Every finding on record at Shields Nursing Center

Based on interview and record review the facility failed to ensure necessary treatment and care services were provided for one (Resident1) of three sampled residents in accordance with professional standards of practice and care plan when: 1.Facility did not reevaluate Resident 1's routine administered of Acetaminophen (Tylenol) medication twice a day for pain management when Resident 1's pain symptoms had resolved. (Tylenol - medication used to relieve mild to moderate pain and reduce fever). 2. Facility did not carry out diagnostic laboratory tests dated 8/30/24 for Resident 1 as ordered by the physician. 3. Facility did not monitor Resident 1's fluid intake and output record as indicated on care plan. 4. LVN 1 did not notify physician and document failed attempts to obtain STAT UA specimen via straight catheterization for Resident 1. STAT lab order means immediately. It is a medical instruction that indicates that a laboratory test should be performed, and the results should be provided as soon as possible.Straight catheterization is a medical procedure that uses a straight, hollow tube to drain urine from the bladder These failures had the potential to cause delay to receive the necessary care and services, suffer from unnecessary medication and dehydration for Resident 1.1.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 11/30/24, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 01 and indicated severe cognitive impairment. The MDS indicated Resident 1 was not able to recall the correct year, month, and day of the week, had clear speech, and had difficulty communicating some words or finish her thoughts but able if prompted or given time. The MDS indicated Resident 1 needed supervision with eating food and/or liquid to mouth and swallow. The MDS indicated Resident 1 received a scheduled pain medication regimen. The MDS indicated Resident 1 had had no complaint of pain when interviewed. The MDS indicated Resident 1 had diagnoses to include non-Alzheimer's dementia (a progressive disease that destroys memory and other important mental functions) and malnutrition (lack of sufficient nutrients in the body). During a review of Resident 1's Progress Notes, dated 8/13/22, the Progress Notes indicated the physician ordered Resident 1 to receive acetaminophen tablets 325 mg give two tablets by mouth every 6 hours as needed for pain and give two tablets by mouth two times a day for pain management for complain of generalized pain. Further review of the Progress notes indicated Resident 1 had no complaint of pain and discomfort at the time and no change in level of consciousness. During a review of Resident 1's Medication Review Report (MRR), dated 12/3/24, the MRR indicated on 8/13/22 the physician verbally prescribed Resident 1 to receive Acetaminophen tablet 325 mg give two tablets by mouth two times a day for pain management. During a review of Resident 1's Medication Administration Record (MAR), dated July, August, September, October, November, December 2024 and January 2025, the MARs indicated Resident 1 was administered acetaminophen tablet 325 mg two tablets by mouth two times a day for pain management. Further review of Resident 1's MARs dated July, August, September, October, November, December 2024, and January 2025, the MARs indicated Resident 1 was assessed for pain every shift. MARs indicated Resident 1 had no pain. During an interview on 9/29/25 at 2:10 p.m. with Registered Nurse (RN1), RN 1 stated Resident 1 had generalized chronic pain. RN 1 stated reevaluation may not apply to Resident 1's administration of routine Tylenol medication because Resident 1 had chronic pain. RN 1 stated Resident 1 was assessed every shift for pain and had no pain. During a review of Resident 1's Pain/discomfort Care Plan, initiated 5/24/22, the Pain/discomfort Care Plan indicated Resident 1 had risk for pain/discomfort, interventions included medicate for pain and assess for effectiveness. During an interview on 9/29/25 at 3:05 p.m. with Director of Nursing (DON), DON stated licensed nurses are expected to reevaluate Resident 1's need for pain medication and assess for effectiveness. 2. During a review of Resident 1's Physician's Orders (PO), dated 8/30/24, the PO indicated, Resident 1's physician ordered laboratory testing to include CBC, A1C, TSH/T4, Lipid profile and CMP (blood work) During a concurrent interview and record review on 9/29/25 at 3:05 p.m. with Director of Nursing (DON), Resident 1's PO, dated 8/30/24, was reviewed. The PO indicated on 8/30/24, Resident 1's physician ordered laboratory tests for blood work for Resident 1. DON stated the lab test ordered by the physician for Resident 1 was not carried out. 3. During a review of Resident 1's Nutritional Assessment, dated 12/09/24, the Nutritional Assessment indicated Resident 1's nutritional goal was for oral intake to meet adequate hydration and estimated fluid need =1500ml minimum in a day. During a review of Resident 1's Nutritional Fluid Intake documentation, dated 12/1/24 through 12/31/24 and 1/1/25 through 1/16/25, the document indicated Resident 1's fluid intake ranges from 540 mls to 1,050 ml a day, less than estimated fluid needs of 1500ml in a day. During a concurrent interview and record review on 9/29/25 at 3:05 p.m. with DON, Resident 1's Potential for Fluid Deficit Care Plan related to chronic UTI, initiated on 5/27/22, and facility's policy and procedure (P&P) titled, Intake, Measuring and Recording, dated October 2010 were reviewed. The care plan indicated Resident 1 had the potential for fluid deficit related to chronic urinary tract infection (UTI). Care plan interventions included encouraging Resident 1 to drink fluids of choice and monitor and document intake and output as per facility's policy. Resident 1 needs assistance with fluid intake to meet daily requirement, monitor document, and report any signs and symptoms of dehydration; decreased or no urine output. DON stated Resident 1 did not meet the criteria for keeping fluid intake and output record. DON stated fluid intake and output record was not kept for Resident 1. DON could not provide documentation that Resident 1's fluid intake record was tallied every day, and output record was kept as indicated on care plan to ensure Resident 1 had adequate fluid intake. During a review of Resident 1's Progress Notes, dated 1/16/25 at 00:20, the Progress Notes indicated Resident 1 complained of stomach pain and was given two tablets of acetaminophen, but Resident was still complaining of pain and vital signs were stable. Resident 1's daughter arrived and asked staff to get a UA done. An order was received at 7:17 p.m. from Nurse Practitioner for STAT CBC and UA culture. Staff tried to collect the urine but were unsuccessful and endorsed to the next shift nurse. Further review of Resident 1's Progress Notes, dated 1/16/25, indicated Resident 1 had a change of condition reported abdominal pain, shortness of breath, and unresponsive. An order was received to call 911 and send Resident 1 to hospital emergency room. 4.During an interview on 9/29/25 at 3:25 p.m. with LVN 1, LVN 1 stated an order for a STAT lab test for UA and straight catheter to obtain UA specimen was received for Resident 1 a day before Resident 1 was transferred to the hospital. LVN 1 stated she attempted to obtain urine specimen by straight catheterizing Resident 1 twice but there was no urine. LVN1 stated she endorsed the STAT order for UA to the night shift nurse. LVN 1 stated her mistake was that she did not notify physician of failed attempts to obtain UA specimen. LVN 1 stated Resident 1 complained of pain after receiving routine Tylenol. LVN 1 stated she did not informed physician that Resident 1 continued to complain of pain. LVN 1 said she did not document order for straight catheter in Resident 1's records. LVN 1 stated when she returned the next day, Resident 1 had low grade fever and low oxygen saturation. LVN 1 stated she called the doctor and received an order to transfer Resident 1 to the hospital. During a concurrent interview and record review on 9/29/25 at 4:20 p.m. with DON, LVN 1 and Administrator (Admin), Resident 1's Progress Notes, dated 1/10/25 through 1/17/25, and laboratory reports were reviewed. Resident 1's Progress Notes, dated 1/16/25, indicated LVN 1 received an order from the physician the previous day. DON stated she was not aware that Resident 1's STAT lab order for UA was endorsed from shift to shift. DON stated she did not know that Resident 1's STAT lab orders was received a day before Resident 1 was transferred to the hospital. DON stated the progress notes did not reflect the time upon which the physician order for STAT labs was received.During a review of the facility's P&P titled, Lab and Diagnostic Test Results-Clinical Protocol, dated November 2018, the P&P indicated, The staff will process test requisitions and arrange for tests. A nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality, and the individual's current condition. During a review of the facility's P&P titled, Pain-Clinical Protocol, dated October 2022, the P&P indicated, If pain symptoms have resolved or there is no longer an indication for pain medication, the multidisciplinary team and physician shall try to discontinue or taper analgesic medications to the extent possible. During a review of the facility's P&P titled, Intake, Measuring and Recording, dated October 2010, the P&P indicated, The purpose is to accurately determine the amount of liquid a resident consumes in a 24-hour period. Review the resident's care plan to assess for any special needs of the resident. At the end of your shift, total the amounts of all liquids the resident consumed.

Based on interview and record review, the facility failed to ensure one (Resident 1) of three sampled residents' medical records was accurately documented and systematically organized when Licensed Vocational Nurse (LVN1) did not document in Resident 1's medical records, the physician order to obtain STAT laboratory test for urinalysis (UA) and straight catheterization to include the date and time the order was received in accordance with accepted professional standards and practices.This failure had the potential to cause inaccurate documentation and confusion of care and treatment provided for Resident 1. During an interview on 9/29/25 at 3:25 p.m. with LVN 1, LVN 1 stated an order for a STAT lab test for UA, blood work and straight catheter to obtain UA specimen were received for Resident 1 a day before Resident 1 was transferred to the hospital. LVN 1 stated she attempted to obtain urine specimen by straight catheterizing Resident 1 twice but there was no urine. LVN 1 stated she endorsed the STAT order for UA to the night shift nurse. LVN 1 stated her mistake was that she did not notify the physician of failed attempts to obtain UA specimen. LVN 1 stated Resident 1 complained of pain after receiving routine Tylenol. LVN 1 stated she did not inform the physician that attempts to obtain urine specimen failed. LVN 1 stated she did not informed physician that Resident 1 continued to complain of pain. LVN 1 said she did not document order for straight catheter. LVN 1 stated when she returned the next day, Resident 1 had low grade fever and low oxygen saturation. LVN 1 stated she called the doctor and received an order to transfer Resident 1 to hospital. During a concurrent interview and record review on 9/29/25 at 4:20 p.m. with DON, LVN 1 and Administrator (Admin), Resident 1's Progress Notes, dated 1/10/25 through 1/17/25 and laboratory reports dated 1/16/25, were reviewed. Lab report for STAT UA specimen was received 1/16/25 at 10:15 a.m. Resident 1 Progress Notes, dated 1/16/25 at 00:20 indicated that LVN1 received orders from the physician the previous day. DON stated she was not aware that Resident 1's STAT lab order for UA was endorsed from shift to shift. DON stated she did not know that Resident 1's STAT lab orders was received a day before Resident 1 was transferred to the hospital. DON stated the progress notes did not reflect the time upon which physician order for STAT labs was received.

Based on interview and record review, the facility failed to implement its policy and procedure for reporting an outbreak of communicable disease (COVID-19) when; Administrator (Admin) did not report to the health department two cases among residents positive for COVID-19. This failure had the potential for spread of COVID-19 virus among residents and place residents at risk for infections.During an interview on 8/13/25 at 11:05 a.m. with Director of Nursing (DON), DON stated facility had two residents that was positive for COVID-19. DON stated these cases happened in July 2025. DON stated Resident 1 was transferred to the hospital for shortness of breath and tested positive for COVID-19.During a review of Resident 1's hospital notes, dated 7/30/25, indicated Resident 1 presents to the emergency department (ED) after an episode of hypoxia and decrease responsiveness. Resident 1 was found to be positive for COVID-19.During a review of Resident 2's Laboratory test result, dated 7/21/25, test result indicated Resident 2 was positive for COVID-19.During an interview on 8/13/25 at 11:40 a.m. with Administrator, Admin stated two residents tested positive for COVID-19 in July 2025. During an interview on 9/29/25 at 10:35 a.m. with Licensed Vocational Nurse/Infection Preventionist (IP), IP stated two residents were positive for COVID-19. IP stated facility did not report these cases to the local or state health department. IP stated facility received further instructions from the county public health nurse to report all or any resident's positive for COVID-19 to the health department. During a review of the facility's policy and procedure (P&P) titled, Outbreak of Communicable Diseases, dated September 2022, the P&P indicated, An outbreak is defined as one of the followings: a. One case of an infection that is highly communicable or has serious health implication. The Administrator is responsible for communicating data about reportable diseases to the health department.

Based on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: 1. Two expired containers of sour cream were stored in the kitchen refrigerator. 2. One opened plastic bag of soggy salad was stored in the kitchen refrigerator. 3. Storage used for kitchen utensils was not clean. These failures put the facility at increased risk for food contamination and food borne illness for 33 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview during the initial kitchen tour on 6/2/25, at 9:14 a.m., with the Dietary Supervisor (DS), two expired containers of sour cream were in the kitchen refrigerator. One of the two containers was opened and was almost empty. DS stated the expired sour cream should have been disposed and further stated that the risk for the residents consuming the expired sour cream was stomach upset. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage of Cold Foods, dated 2023, indicated, All the perishable food items purchased by the department of food and dining services will be stored properly. Perishable food will be kept refrigerated or frozen . All open food items will have an open date and use-by-date per manufacturer's guidelines . 2. During a concurrent observation and interview during the initial kitchen tour on 6/2/25, at 9:18 a.m., with the DS, one opened plastic bag of soggy salad was in the refrigerator. DS stated the bag of salad should have been thrown away. DS stated risk for the residents eating the soggy salad was stomach upset. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage of Cold Foods, dated 2023, indicated, All the perishable food items purchased by the department of food and dining services will be stored properly. Perishable food will be kept refrigerated or frozen . All open food items will have an open date and use-by-date per manufacturer's guidelines . 3. During a concurrent observation and interview during the initial kitchen tour on 6/2/25, at 9:25 a.m., with the DS, the utensil holder which stored kitchen utensils used for cooking had brownish stains all over and scattered brownish particles. DS acknowledged that the utensil holder was dirty and that the risk of storing the kitchen utensils in the holder was cross contamination. During a review of the facility's P&P titled, Sanitizing Equipment, Food and Utility Carts, dated 2023, indicated, .All kitchen equipment and surfaces which come in contact with food will be cleaned and sanitized after each use . According to the 2022 Federal Food Code, food-contact surfaces are to be clean to sight and touch, the food-contact surfaces of cooking equipment and pans are to be kept free of encrusted grease deposits and other soil accumulations, and nonfood-contact surfaces of equipment is to be kept free of an accumulation of food residue and other debris.

Based on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation that advanced directives (written statement of a person's wishes regarding the medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), were discussed with the residents and/or responsible parties for four out of 15 final sampled residents (Residents 7, 10, 20 and 21). This had potential for the facility to provide treatment and services against the residents' wishes. Findings: 1. During a review of Resident 7's admission Record, dated 6/4/25, indicated, Resident 7 was admitted to the facility on [DATE] with diagnoses that included chronic pulmonary embolism (a lung disease that can cause heart failure). During a review of Resident 7's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 5/28/25 under Section C, indicated a Brief Interview for Mental Status (BIMS-an assessment tool to used to help evaluate cognition in the elderly) score of 14, meaning Resident 7 was cognitively intact . During a review of Resident 7's Physician Orders for Life-Sustaining Treatment (POLST-a form that gives instructions for the resident's care in life-threatening medical situations), dated 10/1/22, under information and signatures, the POLST indicated the resident did not have an advanced directive. Further review of Resident 7's medical record failed to show a copy of an advanced directive. 2. During a review of Resident 10's admission Record, dated 6/4/25, indicated, Resident 10 was admitted to the facility on [DATE] with diagnoses that included dementia (memory loss and impaired decision-making capacity). Review of Resident 10's MDS, dated [DATE], under Section C, indicated Resident 10's short and long-term memory was impaired, and had severely impaired decision-making capacity. During a review of Resident 10's POLST form, dated 3/6/19, under information and signatures, the POLST showed no information on the presence of an advanced directive. 3. During a review of Resident 20's admission Record, dated 6/4/25, indicated, Resident 20 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease (brain disorder). Review of Resident 20's MDS dated [DATE] under Section C, indicated a BIMS score of 0, meaning Resident 20 had severe cognitive impairment. Review of Resident 20's medical records showed a POLST dated 12/8/20, under information and signatures, indicated the resident did not have an advanced directive. 4. During a review of Resident 21's admission Record, dated 6/4/25, indicated Resident 21 was admitted to the facility on [DATE]. During a review of Resident 21's MDS dated [DATE] under Section C, indicated a BIMS score of 13, meaning Resident 21 was cognitively intact. Review of Resident 21's medical records showed a POLST dated 11/26/21, under information and signatures, indicated the resident did not have an advanced directive. During a concurrent interview and record review on 6/3/25, at 9:08 a.m., with the Social Service Director (SSD), SSD reviewed Residents 7, 10, 20 and 21's medical records and stated there was no documentation that advance directives were discussed and followed up with the residents and their responsible parties. During an interview on 6/3/25, at 3:00 p.m., with the Director of Nursing (DON), the DON stated that the facility residents' advance directives were supposed to be followed up by the Social Services Director (SSD). During a review of the facility's policy and procedure (P&P) titled, Advanced Directives, Revised October 2009, indicated, . Advanced directives will be respected in accordance with state law and facility policy .1. Prior to or upon admission of a resident to our facility, the Social Services Director or Designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives .3. Prior to or upon admission of a resident, the Social Services Director or Designee will inquire of the resident and/or his/her family members about the existence of any written advance directives. 4. Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record .

Based on interview and record review, the facility failed to ensure enough space was provided for a resident council meeting. This failure had the potential to result in lack of residents participation in group meeting and opportunity to discuss problems or concerns with others. Findings: During a resident council meeting on 6/3/25, at 1:34 p.m., in an empty resident room, six residents seated in wheelchairs were in attendance. Resident 6 stated resident council meetings took place sometimes in Resident 6's room or in empty resident rooms. Resident 6 stated facility did not provide enough space and that empty residents' room did not fit residents willing to participate in group meeting. Resident 6 stated she was not comfortable accommodating resident council meeting in her room. During a review of Resident 6's Minimum Data Set (MDS), (Resident Assessment and care guide tool), dated 4/18/25, MDS indicated Resident 6's BIMS score was 15 meaning intact cognition. MDS indicated Resident 6 had clear speech, able to express ideas and wants. MDS indicated Resident 6 was admitted to the facility on [DATE]. During an interview on 6/3/25, at 2:20 p.m., with Activity Director (AD), AD stated residents used empty rooms for council meetings and space was limited. AD stated there was need for more space because more residents willing to participate were not able to attend. AD stated sometimes instead of residents' group meetings AD did one on one meetings with residents in their rooms to review issues and concerns. AD stated more residents would like to attend but there was no space. During an interview on 6/03/25, at 2:23 p.m., with Administrator (Admin), Admin stated there was no specific room assigned for resident council meetings. Admin stated resident group meetings took place in empty resident rooms. Admin stated facility would provide a new location for resident council meetings. During a review of the facility's policy and procedure (P&P) titled, Resident Council, revised February 2021, the P&P indicated,The resident council group is provided with space, privacy and support to conduct meetings.

Based on interview and record review, the facility failed to allow one of 15 sampled resident (Resident 139) to store food brought by family member in the facility's refrigerator. This failure resulted in Resident 139 not being able to store food brought from home to the facility. Findings: During a resident council meeting (resident council meeting is a group meeting of residents living in the facility that meets once a month to discuss concerns, develop suggestions on improving services, or resolve differences) on 6/3/25, at 1:34 p.m., with six residents, Resident 139 stated when her family brought her food, she ate the food immediately and shared it with her care giver because facility had no refrigerator to store food for the residents. Resident 139 stated the facility should have small refrigerator to keep and store food for residents. Resident 139 also stated the facility did not offer a refrigerator. During a review of Resident 139's admission Record (AR), dated 6/4/25, indicated, Resident 139 was admitted to the facility on [DATE]. A review of Resident 139's Minimum Data Set (MDS, an assessment tool used to guide care) dated 5/28/25, the MDS indicated Resident 139 had a Brief Interview for Mental Status (BIMS, a screening tool used to assess cognition) score of 15 out of 15, meaning intact cognition. During an interview on 6/03/25, 12:19 p.m., with the Assistant Director of Nursing (ADON), the ADON stated, the facility used to have a refrigerator for the residents' food brought from home and stated she could not remember when it broke, but it was not replaced. The ADON further stated when the family members brought food for the residents, the facility asked the residents' families just to bring enough food that the residents could eat, and the facility asked the residents' families to bring home the food that the residents could not consume. During an interview on 6/3/25, at 2:54 p.m., with the Director of Nursing (DON), the DON stated, the facility did not have a refrigerator for food brought from home. During a review of the facility's policy and procedure (P&P) titled, Food brought by Family/Visitors, Revised March 2022, the P&P indicated, . Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility prepared food. a. Non-perishable foods are stored in a resealable container with tight fitting lids . b. Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the residents' name, the item and the use by date .

Based on interview, and record review, the facility failed to ensure Consultant Pharmacist (CP) provided consultation on all aspects of the pharmacy services in the facility when : 1. Loose pills were observed in med cart 2. Formula bottles were stored in the cabinet underneath hand washing sink. 3. CP did not assist with disposition of discontinued controlled drugs in sufficient detail to enable an accurate reconciliation. These failures had the potential to result in medication error, contamination of tube feeding formula and possible diversion of controlled drugs. Findings: During a concurrent observation and interview on 6/3/25, at 12:05 p.m., with Registered Nurse (RN) 1 in the medication storage room, thirteen bottles of tube feeding formula were stored in a cabinet underneath the hand wash sink. RN 1 stated she did not know about the storage underneath the hand wash sink. During a concurrent observation and interview on 6/3/25, at 12:18 p.m., with RN 1, the medication cart was reviewed and loose pills were found in the cart behind medication cards. RN 1 stated she did not know about the loose pills. During a concurrent observation and interview on 6/3/25, at 12:31 p.m., with Director of Nursing (DON), in the medication room, thirteen bottles of tube feeding formula were stored under the hand wash sink. DON stated she would remove the stored formula to another location. DON stated facility had a container for loose pills and expected licensed nurses to dispose of medications properly. During further observation and concurrent interview on 6/3/25, at 12: 31 p.m., in the medication room, a cabinet was full of discontinued narcotic medications . DON stated CP last destroyed discontinued narcotics on 11/5/24. DON stated CP remotely reviewed residents medication records. DON stated CP had not visited the facility to assist with the destruction of the discontinued medications. During an interview on 6/4/25, at 8:10 a.m., with Administrator (Admin), Admin stated CP had been inconsistent with visit to facility and did medication review remotely . Admin stated CP had continued to be remote since COVID-19 period. Admin stated he had made several attempts to communicate with CP with no response. Admin stated CP had not attended quarterly Quality Assurance Committee (QA) meetings, with the last documented CP attendance of QA committee meeting in 2022. During an interview on 6/5/25, at 11:23 a.m., with CP's Director of Clinical Operation (DCO), DCO stated he was not aware that assigned CP was not physically present at the facility. DCO stated that not physically visiting and attending QA meetings was not an operational policy; the expectation was for CP to be present in the facility and physically visit . DCO stated the CP should still go into the facility for drug destruction and QA attendance. DCO stated it was the Pharmacy policy to be at the facility physically.

Based on interview and record review, the facility failed to follow its hospice policy and procedure to collaborate, develop and implement a coordinated plan of care (POC) with hospice representatives for one sampled resident (Resident 18) admitted into hospice program, when Resident 18's hospice POC did not reflect the participation of hospice representatives, Resident 18 and Resident 18's representatives. {POC means a written plan of care established, maintained, reviewed, and modified as necessary, for an individual that reflects the participation of hospice, facility, the patient and patient's family, as appropriate and complies applicable to federal and state laws and regulations}. {Hospice- a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease}. This failure had the potential to result in Resident 18 not receiving necessary care and services. Findings: During a review of Resident 18's admission Record (AR), dated 6/4/25, the AR indicated, Resident 18 was admitted to facility on 5/7/25 with principal diagnosis of disorder of brain. During a review of Resident 18's Admission-Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 5/13/25, indicated Resident 18 was on hospice. During a review of Resident 18's hospice service notes, dated 5/7/25, indicated start hospice order. During an interview on 6/4/25, at 9:15 a.m., with Social Services (SSD), SSD stated she was designated to coordinate hospice care provided to Resident 18. SSD stated she had not scheduled a POC conference for Resident 18 with hospice provider. SSD stated facility had not collaborated with hospice representative . SSD stated she was aware of need to schedule a POC conference with hospice provider, but the care conference had not been scheduled. During a concurrent interview and record review on 6/4/25, at 9:20 a.m., with Director of Nursing (DON), Resident 18's care plan reports, hospice agreement and physician orders were reviewed. DON stated social services was designated to coordinate the care plan conference with hospice agency and Resident 18's family members. DON stated Resident 18 and hospice representative had not been invited to participate in development of Resident 18's hospice care plan in collaboration with hospice agency. DON stated facility had not met to collaborate with hospice representatives on Resident 18 POC. DON stated it was an oversight. During a review of facility's policy and procedure (P&P) titled, Hospice Program, revised July 2017, the P&P indicated, Our facility had designated (name) to coordinate care provided to the resident by our facility staff and hospice staff. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services).

Based on interview and record review, the facility failed to ensure two of two sampled residents' (Resident 3 and 31) Preadmission Screening and Resident Review (PASRR) were screened and referred to the appropriate state mental authority for Level II evaluation and determination. (PASRR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care). Resident 3 and 31 with diagnosis of schizophrenia were not referred for Level II PASRR evaluation and determination. This failure placed Resident 3 and 31 at risk for inappropriate placement in the facility and prevent Resident 3 and 31 from receiving appropriate required mental health services. Findings: During a review of Resident 3's admission Record (AR), dated June 4, 2025, AR indicated Resident 3 was originally admitted to the facility on [DATE] with diagnosis that included schizophrenia (a chronic mental illness that affects how a person thinks, feels and behaves, often making it difficult to distinguish between reality and imagination). During a concurrent interview and record review on 6/4/25, at 9:05 a.m., with Director of Nursing(DON) and MDSC coordinator (MDSC 1), Resident 3's PASRR Level I screening result dated 3/24/25 was reviewed. DON stated she was not aware of the need to refer Resident 3 for Level II evaluation. During a review of Resident 31's admission Record (AR), dated June 4, 2025, AR indicated Resident 31 was originally admitted to the facility on [DATE] with diagnosis that included schizophrenia. During a concurrent interview and record review on 6/4/25, at 9:05 a.m., with Director of Nursing(DON) and MDSC coordinator (MDSC 1), Resident 31's PASRR Level I screening result dated 4/14/21 was reviewed. DON stated she was not aware of the need to refer Resident 31 for PASRR Level II evaluation.

Based on interview and record review, the facility failed to ensure Resident 14 received adequate bed mobility supervision and assistance to prevent the resident from falling to the floor. This deficient practice resulted in resident 14 falling on the floor and sustaining a left femur fracture (left femur fracture is a break in the left thighbone. It often causes severe pain and swelling). Findings: During a review of Resident 14's Facesheet (information containing contact details, brief medical history at-a-glance) printed 6/4/25, the facesheet indicated Resident 14 was admitted to the facility on [DATE] with diagnoses that included morbid obesity, hemiplegia and hemiparesis (morbid obesity means having a body weight that is much higher than what is considered healthy; hemiplegia is paralysis that affects only one side of the body and hemiparesis is a condition characterized by weakness on one side of the body). During a review of Resident 14's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/10/25, indicated Resident 14 had a brief interview for mental status or BIMS score of 10 (BIMS score of 8 to 12 indicates moderate cognitive impairment). The MDS also indicated Resident 14 needed substantial to maximal assistance when rolling from lying on back to left and right side which meant when helping the resident to turn from side to side, the helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. During a review of Resident 14's Activities of Daily Living (ADL) care plan indicated Resident 14 required extensive assistance by two staff to turn and reposition in bed every two hours and as necessary. During a review of facility's Interdisciplinary Team's notes (IDT, a group of individuals representing different departments of the facility), dated 3/21/25, indicated on 3/15/25 at 6:56 a.m., Resident 14 was rolled out of bed by Certified Nursing Assistant (CNA) 1 to the floor while providing care. The IDT notes also indicated Resident 14 was screaming in pain and was transferred to the hospital by 911. The IDT notes further indicated a plan of action of maintaining two persons assist during ADL care and to provide more teaching to CNA 1. During a review of Resident 14's Hospitalist (physician specialist in hospital care) History and Physical (H & P) dated 3/20/25, indicated Resident 14 sustained left femur fracture. During an interview on 6/4/25, at 10:09 a.m., with Resident 14, Resident 14 complained of left hip pain and stated she fell from her bed but could not remember when the incident happened. During a telephone interview on 6/4/25, at 10:11 a.m., with CNA 1, CNA 1 acknowledged she needed another person to help her turn Resident 14 from side to side, but she did not ask for assistance. CNA 1 stated Resident 14's bed was in a high position when she fell from the bed. During an interview on 6/4/25, at 11:10 a.m., with Registered Nurse (RN) 1, RN 1 stated Resident 14 required two to three persons to assist when being turned and repositioned due to the resident's morbid obesity. During an interview on 6/4/25, at 2:05 p.m., with Director of Rehabilitation (DOR), DOR stated Resident 14's fall was avoidable and could have been prevented if the CNA asked for help. DOR stated the resident needed two persons assistance all the time when being turned and repositioned in bed.

Based on observation, interview, and record review the facility failed to assess the coccyx (tailbone) pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) wound for one (Resident 1) of three sampled residents. This failure had the potential for Resident 1 ' s wound to worsen, delay wound healing, have pain, infection and hospitalization. Findings: During a review of Resident 1 ' s face sheet, the face sheet indicated Resident 1's admitting diagnoses included unspecified dementia (a progressive state of decline in mental abilities) and urinary tract infection (UTI - an infection in the bladder/urinary tract). During a review of facility document Skin Only Evaluation, the Skin Only Evaluation noted Resident 1 had bluish purplish skin discoloration in coccyx area and foam dressing placed. The facility document Clinical admission Evaluation, noted Resident 1 had a pain score of 1 (1 being the least and 10 being the worst). During a review of Resident 1 ' s face sheet, the face sheet indicated an additional diagnosis of pressure ulcer of sacral region, stage 3 (stage 1 as lowest wound severity and stage 4 as highest wound severity) with onset date twenty months after admission. During a review of the facility document Wound - Weekly Observation Tool, the Wound - Weekly Observation Tool, in 2024, was completed on 2/6, 3/15, 6/14, 6/21, 7/5, 7/26, 8/23, 10/18, and 11/8. During a review of the facility document Long Term Care Evaluation - Weekly Evaluation, the Long Term Care - Weekly Evaluation, in 2024, the Skin Section did not have any skin evaluation documented on 2/8, 3/17, 3/21, 4/4, 4/18, 5/2, 5/9, 5/23. In 2024, the Skin Section did not have wound description documented on 2/29, 3/14, 3/28, 4/25, 5/17, 6/13, 6/20, 6/27, 7/18, 11/7, 11/14, 11/21, and 12/5. During a review of facility document Braden Scale (assessment of a patient ' s risk of developing pressure ulcer) for Predicting Pressure Ulcer Risk, Resident 1 ' s Braden Score was 12 (12 or lower = very high risk). During an interview on 4/23/25, at 12:31 p.m., with the Director of Nursing (DON), the DON stated skin evaluation should be done on admission then on weekly assessments. During an interview on 5/22/25, at 10:25 a.m., with Licensed Vocational Nurse (LVN) 1, LVN1 stated wound description should be documented in progress notes and change of condition. Per LVN 1, wound documentation included description of wound, length, depth, and color. LVN 1 stated wound assessment documentation should be done weekly. Per LVN 1, when doing weekly evaluation charting, it was not expected to include wound assessment. During an interview on 5/22/25, at 11:45 a.m., with the DON, the DON stated weekly wound evaluation should be done once a week. The DON added documentation on wound assessment should include staging. Per DON, if not done, nobody will know if there is infection and not know if wound is getting better. During a review of the facility ' s policy and procedure (P&P) titled, Wound Care, dated October 2010, the P&P indicated, The following information should be recorded in the resident ' s medical record .all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound.

Based on interview and record review, the facility failed to ensure Resident 1 ' s representative (RR) received copies of medical records within forty-eight hours from requested date. This failure resulted in RR not receiving requested documents for forty-two days. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. During a review of the letter of request, dated 2/20/25, the letter was addressed to the facility ' s Custodian of Records. The letter indicated a request for Resident 1 ' s medical records. During a review of the documents, the authorization request was hand delivered and served to the facility on 2/27/25 and received by facility staff. On 3/17/25, Medical Records (MR) staff confirmed to RR the facility received the request. MR said he was still working on it and was not finished gathering the records. During an interview on 5/22/25, at 1:07 p.m., with MR, MR stated he did not see the request as the letter might have been in the Administrator ' s (ADM) office. Per MR, he was not sure when he knew about the request. MR stated the requested documents were placed in a USPS (United States Postal Service) parcel box and ADM mailed it at the post office. Per MR, medical records request must be completed in seventy-two hours. During a concurrent interview and record review on 5/22/25, at 1:07 p.m., with ADM, the USPS receipt was reviewed. The ADM stated he took the parcel box containing the requested documents and mailed it at the post office. The USPS receipt indicated the parcel box was mailed on 3/26/25 at 4:58 p.m Per receipt, the parcel box was mailed with certified mail and return receipt tracking numbers. During a review of the facility ' s policy and procedure (P&P) titled, Release of Information, dated November 2009, the P&P indicated, A resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight (48) hour (excluding weekends and holidays) advance notice of such request.

Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS, an assessment tool used to direct resident care) for one of two sampled residents (Resident 1) within the regulatory specified timeframes when the Minimum Data Set Coordinator (MDSC) did not complete the Admission assessment within 14 calendar days of Resident 1 ' s admission to the facility. This deficient practice had the potential to result in Resident1 ' s unassessed and unmet care needs. Findings: A review of Resident 1 ' s Admission Record, printed 12/17/24, indicated resident was admitted to the facility on [DATE]. A review of Resident 1 ' s MDS record, indicated Resident 1 ' s Admission MDS had an assessment reference date of 9/29/24, and the MDS was not completed within 14 calendar days of resident ' s admission to the facility. During a concurrent interview and record review on 12/17/24, at 1:48 p.m., with the MDSC, Resident 1 ' s MDS Assessments were reviewed. MDSC was unable to provide Resident 1 ' s Admission MDS and stated it was still in progress (not yet completed at the time it was asked). MDSC stated resident ' s Admission Assessment should have been completed by 10/12/24 and submitted on 10/19/24 but was not completed timely due to MDSC ' s workload. A review of the facility ' s policy, Resident Assessment Instrument (RAI), dated October 2023, indicated, The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: a. Within fourteen (14) days of the resident ' s admission to the facility .MDS Completion Date .No Later Than 14th calendar day of the resident ' s admission (admitted + 13 calendar days).

Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to provide Resident 1 a notice of proposed discharge within the timeframe of at least 30 days prior to the actual discharge date and failed to send a copy to the Office of the State Long-Term Care Ombudsman as required. This failure had the potential to result in the lack of added protection to Resident 1 from being inappropriately discharged , without access to an advocate who can inform them of options and rights. Findings: During a review of Resident 1's Admission Record, dated 4/4/24, the Admission Record indicated Resident 1 was admitted to the facility in November 2023 with diagnoses that included cerebral palsy (a group of conditions that affect muscle movement and posture. Symptoms include exaggerated reflexes, floppy or rigid movements and involuntary motions), dysphagia (difficulty swallowing), repeated falls, rhabdomyolysis (life-threatening condition, as a result of muscle injury, muscles break down and releases protein into the blood, this protein damages the kidney), syncope and collapse (fainting, sudden loss of consciousness), and dorsalgia (mild to disabling pain occurring on the spine or back). The Admission Record indicated Resident 1 was self-responsible and Caregiver (CG) was Emergency Contact #1. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 11/28/23, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information.) score of three (A BIMS score of three is an indication of severe cognitive impairment). During a review of Resident 1's Order Summary Report, dated 11/23/24, the Order Summary Report indicated an order for Resident 1 to be discharged home on 1/23/24. During a review of Resident 1's Notice of Proposed Transfer/Discharge with notification date 1/18/24, the Notice of Proposed Transfer/Discharge indicated Resident 1 was being discharged because Resident 1's health has improved sufficiently that Resident 1 no longer needed the services provided by the facility. The Notice of Proposed Transfer/Discharge was signed by CG on 1/23/24, and indicated, If you intend to file an appeal, it is suggested you do so within 10 calendar days of being notified .the decision regarding an appeal will normally be made within thirty (30) working days from the date you were formally notified . The notice also indicated it was required that a copy of it be faxed to the State Long Term Care Ombudsman office and proof the document was faxed will be filed in Resident 1's medical record. During an interview on 4/4/24 at 12:01 p.m. with Physical Therapist (PT), PT stated prior to admission to the facility, Resident 1 was able to walk, but had been falling frequently at home, hence the hospitalization and eventually admission to the facility. PT stated Resident 1's ability to perform ADLs (activities of daily living like turning and repositioning in bed, transfer from bed to chair and back, toilet use, personal hygiene and eating) fluctuated and still needed 24-hour care at the time of discharge. During a telephone interview on 4/9/24 at 10:42 a.m. with Administrator (Adm), Adm stated he did not know if Social Services Director sent a copy of the discharge notice to the Ombudsman office. Adm stated there was no facility policy and procedure that addressed discharge notices. As of 4/9/24 at 4:13 p.m., Adm was not able to provide a proof that the Notice of Proposed Transfer/Discharge issued to Resident 1 on 1/23/24 was sent to the State Long Term Care Ombudsman Office.

Based on interview and record review, for one of two (Resident 1) sampled residents who were discharged from the facility, the facility failed to implement effective discharge planning when Resident 1, who required 24-hour care, was discharged without consideration for Resident 1's discharge needs such as caregiver support availability and mechanically altered diet (foods that can be safely and successfully swallowed). This failure resulted in Resident 1's re-admission to the hospital. Findings: During a review of Resident 1's Admission Record, dated 4/4/24, the Admission Record indicated Resident 1 was admitted to the facility in November 2023 with diagnoses that included cerebral palsy (a group of conditions that affect muscle movement and posture. Symptoms include exaggerated reflexes, floppy or rigid movements and involuntary motions), dysphagia (difficulty swallowing), repeated falls, rhabdomyolysis (life-threatening condition, as a result of muscle injury, muscles break down and releases protein into the blood, this protein damages the kidney), syncope and collapse (fainting, sudden loss of consciousness), and dorsalgia (mild to disabling pain occurring on the spine or back). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 11/28/23, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information.) score of three (A BIMS score of three is an indication of severe cognitive impairment). During an interview and concurrent review on 4/4/24 at 10:56 a.m. with Social Services Director (SSD), Resident 1's Care Conference Summary, dated 11/22/23, was reviewed. SSD stated during the Care Conference for initial discharge planning, Resident 1's family agreed to take Resident 1 home only when Resident 1 was able to use the bathroom independently, without needing physical help from another person. The Care Conference Summary indicated Resident and caregiver both verbalized that upon discharge from SNF [skilled nursing facility], resident will return home. [Resident 1] needs to work hard with PT [physical therapy] and OT [occupational therapy] and be able to go back to his baseline. SSD will provide resources to fit resident needs. During a review of Resident 1's Inpatient Medicine Discharge Summary (from prior hospitalization ), dated 11/15/23, the Inpatient Medicine Discharge Summary indicated Resident 1 had five unwitnessed falls at home prior to admission to the hospital. Resident 1 was discharged to the facility for physical therapy as Resident 1 independently performed his activities of daily living like turning and repositioning in bed, transfer from bed to chair and back, toilet use, personal hygiene and eating (ADLs) with intermittent help from Caregiver (CG) a few hours a day. During a review of Resident 1's Care Conference Summary, dated 1/18/24, the Care Conference Summary indicated Resident 1 had reached functional goals and will be discharged home with family, caregiver, and home health care services. During a review of Resident 1's Order Summary Report, dated 11/23/24, the Order Summary Report indicated an order, dated 11/28/23, for speech therapy to evaluate and treat Resident 1's dysphagia. The Order Summary Report also indicated an order for Resident 1 to be discharged home on 1/23/24. During a review of Resident 1's Discharge Plan of Care, dated 1/22/24, the Discharge Plan of Care indicated Resident 1 needed 24-hour care for minimal to moderate assistance with transfers and walking with front wheel walker and for Resident 1's diet to be regular puree, nectar thick liquid. During an interview and concurrent review of Resident 1's Discharge Plan of Care, dated 1/22/24, on 4/4/24 at 11:38 a.m. with Director of Nursing (DON), DON stated not being aware of Resident 1's need for 24-hour care as indicated in the Discharge Plan of Care. DON stated if she had been aware, it would have changed Resident 1's discharge plan to stay at the facility for long-term care. DON stated Resident 1 had coverage for long term stay. DON also stated the Discharge Plan of Care was the last paperwork to be completed by a representative of each department and issued to Resident 1 on the day of actual discharge and may not have been reviewed by the entire team. During an interview on 4/4/24 at 12:01 p.m. with Physical Therapist (PT), PT stated prior to admission to the facility, Resident 1 was able to walk, but had been falling frequently at home, hence the hospitalization and eventually admission to the facility. PT stated Resident 1's ability to perform ADLs fluctuated and still needed 24-hour care at the time of discharge. PT stated Resident 1 had a caregiver who did not show up for caregiver training with therapy. During a review of Resident 1's Physical Therapy Discharge Summary, dated 1/13/24, the Physical Therapy Discharge Summary indicated Resident 1 was able to turn, reposition in bed, and transfer in and out of bed with minimal assistance and able to walk on level surfaces with moderate assistance. The summary also indicated discharge reason as discharged per Physician or Case Manager. During a second interview and concurrent review of Resident 1's clinical records on 4/4/24 at 12:51 p.m. with SSD, Resident 1's Discharge Plan of Care, dated 1/22/24, was reviewed. SSD stated she thought Resident 1 only needed some assistance with ADLs and not needing 24-hour care. During a telephone interview on 4/8/24 at 1:12 p.m. with CG, CG stated being told Resident 1's insurance would not cover for long term-stay at the facility, so facility needed to discharge Resident 1. CG stated telling the facility staff of being unable to care for Resident 1 but was told Resident 1 could walk and go to the bathroom independently and not needing much help which turned out to be untrue. CD stated the night Resident 1 came home, Resident 1 fell , and CG had to go to Resident 1's home because Resident 1's sister was also bedridden and could not pick up Resident 1 off the floor. CG stated Resident 1 had four more falls over two days after that night. CG stated not being able to provide 24-hour care for Resident 1 as CG only went to Resident 1's home an hour a day, five days a week. CG stated, five days after being discharged from the facility, Resident 1 was sent to the hospital for severe pain and for repeated falls. CG also stated one had to prepare pureed food and thickened soup for Resident 1 to eat at night when CG was not at the home. During a review of the Attending Physician's Progress Notes, dated 11/22/23, the Progress Notes indicated for Resident 1's dysphagia, Continue ST swallow evaluation, Unclear why [Resident 1] is having this trouble. During an interview on 4/4/24 at 12:40 p.m. with SSD, SSD stated there was no ST evaluation and treatment done on Resident 1. During a telephone interview on 4/9/24 at 10:42 a.m. with Administrator (Adm), Adm stated appropriate discharge for a resident who needed 24-hour care should be to an assisted living facility if the resident was financially able and willing to pay, to a care home, or to another skilled nursing facility of choice. During a review of the facility's policy and procedure (P&P) titled Discharge Summary and Plan, last revised December 2016, and Resident 1's Discharge Plan of Care, dated 1/22/24, the P&P indicated a post-discharge plan will be developed by the Interdisciplinary Team With the assistance of the resident and his or her family and will include . c. A description of the resident's stated discharge goals; d. The degree of caregiver support person/availability, capacity, and capability to perform required care; . f. What factors may make the resident vulnerable to preventable readmission; and g. How those factors will be addressed. The Resident 1's Discharge Plan of Care did not indicate any of this information.

Based on observation, interview, and record review, the facility failed to follow infection control procedures when: 1. The facility did not have procedures in place for monitoring and testing the presence of Legionella and other water borne pathogens in their water system. 2. The facility did not properly label, disinfect and store wash basins. 3. A licensed nurse failed to disinfect reusable medical equipment between resident use. Findings: 1. During an interview with the administrator on 11/15/23 at 10:15 a.m. and concurrent review of the facility's water management system, the administrator stated the facility did not have measures in place to prevent the growth of Legionella and other opportunistic waterborne pathogens (microorganism, bacterium or virus that cause a disease) that was based on nationally accepted standards. The administrator stated the facility was in the process of finding a vendor who would provide Legionella testing to the facility. 2. During multiple observations of resident bathrooms on 11/13/23, 11/14/23, and 11/15/23, there were piles of wash basins laying on the bathroom floor of rooms [ROOM NUMBERS], 4 and 5, and 6 and 7. The wash basins were not labeled with the name of a resident, they were dirty and had soap scum on the rims. During an interview with the infection preventionist (IP) on 11/15/23 at 2:00 p.m., IP stated the wash basins should not be on the floor and should be washed after each use. During an interview with the Director of Nursing (DON) on 11/16/23 at 8:45 a.m., DON stated the wash basins should be labeled with the resident's name, washed, disinfected, and stored in the resident's bedside table. 3. During an observation on 11/14/23 at 11:30 a.m., Registered Nurse (RN) 1 used a glucometer (a handheld instrument that tests the amount of sugar in a drop of a person's blood) to test the amount of glucose (sugar) in Resident 17's blood. During an observation on 11/14/23 at 11:43 a.m., RN 1 used the same glucometer to test Resident 16's blood glucose. RN 1 did not sanitize the glucometer between testing Resident 17's blood and Resident 16's blood. During an interview on 11/14/23 at 11:45 a.m. with RN 1, RN 1 stated the glucometer should have been sanitized between testing Resident 16 and Resident 17 to decrease the risk of the spread of infection. During an interview on 11/14/23 at 12:10 p.m. with DON, DON stated RN 1 should have sanitized the glucometer between testing the blood of Resident 16 and 17 to reduce the risk of the spread of infection. During a review of Resident 17's Admission Record (AR), printed 11/14/23, the AR indicated, Resident 17 was diagnosed with diabetes mellitus (a chronic disease in which the body cannot regulate the amount of sugar in the blood). During a review of Resident 17's Medication Record Report (MRR), dated 11/14/23, the MRR indicated, Finger stick blood glucose QAC (before every meal) and QHS (at bedtime) four times a day. During a review of Resident 16's Admission Record (AR), printed 11/14/23, the AR indicated, Resident 16 was diagnosed with diabetes mellitus. During a review of the facility's policy and procedure (P&P) titled, Obtaining a Fingerstick Glucose Level, dated Revised October 2011, the P&P indicated, 3. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses.

Based on observation and interview, the facility failed to follow safe food practices when: 1. Two plastic bags of chicken parts were unlabeled and undated. 2. One plastic bag of sausage links was unlabeled and undated. These failures placed residents at risk for foodborne illnesses. Findings: During an observation on 11/13/23 at 9:30 a.m. in the kitchen, the freezer contained two plastic bags of frozen chicken parts which were undated and had no label identifying the contents and one plastic bag of sausage links which was undated and had no label identifying the contents. During an interview on 11/13/23 at 9:32 a.m. with Dietary Manager (DM), DM stated two plastic bags containing chicken parts and one plastic bag containing sausage links were in the freezer and were undated and had no labels identifying the contents. DM stated the three bags were supposed to be labeled and dated so the food was identified and was not kept too long. During an interview on 11/15/23 at 12:00 PM with Registered Dietician (RD), RD stated all food in the freezer should be labeled and dated. RD stated the bags of chicken parts and sausages should have been labeled identifying the contents and dated. RD stated not being labeled and dated could lead to use of food that was outside of the date when food could be used safely, could lead to the use of spoiled food, and increased risk of foodborne illness.

Based on observation, interview, and record review, the facility administered a crushed tablet of carbamazepine ER (carbamazepine ER is an extended release medication, releasing medication into the body over a 12 hour period, used to treat and relieve nerve pain) 100 milligrams (mg) to one (Resident 136) of eight sampled residents. This failure resulted in Resident 136 not receiving medication as prescribed by the physician and placed Resident 136's health at risk due to risk of an adverse effect on Resident 136's trigeminal neuralgia (a condition that causes nerve pain) and health. Findings: During a review of Resident 136's Admission Record (AR), printed 11/14/23, the AR indicated Resident 136 was admitted to the facility in October 2023, and had a diagnosis of trigeminal neuralgia. During a concurrent observation and interview on 11/14/23 at 8:17 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he crushed Resident 136's medications. LVN 1 crushed Resident 136's carbamazepine ER 100 mg tablet and gave it to Resident 136 in applesauce. During a review of Resident 136's Medication Review Report (MRR), dated 11/14/23, the MRR indicated, Carbamazepine ER Oral Tablet Extended Release 12 Hour 100 MG (Carbamazepine) Give 1 tablet by mouth one time a day . During a review of Resident 136's Medication Administration Record (MAR), dated 11/1/23 - 11/30/23, the MAR indicated Resident 136 received one tablet of Carbamazepine ER Oral Tablet Extended Release 12 Hour 100 MG on 11/14/23 at 8:00 a.m. During an interview on 11/14/23 at 10:37 a.m., with Director of Nursing (DON), DON stated, Resident 136's carbamazepine ER should not have been crushed, because it was an extended release medication. DON stated, the extended release medication was meant to be released into the body over time, but when given crushed the medication was released into the body all at one time. DON stated, receiving the crushed medication had the risk of adversely affecting Resident 136's health by adversely affecting his Trigeminal Neuralgia. During a review of the facility's policy and procedure (P&P) titled, Administering Medication, dated Revised April 2019, the P&P indicated, . 4. Medications are administered in accordance with prescriber orders . During a review of the facility's policy and procedure (P&P) titled, Crushing Medications, dated Revised April 2018, the P&P indicated, Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders.

Based on observation and interview, the facility failed to provide necessary services to maintain good grooming to one sampled resident (Resident 25). This deficient practice had the potential for Resident 25 to accidentally scratch her skin with long and jagged fingernails, have skin problems around the nail bed, infection, and low self-esteem. Findings: During a concurrent observation and interview on 11/13/23 at 9:25 a.m., Resident 25 was observed with long, jagged fingernails. There were thick dark brown substances underneath her nails. Resident 25 apologized for having long and dirty fingernails. Resident 25 stated she preferred short, well-trimmed fingernails, however, she did not have a nail clipper. During an observation of Resident 25 and concurrent interview with Certified Nursing Assistant (CNA)1 and Registered Nurse (RN)1 on 11/14/23 at 12:10 p.m., CNA 1 and RN 1both confirmed the nails of Resident 25 were long and dirty. CNA 1 stated they were supposed to trim the residents' fingernails when they are long and clean underneath fingernails each time they washed their hands. During a review of Resident 25's Admissions Records, the records indicated she was admitted to the facility in April 2022 with diagnoses that included: peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs), obsessive-compulsive disorder (excessive thoughts that lead to repetitive behaviors), and schizophrenia (a disorder which affects a person's ability to think, feel and behave clearly). During a review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/13/23, the MDS indicated moderate cognitive impairment and required moderate assistance with activities of daily living. During a review of the facility's policy and procedure titled: Fingernails/Toenails, Care of, dated February 2018, the policy indicated under General Guidelines: 1. Nail care includes daily cleaning and regular trimming, 2. Proper nail care can aid in the prevention of skin problems around the nail bed, 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .