan was updated and the CNAs knew to have 2 people assist the resident. During an interview on 9/13/10 at 11:10 AM, CNA "B" stated a CNA care plan book was at the nurses station, and she looked at it every day. Observation on 9/13/10 at 11:20 AM, accompanied by CNA "B", revealed the CNA care plan book she looked at daily was the ADL Flowsheet book, which the CNAs initialed every shift for the care they provided to individual residents. CNA "B" did not know where to find the Cardex care plan book, which was located on a shelf behind the desk at the back hall nurses station. In an interview on 9/13/10 at 11:30 AM, the ADON was notified that Resident ID #2's ADL Flowsheet dated September 2010 documented 1:1 assist for transfers, and had not been updated to be consistent with the Nurse Aide Information Sheet in the Cardex care plan book, which documented the resident was to have 2 persons assist him with transfers as of 3/28/10. The ADON stated the CNA ADL Flowsheets needed to be looked at and updated. In an interview on 9/13/10 at 1:25 PM, the ADON stated the facility's transfer policy included the use of gait belts during transfer assistance of residents. Review of the facility's Nursing Services Procedure Manual revealed it was initially reviewed and approved 7/26/06, and most recently reviewed and approved 4/12/10. Review of the Nursing Services Procedure Manual revealed the policy for "Safety (General Guidelines for Resident Safety)" documented (in part): Purpose - "To create a safe environment for the resident." General Instructions - "...7) Support the resident's body well during all positioning, transferring and ambulation. Avoid pulling on the resident's extremities. Provide two or more persons to assist when necessary for resident and staff safety....14) Use assistive devices as necessary." Review of the Nursing Services Procedure Manual revealed the policy for "Transfer Activities" documented (in part): Purpose - "To transfer the resident from bed to chair, toilet or tub safely." Procedure - Transfer From Bed to Wheelchair - "...2) Obtain assistance of another individual if necessary for safe transfer....5)...Put on gait belt and shoes." "NOTE:...Support may be provided by use of a waist belt. Do not support the resident under the arms as this prevents the resident from using his/her unaffected extremity. Do not allow resident to put arms around your neck." The facility's Resident Transfer Status list, dated 8/27/10, documented 17 current residents required 2 person transfer assistance.