Every finding on record at Shores Nursing and Rehab Center

Based on interview and record review, the facility failed to ensure informed consent was obtained prior to the administration of psychotropic medications for 2 of 6 residents reviewed for psychotropic medication use. (Residents #4 and #11) The findings include: 1. On 8/12/26 at approximately 11:30 AM, a record review for Resident #4 revealed a physician's order of Paroxetine 40 mg once a day for depression, Trazodone 100 mg once a day for depression, Divalproex 500 mg twice a day for Bipolar Disorder (lifelong mental health conditions defined by severe shifts in mood, energy, and activity levels), and Risperidone 2 mg three times a day for Schizophrenia (a severe, chronic brain disorder that affects how a person thinks, feels, and acts). Resident #4 was admitted with diagnoses of major depressive disorder, depression, bipolar disorder with manic severe psychotic features, and Paranoid Schizophrenia. During an interview on 8/12/26 at approximately 1:30 PM, the Director of Nursing (DON) was requested to provide documentation of informed consent for Resident #4's Paroxetine, Trazodone, Divalproex, and Risperidone. The DON was unable to provide evidence that the resident or resident representative had been informed of and consented to the use of the psychotropic medications prior to their administration. 2, On 08/12/2026 at 05:56 PM, a record review of Resident #11 revealed an admission date of 6/2/25 with diagnoses including Traumatic Brain Injury, Schizoaffective disorder-Bipolar type, Major Depressive Disorder, and Paraplegia. Resident #11 is currently receiving the psychotropic medications Haldol 10 mg three times a day and Olanzapine 10 mg at bedtime for schizoaffective disorder (a mental health condition that combines symptoms of hallucinations or delusions with mood disorder such as depression or mania) and Divalproex sodium tablet 500 mg every 12 hours for Bipolar disorder (a lifelong mental health condition that causes extreme shifts in mood, energy, activity level, and concentration). Resident #11 did not have any consent for psychotropic medication use explaining the risks and benefits of the medication prior to administering medication in their record. An interview was conducted on 08/12/2026 at 1:30 PM with the DON requesting consents signed for the use of psychotropic medication for Resident #11. The DON stated that the residents are being seen by the Nurse Practitioner (NP) and she obtains the consents for the medication and treatment consents when she comes to visit the residents. An interview was conducted with the NP on 08/12/2026 at 02:30 PM. The NP stated it is the facility's responsibility to obtain the medication consents when a resident is admitted to the facility on psychotropic medications and when there is dosage increase or decrease or change in the medication. The facility policy titled Behavior Management-Psychotropic Medications (with an effective date of 09/01/2024) stated, Psychotropic medication is any medication that affects brain activities associated with mental processes and behavior. These drugs include anti-psychotic, anti-depressant, anti-anxiety, and hypnotic (sleep) medications. The procedure for these medications reveals that residents receiving psychotropic medication to have the risk and benefits reviewed and consent completed prior to initiation of the medication.

Based on record review, staff interview, and policy review, the facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASARR) for 2 of 2 sampled resident reviewed for PASARR. (Resident #8 and #22)The findings include: 1. On 8/11/26, a review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE]. Review of the Level I PASARR, dated 10/27/23, revealed the resident was identified with bipolar disorder, was receiving mental illness services, and was identified as requiring a Level II PASARR evaluation for serious mental illness. There was no evidence the facility obtained the required Level II PASARR evaluation and determination prior to the resident's admission or thereafter. The facility did not initiate action to obtain the required Level II PASARR until 8/12/26, during the survey. An interview with the Director of Nursing (DON) was conducted on 8/12/26 at approximately 9:30 AM, the DON stated the facility process for PASARR was a review by the admissions team, social services and audits were currently in place. Review of the documentation provided by the DON revealed a PASARR case was submitted on 8/12/26 at 9:53 AM. She acknowledged that the Level II PASARR review was overlooked. 2. A record review was conducted for Resident #22 on 08/12/2026 at 09:00 AM. Resident #22 was admitted to the facility on [DATE] with the diagnoses including Major Depressive Disorder, Personality Disorder, Psychoactive Substance Abuse, and Post Traumatic Stress Disorder (PTSD). He has a plan of care for communication difficulty with word sequencing and processing and alteration in mood and behaviors with physical and verbal aggression toward others, prefers to wear dresses and believes he is a woman. Resident #22 was admitted with a Level I PASARR completed on 07/09/2026 revealing he had received previous services for mental illness issues. Resident #22 's PASARR indicated a Level II PASARR evaluation must be completed prior to admission. An interview was conducted with the DON on 8/12/26 at 1:02 PM, who stated she is the one who completes the PASARR and reviews them for correct information upon admission to facility. The DON reviewed Resident #22's Level I PASARR and confirmed that it is incorrect and should have been caught when it was reviewed on admission and upon review when an audit was completed and that a Level II PASRR evaluation should have been initiated. The facility policy PASARR Guidance (effective 11/8/21) states that all residents with Serious Mental Illness (SMI) or Intellectual Disabilities (ID) receive appropriate PASARR screenings before admission, following federal and state requirements. The center must obtain Level I or II screening results prior to admission and place them in the resident's medical record. Certain individuals may be exempt from PASARR (e.g., recent hospital discharge under 30 days, terminally ill, comatose, certain severe neurological conditions, or dementia with proper documentation).

Based on observations, record reviews, and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for the residents in 7 of 60 rooms. (rooms 341, 342, 343, 344, 345, 346, 347) The findings Include: On 08/10/2026 at 12:25 PM, during an observation of the 300 Hall, the resident bathrooms for Rooms 341-347 were observed to have black and dark-colored filmy growth on multiple surfaces, including the bathroom ceilings, walls, doors, and door frames. The bathroom environments were observed to be warm and had a musty and foul odor. (Photographic evidence obtained) On 08/11/2026 at 8:45 AM, 8/12/2026 at 8:51 AM and 1:33 PM, and 8/13/2026 at 9:03 AM, follow-up observations of the bathrooms associated with Rooms 341 - 347 revealed the black/dark growth remained present on the ceilings, walls, doors, and/or door frames. The bathrooms remained warm and musty, with foul odors noted. On 8/11/2026 at 12:30 PM, the Maintenance Repair/Housekeeping Logs and Work Orders records were reviewed for the facility. The Maintenance Repair/Housekeeping Logs and Work Orders/Repair Requests revealed documentation of environmental, moisture, ventilation, water intrusion, and mold-related concerns predating the survey observations. For room [ROOM NUMBER], on 05/09/2026 a Work Orders/Repair Requests form revealed a request stating, Mold in bathroom (resident complaining). For room [ROOM NUMBER] on 05/22/2026, another maintenance/work-order log stated, Air filters need to be replaced, windows need cleaning/mold on ceilings. The reviewed entry did not contain documentation demonstrating completion of the identified work. The Maintenance Repair/Housekeeping Log revealed an entry dated 04/24/2026 for room [ROOM NUMBER] documenting: A/C/heat not working. room [ROOM NUMBER] was among the rooms where a warm, musty bathroom environment and dark growth were observed during the survey. The Maintenance Director reviewed the entries and acknowledged that they did not contain documentation of a date of completion.

Based upon observation, interview and review of facility policy, the facility failed to ensure medications were stored in a locked secure manner.The findings include:On 08/10/2026 at 2:38 PM while making resident observations on the 300 unit, the medication cart was observed sitting in the hallway outside of room [ROOM NUMBER]. Staff B, a Licensed Practical Nurse, was observed walking from the medication cart to the nurses' station, leaving the medication cart unlocked, the computer screen visible with resident information displayed, and a small clear medication cup was sitting on top of the medication cart with a small greenish-white color tablet sitting inside the cup. Staff B was at the nursing station for approximately 10-15 minutes, out of view of the medication cart. Residents were observed in the hallway passing the cart.Staff B returned to the medication cart at approximately 2:55 PM, when an interview was conducted. Staff B confirmed the cart should have been locked, the computer screen closed, and medication should not have been left unattended prior to walking away.On 08/12/2026 at 09:00 AM, a treatment cart was observed sitting at the nurses' station with prescribed ointments and creams for topical use sitting on top of the cart unattended. There was approximately 6-7 residents sitting at the nurses' station and 2 residents walked by the treatment cart.On 08/12/2026 at 09;30 AM, the medication cart for the 300 unit was observed with the lock halfway pushed in, which left the cart unlocked. No nurse was observed on the unit during this time.An interview was conducted with the Director of Nurses (DON) on 08/13/2026 at 02:00 PM, who confirmed that the medication carts should always be locked when unattended by a nurse, medications should never be stored on top of the medication cart or treatment cart or left unattended by a nurse. The policy Medication Administration General (dated 08/07/2023) was conducted on 08/12/2026. The policy outlined procedures and policies for safe medication preparation, administration, verification, and documentation by licensed nurses in compliance with applicable laws. The policy specifically states, Medication carts are always locked when out of sight or unattended.

Based upon interviews and record review, the facility failed to ensure adequate monitoring for behaviors and side effects were documented for 3 out of 6 residents reviewed. (Resident #1, #4, and #11). 1. On 8/12/26, a chart review for Resident #1 revealed an admission date of 7/4/25 with diagnoses including dementia, seizure disorder, psychotic disorder, anxiety disorder, and depression. Resident #1's physician prescribed the psychotropic medications Olanzapine Oral Tablet 20 mg, 1 tablet by mouth at bedtime for restlessness, agitation, generalized anxiety disorder, and depression; Haloperidol Oral Tablet 10 mg, 1 tablet by mouth three times daily for intermittent explosive disorder; and Ativan Oral Tablet 0.5 mg, 1 tablet by mouth three times daily for anxiety. No orders directing staff to monitor Resident #1 for behaviors or side effects related to these psychotropic medications was found. On 8/13/26 at approximately 9:40 AM, an interview with Staff A, Licensed Practical Nurse (LPN), was performed. Staff A was asked if orders were in the electronic medical record (EMR) to monitor Resident #1 for psychotropic medication behaviors or side effects. Staff A checked the medication administration record (MAR) and Treatment Administration Record (TAR), confirmed no such orders were in the chart. On 8/13/26 at approximately 11:30 AM, an interview with the DON revealed that after reviewing Resident #1's EMR and TAR, that staff missed restarting Resident #1's behavioral and side effect monitoring orders for psychotropic medications following the resident's readmission from the hospital. 2. A record review was conducted for Resident #11 on 08/12/2026 at 05:56 PM revealed an admission date of 6/2/25 with diagnoses including Traumatic Brain Injury, Schizoaffective disorder -Bipolar type, Major Depressive Disorder, and Paraplegia. Resident #11 has physician's orders including the antipsychotic medications Haldol 10 mg three times a day and Olanzapine 10 mg at bedtime for schizoaffective disorder (a mental health condition that combines symptoms of hallucinations or delusions with mood disorder such as depression or mania) and Divalproex sodium tablet 500 mg every 12 hours for Bipolar disorder (a lifelong mental health condition that causes extreme shifts in mood, energy, activity level, and concentration). The record did not have an order for behavior monitoring (tracking and assessing behaviors over time) or to assess side effects of anti-psychotic medication (medications used to treat mental health conditions) use. On further record review, Resident #11 did not have a behavior monitoring flow record sheet in the electronic medical record. Resident 11 has an AIMS assessment that was completed on 3/29/26 indicating Resident 11 has no abnormal movements from the use of psychotropic medication use. Medication Haldol had an increase in dosage on 5/29/26 and an increase in dosage for Divalproex on 5/18/26 with no AIMS assessment completed for dosage increase or for the scheduled quarterly assessment in June 2026. 3. On 8/12/26 at approximately 11:30 AM, a record review for Resident #4 revealed physician's orders for Paroxetine 40 mg once a day for depression, Trazodone 100 mg once a day for depression, Divalproex 500 mg twice a day for bipolar disorder (lifelong mental health conditions defined by sever shifts in mood, energy, and activity levels), and Risperidone 2 mg three times a day for Schizophrenia (a severe, chronic brain disorder that affects how a person thinks, feels, and acts). Resident #4's Medication Administration Record (MAR) revealed the psychotropic medications were administered as ordered. Review of the resident's clinical record, including nursing documentation, behavior monitoring records, and medication-related documentation, revealed no documented behaviors, symptoms, frequency, severity, or other clinical indicators demonstrating the continued need for psychotropic medications. During an interview on 8/12/26 at approximately 1:30 PM, the Director of Nursing (DON) was asked to provide documentation of monitoring related to Resident #4's target behaviors related to the use of the above medications. The DON was unable to provide documentation demonstrating that the resident's behaviors or symptoms were routinely monitored to evaluate the effectiveness and continued clinical need for psychotropic medications. Facility policy Behavior Management – Psychotropic Medications, effective 9/1/24, requires staff to monitor behavior and side effects every shift using the electronic Behavior Monitoring Flow Record.

Based on observation, interview, record review and facility policy review, the facility failed to ensure adequate assessment and implementation of smoking safety interventions to reduce the risk of accidents and injury associated with smoking for 4 of 4 sampled residents for smoking safety. (Residents #12, #85, #52 and #11)The findings include: 1. During a review of smoking periods, Residents #12 and #85 were observed smoking in the designated smoking area with staff supervision on 8/10/26 at 2:49 PM, 8/11/26 at 2:30 PM, 8/12/26 at 10:14 AM, 2:44 PM and 8/13/26 at 9:55 AM. Neither resident was observed with a smoking apron although the binder with the smoking assessments stated they needed one. An interview was conducted with the Assistant Director of Nursing (ADON) on 8/11/26 at approximately 2:22 PM while observing the smoking times. The ADON was confirmed the two residents were listed with Apron beside their names. The ADON stated the residents complained about the apron at times but reminds that they should not smoke unless they put it on. The ADON stated he doesn't go out with smokers often and does not know when assessments are completed. A record review of Resident #12 revealed an admission date of 8/2/25 with diagnoses including chronic obstructive pulmonary disease (lung disease that makes breathing hard), muscle weakness, and epilepsy (brain disorder that causes people to have repeated unprovoked seizures). A review of the resident evaluations revealed a smoking evaluation completed on 9/18/25, which stated resident was not a smoker, and 4/28/26, which stated the resident utilizes tobacco and has balance problems while sitting or standing. Smoking was added to the care plan on 6/25/26 with a review date of 8/5/26, which included the need for a clothing protector while smoking. A record review of resident #85 revealed an admission date of 4/24/26 with diagnoses including hemiplegia (the total or severe loss of movement on one side of the body) and right-hand contracture with splint to be worn daily. Review of the residents' evaluations revealed no smoking evaluation. Initial smoking evaluations were created on 4/24/26, which indicates the resident utilizes tobacco with no impairments. Smoking was added to the care plan on 7/22/26 with the review date of 8/10/26, which included a need for clothing protection while smoking. 2. On 08/11/2026 at 4:00 PM, a record review was conducted for Resident #52. Resident #52 was admitted to the facility initially on 10/29/20 and a re-admission date of 6/20/26 with the diagnoses including Cerebrovascular Accident (stroke) with right sided weakness and paralysis, Type II diabetes, mood disorder, history of mental and behavior disorders, major depressive disorder, and contracture (tightening of muscles, tendons, ligaments or skin that prevents normal movement of a joint) of the right hand and upper arm. Resident #52 has a plan of care for smoking and is considered unsafe with the goal that Resident #52 will adhere to the facility smoking policy and will wear a smoking apron for smoking safety. An intervention was initiated on 5/7/2025 for care staff to ensure Resident #52 wears a smoking apron when out to smoke. The facility smoking policy and agreement was signed by Resident #52 on 05/23/2024. A record review was conducted for Resident #11 on 08/12/2026 at 05:56 PM. Resident #11 was admitted to facility on 6/2/25 with a diagnosis of Traumatic Brain Injury, Schizoaffective disorder -Bipolar type, Major Depressive Disorder, Paraplegia, and upper extremity contractures of both arms. Resident #11 has a plan of care for smoking with the goal that Resident #11 will not sustain any injury related to smoking. Resident #11's current intervention includes ensuring that Resident #11 wears a smoking apron for safety when smoking. An observation was conducted on 8/10/2026 in the smoking area at 01:30 PM. Resident #52 was observed sitting in his wheelchair smoking a cigarette without a smoking apron in use. Further observations on 8/11/2026 at 1:30 pm and 8/12/2026 at 01:38 pm revealed Resident #52 sitting in his wheelchair in the smoking area without a smoking apron. On 08/12/2026 at 1:45 PM, an observation of Resident #11 was made, revealing he was sitting in his wheelchair in the smoking area without a smoking apron on. The area had a smoking monitor, but no attempt was made to get Resident #11 to put his apron on. On 8/12/2026, an interview was conducted with the Director of Nursing (DON). She provided a list of current residents residing in the facility indicating Resident #52 and Resident #11 are to wear smoking aprons when smoking. The facility policy titled Smoking – Residents (effective date of 8/1/2023 was reviewed on 08/11/2026) states, The policy was established and to maintain safe smoking practices for residents with procedural guidelines listed. Residents who smoke will be educated to the smoking policy upon admission, re-admission, and quarterly. Residents are to be evaluated for smoking upon admission, re-admission, and quarterly.

Based upon observation, interview, and record review, the facility failed to ensure a medication error rate less than 5 percent. 28 medication opportunities were observed with 3 errors occurring, for a total medication error rate of 10.71 percent.The findings include:A medication administration observation was conducted on 08/12/2026 at 08:00 AM with Staff Nurse A, Licensed Practical Nurse (LPN). Staff A was observed administering prescribed eye drops to Resident #61. Staff A applied 2 drops to Resident #61's right eye and then to the left eye. Staff A did not offer any tissue or instruct Resident #61 not to rub his eyes after administration. Resident #61 immediately rubbed both eyes with the inside of his t-shirt, removing the drops that were instilled. Staff A then pulled out ear drops to be administered to Resident #61. Staff A placed the tip of the dropper inside the ear canal and instilled drops into his left ear. Staff A instructed Resident #61 to lean his head over to the left and repeated the process to the right ear. Resident #61 then used his t-shirt to wipe the drops from his ears.Another medication administration observation was conducted on 08/12/2026 at 08:23 AM for Resident #65. Resident #65 was administered oral medications along with a nebulizer treatment. Staff A set up the nebulizer machine and instilled the nebulizer treatment into the nebulizer cup, handed the nebulizer mask to Resident 65, and instructed him to place on himself. Staff A then washed her hands and left the room, leaving Resident 65 unsupervised during the administration and did not monitor the response to treatment or disassemble and clean the nebulizer mask after use.An interview was conducted with Staff A, who confirmed that the nebulizer administration should not be left unattended with a resident and that she did not perform an assessment of Resident #65 prior to or after administration of medication.A record review was conducted for Resident #61 on 08/12/2026 at 10:00 AM. They had physician's orders for artificial tears to instill 2 drops in both eyes twice a day for the diagnosis of Blepharitis (chronic condition causing red, swollen, itchy, irritation to the eyelids). They also had an order for Carbamide peroxide external solution (ear drops), instill 5 drops in both ears two times a day for 6 days with additional instructions for resident to lay on one side instill the drops, wait 5 minutes and rinse with warm water and then repeat on the other side.A record review was conducted for Resident #65 at 10:30 AM and revealed a physician order for Ipratropium-Albuterol inhalation solution to be inhaled three times a day. On further review, Resident #65 does not have any documentation concerning self-administering medications.The skills competency assessment for nebulizer treatments indicates that the nurse will explain the procedure to the resident, evaluate the resident establishing a baseline respiratory rate, pulse, oxygen saturation, and breath sounds. Then nurse will assemble the equipment, instilling the prescribed medication in the medication cup of the nebulizer mask, and placing the nebulizer mask on the resident. Nurse will then instruct the resident to take slow deep breaths and exhale slowly, then administer the medication until medication is depleted. The nurse is then to assess and evaluate the resident's response to the treatment, disassemble the device, rinse the nebulizer cup and allow it to dry before placing it in a bag that is maintained in the resident's room.On review of the procedural guideline for instillation of eye drops instructs that the nurse will gently pull the lower eye lid down and instruct the resident to look up while instilling the medication into the mid lower eye lid without touching the eye or eyelid with the dropper. Then to instruct the resident to close his / her eyelid to allow for even distribution of the drops, then gently dry the eyelid with a cotton ball if dripping occurs.On review of the procedural guideline for installation of ear drops instructs the nurse to gently cleanse the external auditory canal with [NAME] applicators, draw the warmed medication into the dropper and gently instill the medication into the ear. Then the nurse is to grasp the flap of the ear to straighten the canal and allow medication to enter the ear, then place a small amount of cotton in the external ear canal to prevent medication from running out.Documentation confirmed that Staff A had been reviewed and approved on all of these procedures.

Based on observation, interview, and policy review, the facility failed to provide an environment that is free of offensive odors and failed to maintain a sanitary and clean environment in 7 of 15 rooms on the 300 unit and 8 of15 rooms on the 400 unit. (Rooms identified are 341, 342, 348, 352, 353, 354, 355, 456,461,464, 466, 467, 468, 469, 470, including the patio outside the 400 unit.)The findings include:On 4/29/26 upon entrance to the facility, a strong, pungent urine-like smell was noted. The smell of urine was present throughout the facility but noted to be stronger on the 200, 300, and 400 halls. On 4/29/26 at 10:30 AM, upon entry into the facility and while observing the clinical nursing units, a strong odor of urine was noted. At 10:40 AM an observational tour was conducted on unit 300 and 400 nursing units, where a strong odor of urine was noted. The 300-unit hallway observation revealed torn flooring, food particles, and a butter knife laying in the floor in the hallway. room [ROOM NUMBER] had a straw and multiple food particles lying on the floor and broken blinds on the window. The bathroom had a dark brown color stain on the wall, rusted ceiling tile trim, the toilet has a brownish like substance inside of it, and the floor surrounding the toilet appears wet. No trim was observed around the base of the toilet, exposing a black mold like substance. Corrosion was observed on the sink faucet handles and surrounding area and appears to be leaking at the base of the faucet. There were rusted pipes under the sink with a buildup of corrosion. A rusted sprinkler head was observed in the bathroom. The door facing was rusted and scrape marks were noted on the door jambs, with paint peeling. room [ROOM NUMBER] had a three in one toilet with duct tape noted on the front of it, rusted and corroded pipes under the sink. The door was observed with scuff marks and paint peeling exposing the wood of the door. A black substance that has a mold-like appearance was observed on the bathroom walls. room [ROOM NUMBER] had corrosion on the fixture above the toilet that is brown and blackish in color. A black substance was observed on the bathroom walls. room [ROOM NUMBER] had no cover on the outlet with an oxygen concentrator plugged into the wall. room [ROOM NUMBER] had boards covering the window in the room. room [ROOM NUMBER] and 354 had no coverings on the lights over the bed with sockets exposed. One light fixture had only one light bulb. room [ROOM NUMBER]'s resident bed appeared dirty with a black substance noted on the foot of the bed, room [ROOM NUMBER] had a broken cover on the outlet, the dresser drawer facing is sitting on the floor next to the dresser, bathroom fixture above the toilet had a brown substance on it and on the wall below it. room [ROOM NUMBER] had dark colored areas along the side of the wall by the toilet, chipped paint on the wall, and, on the opposite side of the wall in the bathroom, there was scattered black substances on the wall and baseboard trim. An observational tour of the 400-unit hallway revealed: Upon entry through the locked unit doors, a strong odor of urine was noted. room [ROOM NUMBER] bathroom had a missing ceiling tile, broken emergency light covers with no pull string, and the toilet cover does not fit over the back of toilet tank. room [ROOM NUMBER]'s toilet tank cover did not fit properly, exposing the inside of the tank. room [ROOM NUMBER] was observed with torn toilet paper and used briefs lying in the corner of the bathroom floor. room [ROOM NUMBER] was observed with what appeared to be a brown rust- like substance inside the toilet bowl. The bathroom door facing appeared cracked with a brown substance noted along the side. In rooms [ROOM NUMBER], the bathroom toilets appeared to have a brownish blackish substance build up surrounding the bases of toilet with broken, peeling trim. room [ROOM NUMBER]'s light base on the wall appeared to have a rust-like appearance on the light fixture base attached to the wall, broken blinds observed on the windows in multiple rooms, and no outlet cover observed in room with cords plugged into the wall. room [ROOM NUMBER] appeared to have a reddish-brown substance on the wall, and broken blinds in the room. room [ROOM NUMBER] and 470 had no blinds covering windows, beds were unmade, no outlet covers were covering exposed wire coming from the wall. The toilet had a dark brown blackish color ring around the base and flooring, uncovered light fixture on wall above the television. room [ROOM NUMBER]'s bathroom sink appeared to be leaking and the pipes connecting to had a rusted like appearance. room [ROOM NUMBER] had loose flooring in the room, the toilet had a loose cover on the tank and a brown rust like stain substance inside the toilet base with the toilet seat being loose and sitting crooked on the toilet. A dry red substance was noted on the door frame leading into the bathroom. Observation of units made on 4/29/26, 4/30/26, 5/1/26, and 5/2/26 with the same results listed above. (photographic evidence obtained) On 4/30/26 at 10:00 AM the Administrator came to the locked unit; she entered the code into the keypad and walked down the outside patio walkway. She stated there was a pad lock on the gate in the back because the gate code was broken. Observation of the patio and outside back fencing revealed limbs from palm trees lying on the grass next to sidewalk and woodened fence railings. Observation of the woodened fence railings aligning the sidewalk on both sides revealed broken and rotted like boards and unsteady railings, multiple exposed rusted nails sticking up from the railings where boards are broken off and splintered off from base of railings. An overgrowth of tree limbs and bushes from the perimeter surrounding the fencing is observed coming through between the railings of the fence. Upon asking about the condition of the fencing, the Administrator stated that the area was not safe for residents, but they are planning to have it all redone this summer, (photographic evidence obtained). On 4/30/26 at approximately 4:00 PM, Staff L, Licensed Practical Nurse (LPN) was interviewed on hallway 200 regarding the urine odor. Staff L stated that the facility usually smells like urine. Staff L stated that the 200 hall residents defecate and urinate on the floor. She stated that housekeeping staff should clean those rooms more frequently and that the building is old and the smell has seeped into the floor and walls. On 4/30/26 at approximately 9:30 AM. Staff Q, Housekeeping was interviewed about the strong urine odor. Staff Q stated that staff clean resident rooms daily, but the disinfectant cleaner used has no air freshening effect to help mask odors. On 4/30/26 at 11:00 AM, an interview was conducted with Staff R, Housekeeping. She revealed that she had been employed at the facility for about a month and she worked 5 days per week on the 400 unit. She described her work duties as standard cleaning, of rooms, hallway, and common areas that involves sweeping, mopping, cleaning the bathrooms, and removing the trash from the rooms. Upon asking what her responsibility was when she saw broken equipment, broken blinds, or anything in residents' rooms that required repairs, she stated, I put it in the work order book at the nursing station, or I will text maintenance with my concerns. Upon asking if she has noticed any concerns with stains or appearance of biohazard materials on the walls and door frames, anything that requires repairs of the residents' rooms and bathrooms? She stated, No, I'm in there pretty much in the rooms every day to clean them. On 4/30/26 at 2:00 PM, an interview was conducted with the facility Maintenance Director, who revealed that he has been employed since September 2025. He stated that he and one other maintenance person worked at the facility. He stated they checked the work orders daily and throughout the day, but sometimes the staff would tell them verbally something needed to be repaired. In that instance, he said he would remind the staff to write what needed to be fixed in the work order book at each nurse's station. When asked if he was aware of the rooms and equipment on the 300 and 400 units that required repair, he stated he was not aware of the issues listed above. On 5/1/26 at approximately 9:45 AM, an interview was conducted with the facility Environmental Services Director regarding the persistent odor of urine throughout the facility. The Environmental Services Director stated the smell was not due to a lack of cleaning because staff cleaned resident's rooms daily. She stated that the nursing staff must clean potentially infectious waste before housekeeping can sanitize the area. She stated delays by care staff postponed housekeeping arrival to the site. She further stated that it is an old building, the odor has seeped into the floors, and the cleaning chemicals disinfect and sanitize but do not deodorize. On 5/2/26 at 1:30 PM, an interview was conducted with the Director of Nursing (DON). When asked about the broken blinds, leaking faucets, and environmental concerns observed on 300 and 400 units, she stated they had changed out blinds, about 20 of them and they have bought new cabinets and door handles. When asked about expectations of the cleanliness of the residents' rooms and the facility, she responded that they were directed to use standard precautions when cleaning rooms. The Director of Nursing stated no policy specific to cleaning the environment was available. Review of the Housekeeper job description under section Duties and Responsibilities revealed, purpose of job position is to perform the day-to-day activities of the housekeeping department in accordance with current federal, state, and local standards, To coordinate daily housekeeping services with nursing services when performing routine cleaning assignments in residents living and / or recreational areas. on a daily basis, clean all areas of the facility assigned. adhere to all facility sanitation, safety, and infection control procedures, report any maintenance problems noted during cleaning routine. Ensure that assigned work areas are maintained in a clean safe comfortable and attractive manner. A review of facility policy entitled Policies and Practices - Infection Control, undated, stated, Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public.

Based on observation, interviews, and record review, the facility failed to provide the necessary care and services to maintain grooming and incontinence care for 1 of 2 residents sampled for incontinence care (Resident #7).The findings included:On 4/29/26 at 3:45 PM, Resident #7 was observed standing in the doorway of his room holding onto a wheelchair. Resident #7's navy-colored pants were observed to be wet, covering the seat of his pants extending down both legs to the calves. Resident #7 had a strong odor of urine and stated, I have been waiting on them to change my clothes. A follow up observation was made on 4/29/26 at 5:18 PM. Resident #7 was observed to be wearing the same soiled navy-colored pants and red shirt, seated in a wheelchair next to the nurses' station.An observation was conducted of Resident #7 on 4/30/26 at 1:20 PM. Resident #7 was observed wearing the same soiled clothes as the previous day. Resident #7 smelled of urine, and his shirt was soiled with food and a dark liquid. Upon interview, Resident #7 stated that he wanted fresh clothes and that he had asked for assistance from staff, but staff had not come to help. Resident #7's room had a strong odor of urine, and the bed was soiled with urine. Two pairs of pants were observed on the chair in Resident #7's room. No other clothes were observed inside the room. On 5/1/26 at 11:45 AM, Resident #7 was observed to be seated on the edge of his bed wearing khaki-colored pants and no shirt. The sheets underneath him were noted to be soiled and yellow. Resident #7's soiled red shirt and navy-colored pants from the previous 2 days were observed on the floor at the end of the bed. Resident #7 stated that, despite requesting assistance with changing clothes, no staff had come, so he had to change himself.A review of Resident #7's medical record revealed he had a history of a stroke, seizure disorder, anxiety, depression, psychotic disorder, and repeated falls. Review of the most recent Quarterly Minimum Data Set (MDS) revealed that Resident #7 had a Brief Interview for Mental Status (BIMS) score of 10 which indicates he was moderately cognitively impaired. The MDS documented Resident #7 was independent for toileting, showering, personal hygiene, and dressing. The MDS stated Resident #7 was occasionally incontinent of bowel and bladder. Review of Resident #7's Care Plan dated 3/26/26 revealed the care plan did not include what level of assistance Resident #7 required from staff for incontinence care and other activities of daily living. An interview was conducted with Staff O, Licensed Practical Nurse (LPN) on 5/1/26 at 11:50 AM. Staff O stated she was familiar with Resident #7 and that he did require staff assistance with bathing, dressing, grooming, toileting, and incontinence care. Staff O confirmed that Resident #7 did not refuse assistance with personal cares and that he was compliant with requesting staff assistance for activities of daily living. Staff O stated that Resident #7's personal clothing was labelled with his name and washed at the facility. However, Staff O stated the laundry staff did not return the resident's laundry to their individual rooms but rather left the clean laundry it in a bag in the linen room for the nursing staff to put backAn interview was conducted with the facility Director of Nursing (DON) on 5/3/26 at 11:40 AM. The DON stated the nurses and Certified Nursing Assistants (CNAs) were expected follow standard best practices when providing resident care. She further explained this included frequent rounding, keeping incontinent residents clean and dry, turning and repositioning of dependent residents, and all other care areas. The DON stated staff were educated during new hire orientation and during morning meetings that the residents required incontinence care every two hours and as needed and that this was best practice and the standard for nursing care in general. When a copy of the facility's policies for incontinence care and activities of daily living care was requested, the DON stated that facility did not have an Activities of Daily Living (ADL) policy, resident care policy, or quality of care policy. The DON stated that the expectation was that nurses and CNAs completed rounds on all residents every two hours and as needed, especially if resident was incontinent. The DON said if a resident was known to be a heavy wetter, the staff were expected to round more frequently. The DON also stated that all of the facility's residents required some level of assistance from staff for care and activities of daily living.

Based upon interviews and record reviews, the facility failed to notify state and federal agencies of an incident involving elopement of a resident from the facility for 1 of 2 residents reviewed for elopement. (Resident #5)The findings include:During review of facility incidents, it was documented that on 2/28/26 at approximately 12:15 PM, Resident #5 exited the facility building from his bedroom window and walked across the facility property toward the perimeter fence. It was documented that a CNA saw Resident #5 and called out for assistance. It was documented that staff were able to redirect Resident #5 and escort him back to the facility where he was placed on one-to-one supervision for safety. It was documented that facility maintenance conducted an inspection on all window seals in Resident #5's room to ensure proper securement was in place. It was noted that this investigation did not include any staff or witness statements for review.An interview was conducted with Resident #5 on 5/1/26 at 10:30 AM concerning his leaving the facility on 02/28/26. Resident #5 remembered the event and was able to retell the details of what happened. He also recalled that he was brought back to the facility by staff and the police man. Upon returning to the facility, he stated, the police informed me that I shouldn't be leaving the facility like that and that I did not need to do it again. Upon request, the local police department shared a police report which documented they had an encounter outside the facility with Resident #5 on 2/28/26. The report confirmed a police officer helped facility staff escort Resident #5 back to the facility without incident.An interview was conducted with Staff G, Maintenance on 4/30/26 at 2:00 PM regarding the elopement investigation for Resident #5. Staff G confirmed that he was working on 2/28/26. Staff G stated he was the staff member who saw Resident #5 outside of the facility and escorted him back to the facility with a police officer. He recalled that Resident #5 exited the facility by climbing out of the window of his room. Staff G stated Resident #5 then went through the gate located at the back of the facility's property and left the facility premises. Staff G stated, I was able to reach [Resident #5] down the road. I was able to get [Resident #5] to stop walking and I re-directed him back to the facility with the assistance of law enforcement. Law enforcement spoke with [Resident #5] at the facility in regard to the incident and why he left the facility. An interview was conducted with the facility Director of Nursing (DON) on 4/30/26 at 3:00 PM. The DON confirmed an incident that occurred in late March or early April where [Resident #5] climbed out the window and was seen outside by a staff member. The staff member alerted other staff of the resident being outside and was brought back to the facility by [Staff G]. She stated that Resident #5 never left the facility grounds and was brought back to the facility without any injuries. When asked if Law Enforcement was notified of this elopement, the DON stated, No, they were not notified, not that I am aware of. I discussed it with the Corporate Regional Director and, because he never left the grounds and staff had eyes on him the whole time, it was not reportable. The DON further stated, It wasn't something we concentrated on because the staff responded very well to the incident.A follow up interview was conducted with the DON on 5/2/26 at 1:30 PM. She reiterated, I did not have to report this incident due to staff having visual contact with Resident #5 the entire time. I used this incident as a drill and educated staff. Upon asking if law enforcement was notified of the event, she stated, Yes, but they did not do anything, they did not come to the facility or give us a report on it. Upon informing the DON of the police report received by the local police department, she stated, they never came into the facility, they only stood out on the porch and spoke to staff and [Resident #5]. The DON confirmed she was required to report any incident in which law enforcement investigates or responds.Review of the facility policy titled Incidents and Accidents, dated 4/24/25 revealed it is this facility policy for staff to report . any accidents or incidents that occur . on facility property and may involve . a resident and ensure residents receive adequate supervision to prevent accidents.

Based on observations and interviews, the facility failed to ensure residents in the 400 Hall Memory Care Unit lived in a clean, comfortable, homelike environment. The findings include:On December 8, 2025 at 1:40 pm, a tour of the facility's Memory Care unit (400 Hall) revealed the floors throughout the unit had food/debris. The floors were sticky in the Dining area and throughout the all the resident rooms. room [ROOM NUMBER]'s floor was full of debris and food. room [ROOM NUMBER] had a mattress on the floor with fall mats. The floors were extremely dirty, the mats were dirty, and the sheets on the bed were stained. (photographic evidence obtained)At this time, Staff A, Personal Care Assistant (PCA), was observed using a mop at the end of the hallway. When asked about housekeeping, he stated he is normally a PCA but all of maintenance and housekeeping called out sick today, so he was fulfilling those duties. At 2:00 pm, an interview with the Director of Nursing revealed several staff in housekeeping called out sick today. She advised they will address the cleanliness immediately. An interview was conducted with Staff B, Registered Nurse (RN), who was passing medications on the hallway. When asked about the state of the floors and resident rooms, she stated the cleaning definitely needs to improve on this unit and agreed the floors were not clean and had a sticky substance.At approximately 3:15pm, a second observation of room [ROOM NUMBER] revealed the floors had been swept and mopped and the fall mats had been cleaned off; however, the mattress still had stained/soiled bedsheet.

Based on resident council interviews, review of resident council grievances, staff interviews, and policy reviews, the facility failed to demonstrate acting upon 1 of 1 sampled grievances filed by the resident council regarding food. The findings include: A meeting was held with the Resident Council members in the facility on 5/7/25 at 2:20 PM, which included Residents 2, 17, 30, 32, and 55. During the meeting, the residents voiced ongoing concerns about the variety and quality of the food served by the facility. The residents stated the food was sub-par and the menu changed based on what the kitchen has available. The only alternate meal items that are available were a grilled cheese sandwich, egg salad sandwich, tuna sandwich, or peanut butter and jelly sandwich. They have voiced several complaints about the food and do not always receive the monthly resident choice meal either. They can no longer have fried chicken because the facility cannot purchase oil to fry the chicken, and they bake the chicken instead. They stated that families bring in food from outside to the residents. The Resident Council meeting minutes dated 2/27/25 revealed the residents wanted meal changes and different food. The Resident Council minutes dated 12/2024 revealed that the residents wanted a change of their food menu. A grievance filed by the Resident Council dated 3/19/25 and documented by the Social Services Director revealed a concern with the lack of variety of food and having the same dinners over and over. The findings of the investigation stated,Pictures of portion sizes and repetitive menu items sent to corporate. Plan to resolve grievance: facility will work with contracted company to improve portion size and variety of menu items offered. Expected results of actions taken: corporate to work with agency providing kitchen food services to improve food offered to residents. Post-investigation follow-up notes indicate that the grievance was not resolved and the facility continues to work with the agency to provide better food options. The original complainant stated they were not satisfied and had ongoing concerns with food. The investigation results and resolution steps were reported to Resident Council dated 3/26/25. An interview was conducted with the Dietary Manager on 5/8/25 at 9:55 AM. She stated that the Resident Council has complained about portion sizes and the quality of the food served by the facility. She had no knowledge of the grievance filed by the Resident Council on 3/19/25. She stated the menu was changed to the summer menu but that was not in response to the grievance and was a routine process this time of year. She stated the last resident choice monthly meal was served in February 2025 and she had not received the requested meals from the Activities Director monthly. An interview was conducted with the Social Services Director on 5/8/25 at 10:15 AM. She stated the Resident Council had ongoing concerns with the food and lack of variety. The staff were to take pictures of the food and send to corporate. She stated a contractor has a budget for the food and oversees the purchases for the food supply. She stated the grievance was reported to the corporate entity and she was not able to provide any evidence of measures the facility took to resolve the grievance or follow-up regarding the food. The facility policy for Grievances (dated 9/7/23) states, The center will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and inform the resident of progress towards resolution. The resident should have reasonable expectations of care and services and the center should address those expectations in a timely, reasonable, and consistent manner.

Resident #51 On 05/08/25 at 09:08 AM, an observation of Resident #51 revealed the resident was sitting next to beauty salon waiting to get her hair done this morning. When asked if she felt that she was being treated with dignity and respect, she stated that they aren't treating me right. When asked who is not treating her right, she responded, all of them. The resident was well dressed and groomed. On 05/08/25 at 12:06 PM an interview was conducted with the daughter of Resident #51. She stated there were times when the aids were rough with her mother. She stated her mother complains a lot about the staff. She knows her mom has dementia, but she can still say what is going on around her. A review of the care plans for Resident #51 revealed there were no care plans in place for the resident behaviors or false allegations. Resident #51 has care plans risks for falls/injury related to falls related to History of falls, Impaired mobility, Poor balance, Poor safety awareness, Cognitive status increases risk, Forgets to use assistive devices, Antidepressant medications, antiplatelet medication use, Visual deficit and Risk for alteration in communication related to being Hard of Hearing. However, there are no care plan interventions in place for behaviors as described by the staff for Resident #51. On 05/08/25 at 12:31 PM, an interview was conducted with the DON. The DON stated Resident #51 complains about a lot about things. The facility has had many aides not coming back to work because of the demands the daughter has made. When asked why these behaviors are not in her care plan, she stated that the behaviors should have been care planned. Based upon observations, record reviews, and interviews, the facility failed to provide a comprehensive person-centered care plan process to meet the needs and services for six out of twenty-one residents reviewed. (Residents #5, #10, #27, #79, #31, and #51) The findings include: Resident #5 A record review on 5/6/25 of Resident #5 revealed diagnoses of Chronic obstructive pulmonary disease (COPD), Dementia, Schizophrenia, Cerebrovascular accident (CVA), Type 2 Diabetes, Epilepsy, and Heart Failure. A plan of care was initiated on 8/26/24 for review of functional abilities with goal to maintain current level of functioning abilities but no interventions were in place. Resident #5 had no plan of care in place prior to 5/7/25 for limited range of motion. This plan of care was initiated post interview with the Director of Nursing (DON) on 5/6/25. The DON stated that the facility only had a partial restorative program in place for dining activities only. Resident #10 A record review on 05/06/25 for Resident #10 revealed diagnoses of Chronic respiratory failure, Arteriosclerotic Heart Disease (AHD), systolic congestive heart failure, Paraplegia, Type 2 diabetes, and epilepsy. Resident #10 is on hospice services. Resident #10 requires oxygen at 2 liters per minute by nasal cannula continuously except when smoking. The plan of care does not reflect if Resident #10 is a safe smoker and does not reflect that she requires supplemental oxygen therapy. Resident #10 has a indwelling foley catheter with current interventions: position catheter and tubing below bladder and away from entrance room door and to monitor for pain and discomfort only. Resident #27 A record review on 5/7/25 for Resident #27 revealed diagnoses of CVA, Dementia, COPD, Atrial fibrillation (AFIB), Cognitive communication deficit and requires assistance with personal care. Resident #27 has a elopement risk plan of care initiated on 3/17/25 with interventions to include monitor for fatigue and secure unit. Resident #27 is currently not residing on a secure unit. She has a plan of care for alteration in functional performance with current interventions that include providing a wheelchair with partial / moderate assistance of 1 person and reporting changes as needed. Resident #27 does not have a plan of care for Dementia, CVA, behaviors related to psychotic disorders, or for communication deficit. Resident #79 A record review on 5/6/25 for Resident #79, who was admitted to facility on 1/12/25, revealed diagnoses of CVA, Dementia, phonological disorder, type 2 diabetes, and receiving hospice services. Resident #79 requires cueing, supervision, and minimal assistance with Activities of daily living. On 1/24/25, a care plan was initiated for alteration in functional status with intervention to report changes in functional performance. A plan of care for alteration in activities of daily living was not initiated until 05/05/2025. Resident #79 was admitted to the facility with hospice services, and a plan of care was initiated on 1/13/25 for end stage disease process. On 5/5/25, a plan of care was initiated for Hospice services with a terminal diagnosis. On 5/5/25 a plan of care was initiated for diabetes, incontinence of bladder, and incontinence of bowel, although he was admitted to facility on diuretic medication. Resident #31 A record review on 5/7/25 revealed Resident #31 had diagnoses of Atrial Fibrillation, Type 2 Diabetes, Epilepsy, AHD, Cardiac pacemaker, Cirrhosis of the liver, and Hepatic encephalopathy. There were no plans of care specific for each disease process for Resident #31. Resident #31 had a plan of care for antibiotic therapy initiated on 2/10/2025 with a goal for the resident to be free from complications related to infection. She is care planned for emotional and physical trauma with a goal that she will feel safe and supported. She is care planned for alteration in functional status with intervention for one staff member to assist with personal care and to report changes; high risk medication use with intervention to monitor for side effects of medications and report changes. On 5/8/25, an interview with DON was performed about the care plans. She acknowledged that these care plans did not directly address the residents' care needs.

Based upon observations, interviews and record reviews, the facility failed to meet the needs and services of resident number 27 who is unable to carry out activities of daily living. The findings include: An observations was conducted on 05/05/27 at 12:30 PM revealed resident 27 lying in bed with her head resting against the side rail, hair appears tangled, unkept, and messy with her bangs hanging over into her eyes. Resident 27 teeth appear to have yellowish colored substance build up around teeth and gums when she smiled, shirt unclean with notable stains on the front of the shirt. On 5/6/27 at 08:40 AM resident 27 is observed laying in bed with a yellow and white striped shirt on, pulled up to her upper torso just below her breast area, incontinent brief on, with a white thin sheet covering her lower extremities. Her teeth is observed with a thick yellowish substance around her teeth and gum line. Her hair is messy and unkept. An observation was made on 5/6/27 at 12:21 PM of resident 27 coming out of dining room with assistance from staff noted to be in a pair of black pull up pants, incontinent brief appearing over the top of her pants, white short with tan and brown stains on left arm sleeve of shirt, on the front of her shirt down to her torso area, shirt is pulled up exposing her abdomen area, hair is messy with food particles in her lap. At 01:30 PM and 04:01 PM resident is sitting I wheelchair at nurses station, slumped down in the wheelchair with her legs extended outward in front of her, eyes closed, her head is resting on the left hand, she is wearing the black pants and white stained shirt with food particles in her lap. An observation was made on 5/7/25 at 12:00 PM sitting in hallway in her wheelchair at nurses, she is dressed in a dark pink pair of capri pants and matching top, yellow non-skid socks on bilateral feet. She has food particles and stains on the front of her shirt and in her lap. Her hair is disheveled, and her bangs are hanging in her eyes. Her teeth continues to have thick yellowish build up around them and her gumline. On 05/07/25 at 03:30 PM and at 06:00 PM resident 27 is observed sitting up in wheelchair, with same dark pink clothing on with continued food stains and food particles on her clothing. She is in slouching position with feet extended outward in front of her; her upper back and neck area is resting against the back top of the wheelchair and has her head propped up against her left hand. On 5/08/25 at 08:10 AM an observation of resident 27 revealed her laying in bed with a pajama top on, navy blue with small different color flowers on it, food particles on her mouth, lips and on the front of her shirt. A white sheet is noted to be covering her from the waist down. Hair is messy and appears unkept. Her teeth has a thick yellowish substance around her gum line and teeth. At 11:45 AM an observation of resident sitting in dining room, hair appears to be brushed, staff member states, the therapist just brought her in here, she is in a shirt sleeve multicolored striped shirt and dark blue pants. Her teeth continues to have a thick yellowish substance around her gum line and teeth. Upon record review the MDS assessment with ARD date of 3/11/25 section GG indicates resident 27 requires moderate to maximum assistance with personal hygiene care, showers, incontinent care, dressing, toileting, and transfers. Resident 27 plan of care reveals resident 27 has an alteration in functional performance, requires assistance to complete self-care tasks with goal that resident 27 will maintain the highest practical level of functioning performance, Interventions include staff will provide assistance with hygiene, mobility, dressing, grooming, oral care, and toileting needs.

Based upon observations, interviews and record review, the facility failed to provide care and services for 1 of 1 residents reviewed for range of motion (Resident #5). The findings include: An observation of Resident #5 was made on 5/6/25 at 08:30 AM. The resident was lying in bed awake and alert, with the head of the bed (HOB) elevated at an approximately 90-degree angle. The bedside table was placed in front of Resident #5 across her lap area with her breakfast tray sitting on top. Resident #5 reached for her cup with her left hand. Her left hand had a contracture with the third, fourth, and fifth digits resting on her left inner palm. No splints or devices were observed on her left hand. At 12:00 PM, Resident #5 was observed sitting up in her bed with the HOB elevated at a 90-degree angle. Her lunch tray was sitting on top of the bedside table. Again she was observed without splints or devices to the left hand. Further observations on 5/6/25 at 2:00 PM and 4:30 PM; on 5/7/25 at 8:30 AM, 11:30 AM, 1:00 PM, and 3:30 PM; and on 5/8/25 at 8:33 AM, 9:30 AM, and 12:00 PM revealed that Resident #5 did not have any splints or devices in her left hand to address the contractures. On 5/8/25, Staff Member B (a Certified Nursing Assistant (CNA)) was at her bedside assisting resident 5 up out of bed. An interview was conducted with Staff Member B at that time. She revealed that she is the restorative aide for the facility. She was asked about Resident #5's contracture to her left hand. Staff Member B stated the resident has had these contractures since she was admitted to the facility. Staff B stated they provide range of motion and splints devices for Resident #5 when they have enough staff. Staff B stated she has to perform regular CNA duties at least three times a week if not more. Staff Member B stated they have not had a restorative program for a while, but she became the restorative aide in January of this year. Her job duties include splints, range of motion, dining, and all the monthly and weekly weights for the entire facility. Upon record review of the Minimum Data Set (MDS) assessment from 2/17/25, it was discovered that Resident #5 has a Brief Interview for Mental Status (BIMS) score of 6. The MDS revealed that Resident #5 has impairment to upper extremity and impairment to bilateral lower extremities. A review of physical and occupational therapy screenings revealed the resident's initial physical therapy screening was conducted on 8/20/24, revealing that Resident #5 had functional limitations due to contractures and limited range of motion to right hip, right knee, left hip, and left knee. Her Discharge summary dated [DATE] from physical therapy services reveals recommendation for 24-hour care, but no restorative and functional programs indicated at this time. The initial occupational therapy screening dated 8/24/24 revealed right and left upper extremity were Within Functional Limits with no contractures noted. The occupational Discharge summary dated [DATE] recommends 24-hour care but no restorative program or functional maintenance program not indicated at this time. A record review reveals a care plan for alteration in functional performance due to a history of CVA and left side hemiparesis with a left hand contracture that was initiated on 8/26/24. An interview with the Director and Assistant Director of Nursing was conducted on 5/7/25 at 02:20 PM. They stated that the facility had a partial restorative program for dining only. A care plan was initiated on 05/07/25 for alteration in musculoskeletal status related to left hand contracture and will remain free from pain and will remain free from complications related to left hand contracture.

Based on resident interview, record review, and staff interview, the facility failed to provide appropriate care and services of an arteriovenous (AV) fistula for 1 of 1 sampled residents receiving dialysis services. (Resident #39) The findings include: An interview was conducted with Resident #39 on 5/6/25 at 9:15 AM. She stated she had a new fistula in her left arm and the nursing staff did not touch, palpate, or assess the fistula. A review of the resident's medical record revealed the new AV fistula was placed on 4/10/25. The record revealed no physician's orders to check the bruit and thrill of the fistula until an order was placed on 5/7/25. (A thrill is a vibration felt when touching the fistula, and a bruit is a swishing or whooshing sound that can be heard with a stethoscope over the fistula. Both are indicators of normal blood flow through the fistula and are essential for its proper function.) A review of the hospital discharge instructions dated 4/10/25 revealed on page 7 that the fistula site should be checked daily to make sure the thrill feels the same. The record revealed the thrill was only assessed by nursing staff on 4/12/25, 4/13/25, and 4/20/25. An interview was conducted with the Director of Nursing (DON) on 5/8/25 at 11:12 AM. The DON stated the resident had no orders prior to 5/7/25 to monitor the bruit and thrill of the new fistula in her left arm. She stated the resident should have had the bruit and thrill monitored since the fistula was placed on 4/10/25.

Based on record review and staff interview, the facility failed to provide medication to prevent hepatic encephalopathy (swelling of brain caused by liver disease) as prescribed to Resident #31 who subsequently experienced a change in condition which required transfer to a hospital. The findings include: A record review conducted on 5/6/25 for Resident #31 revealed that the resident was admitted to the facility with a diagnosis of hepatic encephalopathy and liver cirrhosis (scarring of the liver affecting its function). Resident #31 was prescribed rifaximin 550 mg (milligrams) twice a day to treat hepatic encephalopathy . The nursing home medication administration record and progress notes revealed that Resident #31 did not receive rifaximin 1/27/25, 1/26/25, 1/24/25, or 1/18/25 due to the medication not being available from the pharmacy. On 1/31/25 a change of condition progress note revealed Resident #31 was experiencing increased tremors, increased confusion with sudden decline in self-care activities of daily living . A review of the hospital notes found on 1/31/25 Resident #31 was transferred to an acute care hospital for altered mental status exhibiting uncooperative behaviors and tearfulness. Upon further review the hospital discharge summary report dated 2/4/25 documented the nursing home was out of the rifaximin for the last several days. A review of the package insert for rifaximin found that an indication for use is to reduce the risk of overt hepatic encephalopathy (HE) recurrence. Symptoms of hepatic encephalopathy range from mild cognitive changes to severe neurological disturbances, including confusion, disorientation, and even coma. An interview conducted with Director of Nursing (DON) on 5/6/25 at approximately 10:00 AM revealed that Resident #31 has episodes of confusion but is cooperative with care and services. The DON further stated, on most days, Resident #31 will be up out of bed, dressed and groomed with her hair done and make-up on; with other days when she will sleep most of the day. The DON stated that Resident #31 becomes more confused and more emotionally upset when she does not get her liver medications. The DON stated the pharmacy sends only a five-day supply of rifaximin at a time because it is really expensive, costing over $100 dollars per day. The surveyor inquired about the several days of missing medication, and the DON responded that Resident #31 only missed that one day, on 1/31/25, when she went out to the hospital. The DON declined to comment on the multiple missed doses of rifaximin as indicated by the MAR.

Based on policy review, record review, and staff interview, the facility failed to provide documentation that 5 of 6 residents reviewed received education and were offered the pneumococcal immunization. (Resident #72, #21, #76, #14, and #50) The findings included: Upon a review of Residents #72, #21, #76, #14, and #50's medical records, it was discovered that they were missing documentation about Education and Consent or Declination of the COVID Immunization. After reviewing the paper and electronic medical record, an interview with the Assistant Director of Nursing (ADON) was conducted on 05/6/25 at 12:45pm about how often the COVID vaccines are offered. The ADON stated they are offered yearly in the fall. If a resident declines immunizations, the ADON stated There should be a declination on the chart. An interview was conducted with the facility's Director of Nursing (DON), Assistant Director Of Nursing (ADON), and Administrator on 05/06/25 at approximately 2:30 pm. The DON stated that every resident receives education on immunizations on admission and, if they decline, there should be a declination form in the chart. When informed that no such forms were present for Residents #21, #76, #14, and #50, they attempted to locate these forms, However, they were unable to provide this documentation. The facility's admission Packet states that every resident is to be offered a form to be educated and offer a COVID vaccination if indicated. Resident or residents' representative is required a signature to indicate if patient will receive or decline a COVID immunization.

Based on observation, resident interviews, and staff interviews, the facility failed to maintain resident equipment in a safe and sanitary manner in 1 of 20 rooms. (room [ROOM NUMBER]) The findings include: On 05/05/25 at approximately 12:00 pm, upon observation of room [ROOM NUMBER], it was noted that the base boards visible from the entrance of the room were damaged, cracked, and held together with blue painter's tape and that the bed frame of one of the residents in this room had extensive rust covering more than half the length of the bed. On 05/06/25 at approximately 12:50pm, an interview was performed with Maintenance Employee A and the Administrator about maintenance issue tracking. Employee A stated that he rounds daily to make sure exit doors are working properly, inspects the hallways for anything obvious that might need fixing, and checking the maintenance log that is located at each nurse's station. When asked about the rusted bed frame and baseboards from room [ROOM NUMBER], Employee A stated that he knows beds are on order and was not aware of the extent of rust on the bed and about the damaged based boards. The maintenance log at the nurse's station indicated that replacement light bulbs were needed in room [ROOM NUMBER] on 05/05/25. Employee A stated that he did enter the room that day to replace the bulbs but did not sign that he completed the work order, nor did he notice the rust on the bed or the broken base boards with blue painter's tape. On 05/07/25 at approximately 12:00pm, an interview took place with the Administrator about the bed frame. At approximately 12:20pm, the Administrator came to clarify that bed order information was requested. However, on 05/08/25 at approximately 2:00 pm, the Administrator confirmed that no beds have been ordered at this time.

Based on policy review, record review, and staff interview, the facility failed to provide documentation that 4 of 6 residents reviewed received education and were offered the pneumococcal immunization. (Resident #21, #76, #14, and #50) The findings included: Upon a review of Residents #21, #76, #14, and #50's medical records, it was discovered that they were missing documentation about Education and Consent or Declination of the Pneumococcal Immunization. After reviewing the paper and electronic medical record, an interview with the Assistant Director of Nursing (ADON) was conducted on 05/6/25 at 12:45pm about how often the flu and Pneumoncoccal vaccines are offered. The ADON stated they are offered yearly in the fall. If a resident declines immunizations, the ADON stated There should be a declination on the chart. An interview was conducted with the facility's Director of Nursing (DON), Assistant Director Of Nursing (ADON), and Administrator on 05/06/25 at approximately 2:30 pm. The DON stated that every resident receives education on immunizations on admission and, if they decline, there should be a declination form in the chart. When informed that no such forms were present for Residents #21, #76, #14, and #50, they attempted to locate these forms, However, they were unable to provide this documentation. The facility's policy titled Pneumonia Vaccine (effective date 09/07/2023) states: * Prior to or upon admission, residents are assessed for eligibility to receive the the pneumococcal vaccine series, and when indicated, are offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated *Assessments of pneumococcal vaccination status are conducted within five working days of the resident's admission if not conducted prior to admission. * Residents/representatives have the right to refuse vaccination. If refused, appropriate information is documented in the resident's medical record indicating the date of the refusal of the pneumococcal vaccination protocol

Based on observation of laundry storage and laundry procedures, staff interviews, review of the laundry policy, review of laundry training, and review of job descriptions, the facility Administration failed to provide oversight in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable level of well-being for all 68 residents in the facility. Administrative staff failed to ensure that essential equipment, washing machines, were in working order and facility textiles and resident clothes were stored, sorted, processed and transported in a manner to prevent cross-contamination in accordance with facility policy. The facility failed to ensure that the facility Infection Preventionist had oversight of the laundry procedures. The facility failed to update their laundry procedures to ensure hygienic laundry after both facility washing machines failed, and the facility made the determination to utilize a local laundromat. The facility had 2 commercial grade washing machines, one broke in December 2022 and the second broke on or before November 2023 (exact date could not be determined). Soiled laundry (linens, towels, resident clothing, mop heads, rags etc) was being transported to a local laundromat in a pick-up truck bed. Soiled linens were visibly contaminated with feces and urine. The laundromat used both large capacity front loading washing machines and typical household style top-loading washing machines. No information was provided that the washing machines had an extractor (device that removes larger debris). The facility ran out of commercial laundry detergent on 1/28/24 and was observed to be substituting consumer products. The wet laundry was placed in clear plastic bags and transported back to the facility in the same vehicle where it remained bagged until a dryer was available, often the next day. Clean wet linen was observed stored in containers labeled for soiled linen on the clean side of the laundry room (by the dryers). Clean wet linen was also observed in clear bags stored outside on facility grounds. Cross reference to F867, F880, F908 and F945. This situation resulted in a finding of Immediate Jeopardy at a scope and severity of widespread, (L). The facility's Administrator was notified of the Immediate Jeopardy on 2/02/2024 at 5:20 PM. The Immediate Jeopardy was determined to have begun on 2/01/2024. At the time of the survey exit on 2/02/2024, the Immediate Jeopardy was ongoing. The findings include: Previous Complaint Survey from 2/2/2023 [refer to the Statement of Deficiencies, Form CMS-2567, Survey Event ID # 8Q7X11]: During a previous complaint survey conducted on 1/31/23 through 2/2/23, the facility was cited for noncompliance at F584 for a lack of available linen supply. During the survey, observations of the linen supply closets on 1/31/23 at approximately 11:05 AM found no clean sheets, washcloths, or towels available. Interviews with 4 staff members and 5 residents identified a lack of linens as a concern. On 1/31/23 at approximately 11:18 AM, the Environmental Services Director stated the facility had 1 out of 2 washing machines not functioning. She stated that the facility had ordered parts for the machine. During a follow up interview on 1/31/23 at approximately 11:51 AM, the Environmental Services Director stated the washing machine had not been functional since about the last week of December 2022. See Statement of Deficiencies Form CMS-2567, Survey Event ID # 8Q7X11 dated 2/2/2023. Current Survey, 2/2/24: During the initial tour of the facility on 01/29/24 between 11:15 AM and 11:50 AM, linen issues were observed. Resident #54 had no pillowcase on the pillow, and the pillow cover was shredded. Resident #16's linen appeared dirty with a grainy like matter and there was no pillowcase on the pillow. Resident #30 had no pillowcase on the pillow. Resident #45 had no pillowcases on their pillows. Residents #1, #9, and #211 were observed to be wearing hospital style gowns. Additionally, Resident #9 had no pillowcases on his pillows and no bottom sheet on his bed. Resident #211 had no sheets on his/her bed. During the observations, a resident in the hallway could be heard asking staff if today was the day that he could wash his clothes, and a staff member was heard asking another staff member if they would go check in the outside storage area to bring in more sheets. On 1/29/24 at 12:00 PM, an interview was conducted with Resident #46. She stated her only concern was related to the non-functional washing machines. She further stated sometimes it took 10 days to get back her clothes and because of that she had to wear her same clothes for a couple of days. On 1/29/24 at approximately 12:42 PM, an interview was conducted with the Maintenance Supervisor who stated that facility textiles and resident laundry was being processed at a local laundromat [by facility staff]. He stated this has been going on for a long time, at least 3 months. He stated that he has been helping with processing laundry on the weekends. He stated, It is disgusting but has to be done. The Maintenance Supervisor indicated that they had been waiting for an ordered part to arrive for about 9 months for a washer. When the second machine went out, the facility was left with no operating washing machine since about November of 2023. The surveyor asked how he ensured that the laundry is properly cleaned. The Maintenance Supervisor explained that the laundry gets washed. He did not express any knowledge of chemical detergents or water temperature requirements for properly laundering of resident clothing and linens. On 1/31/24 at 9:49 AM, an interview was conducted with Staff N, a Registered Nurse (RN). She stated the facility had been saying they were going to fix the washing machines before the new company took over, and it was not being done. She further stated it used to take 3 days turn around and now was 1 to 2 weeks. On 1/31/24 at approximately 11:00 AM, an interview was conducted with an anonymous direct care staff member. The employee indicated that she did not want her name to be revealed due to fear of retaliation. She indicated that the linen supplies at the facility have been inadequate. Frequently there are piles of soiled linens waiting to be washed and left-over wet linens waiting to be dried. She indicated that laundry is not processed after 6:00 PM. The facility often runs out of linen on a daily basis and it has been a problem for months. During the tour of the facility laundry area on 2/1/24 beginning at approximately 10:21 AM, the area appeared disorganized and numerous potential infection control issues were identified. In the soiled laundry area, on the concrete floor there were 2 piles of soiled linens and clothing. The soiled linen was saturated with urine and feces. There was a portable rack of clean clothes that were hanging and a basket with partially folded clothes. The small sink in the room was surrounded by laundry and inaccessible for handwashing. Outdoors, there was a pile of approximately 8 bags containing clean wet linen stacked on a wooden pallet and a cart where clean dry resident clothes were stored outside. Tree leaves were observed to be underneath the linen. In the clean side of the laundry area, there were 4 bins of wet laundry waiting to be dried. The bins were labeled Soiled Linen. The Environmental Services Manager said they were left over from yesterday at approximately 6:00 PM that had not yet been dried. Clean resident clothes were folded and sorted on a table that did not have a barrier present, according to the facility policy. The Environmental Services Manager explained that the washers have not been working at the facility for several months. She indicated that the facility has had trouble maintaining both washers and dryers over the past year. Since the washers broke, they have been taking laundry to the local public laundromat to wash, then bringing the wet laundry back to the facility to dry 7 days a week. The Environmental Services Manager explained that they ran out of commercial laundry detergent on 1/28/24. They have since been using 1/2 cup of Tide detergent and 1/2 cup of bleach per load in the washers at the laundromat. She was unable to verbalize how those amounts were determined. She indicated that the laundromat washers might have a 35-gallon capacity. She was asked to describe the type and capacity of the washers at the laundromat. The manager was unable to provide specific information regarding type, manufacture, or recommendations for detergent and/or hot water temperatures for washers at the laundromat. Refer to F880 for further details. The facility laundry policy was requested for review. The Laundry Services Policy dated 12/8/23 stated soiled and clean linen should be separated at all times. The policy directed staff not to place clean linen in contaminated areas or transport clean linen in containers designated for soiled linen. Employees sorting or washing linen must wear a gown and gloves. The policy directed employees to not leave damp linen in laundry machines overnight. The policy recommended that staff follow manufacturer instructions (instructions from equipment, detergent, rinses etc.) for all laundry processing. The policy directed staff to keep soiled and clean linen and their respective hampers and laundry carts separated at all times. Staff processing clean linen were directed to place a barrier on the sorting folding table before placing any clean linen or clothing items. The laundry services policy did not address any procedures regarding utilizing the local laundromat. During the survey, from 1/29 to 2/1/24, the facility Director of Nursing (DON) was not present at the facility. On 1/31/24 at 11:30 AM, an interview was conducted with the Administrator who stated the DON was on leave for the past 2 weeks and would be working from home for at least 2 more weeks. The Administrator stated that she was serving as the Acting DON, even though she was not a nurse. On 2/01/24 at 05:42 PM, an interview was conducted with the DON via telephone. She stated her regular tasks consisted of overseeing medications, activities of daily living, care plans and nursing staff. Stated she had been on leave since January 16th, 2024. She further stated her return day was February 14th. The DON did not mention any duties related to laundry oversight. An interview was conducted with the facility Administrator on 2/1/24 at approximately 3:42 PM. She stated he started working at the facility on December of 2023. The Administrator stated that the washing machines were not working when she started the position. She stated that parts were ordered. The Administrator was unable to provide exact dates for when each washer became non-functional. She was unable to provide the manufacturer recommendations from the washing machines at the local laundromat. She was asked to provide dates that machines broke along with invoices regarding repairs. The Administrator provided some emails indicating the status of machine part orders. The first email was dated 9/21/23 to the previous administrator stating a screen kit, washer extractor keyboard, mini switch, microswitch drive and a fuse had been delivered. On 10/9/23 there is an email indicating that a 3-inch drain valve was shipped to the facility. An email on 11/14/23 indicating parts on backorder. There was also an invoice for a certified used washer ordered on 1/15/24. Laundry Training: On 2/1/24 at about 1:20 PM, The Environmental Services Manager was asked to provide a list of employees that were assisting with processing laundry. She explained that she, Laundry Worker A, Maintenance Worker K, and the Maintenance supervisor were assisting with transporting and processing soiled linens at the laundromat. The Environmental Services Manager was asked to provide evidence of training for the employees who were processing laundry for the facility. On 2/1/24 at approximately 3:00 PM, an interview was completed with the Infection Preventionist Nurse (IP) who stated that the Environmental Services Manager was in charge of ensuring infection control processes are followed when it comes to handling and laundering linen. The IP nurse was asked who was responsible for providing education regarding handling laundry. The Infection Preventionist Nurse indicated that she was unsure who did the training, but it was probably the Environmental Services Supervisor. The IP nurse was shown images of bins labeled soiled linen which contained clean wet laundry that had waited all night before being placed in dryers. The Infection Preventionist Nurse indicated that clean linen should never be stored in bins that are labeled soiled linen and that clean linen should be processed in an area that does not contain contaminated laundry. On 2/1/24 at approximately 4:36 PM, an interview was conducted with the Administrator. She was asked who provides the education for laundry serves. The Administrator explained that she would find out who is responsible. The Administrator was asked when she last toured laundry area, and replied that she toured the laundry when she first came on board (in December). She stated that nothing caught her eye that was off. The Administrator was shown photographs of laundry on the ground being sorted out of bags. The Administrator stated that it should not be like that, and that she would find out who is responsible for education. On 2/1/24 at approximately 4:00 PM, an interview was conducted with the Environmental Services Supervisor who is also the Housekeeping Supervisor. She provided the latest training regarding handling infectious laundry, dated 4/25/2023. Three employees signed that they completed the training. Laundry Worker A, another employee who was no longer employed and Housekeeping Staff Member P. Maintenance Worker K and the Maintenance supervisor did not sign that they had received the training. Per the in-service materials, to prevent microbial contamination of laundry equipment staff should: -remove solids such as feces or vomit before the wash/dry cycle. -follow manufacturer recommended temperature, detergent and laundry additive guidelines. -do not leave damp textiles in machines overnight. The inservice advised that a temperature of at least 160 degrees Fahrenheit for a minimum of 25 minutes was commonly recommended for washing laundry. Chlorine bleach becomes activated at water temperatures of 135-145 degrees Fahrenheit. The training materials were based on CDC guidance. An interview with the Medical Director was conducted on 1/31/2024 at 11:15 AM. The Medical Director acknowledged that the problem with the laundry has been going on for months. He stated that the facility was under new ownership, and they are working on identifying and correcting the issues. There were a lot of things to fix, and the new owners were working on it. The medical director stated that the facility has a good amount of staff for the first time in years. Job Descriptions: The job description for the Registered Nurse Infection Preventionist (RN IP), undated, under Job Functions: The RN IP is responsible for planning organizing and directing the functions for the infection prevention and control program (IPCP). Under Duties and Responsibilities: Oversight of the IPCP to include preventing identifying, controlling, reporting and investigating infections and communicable diseases for all residents staff and visitors of the centers following local, state and national guidelines as well as recognize best practices. Education enforcement and reinforcement of the written standards of the program as outlined in the infection control policies and procedures and as directed by the center infection control program risk assessment. Collaborate with center leadership and the medical director to develop, implement, evaluate and reevaluate the annual infection control and prevention goals and plans. Develop and present infection control education during orientation, annual review, and department specific and as needed. Make recommendations for changes to infection control and prevention policies and procedures. Under the section Working Conditions: Works in office areas as well as throughout the center (i.e. medication rooms, nurses stations, laundry, kitchen, resident rooms, etc.) The job description for the Director of Environmental Services, undated, duties included: Planning, organizing and directing housekeeping and laundry personnel. Ensuring jobs are completed efficiently and within regulatory guidelines optimizing your personal skills and the environmental personnel. Inspects rooms, corridors and facility for cleanliness or other concerns. Performs other related duties as assigned by facility to assist all departments and facility administration in providing a clean, home-like and caring environment for facility residents and staff. The job description for Executive Director (Administrator), undated, under Purpose of Your Job Position: The primary purpose of the executive director is to direct day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times. Under Job Functions: Supervises the Director of Clinical Services and the Director of Environmental services. Under Duties and Responsibilities: Schedule regular meetings with direct reporting staff to provide supervision, ensure communication, and to monitor facility operations. Maintain and guide the implementation of facility policies and procedures in compliance with corporate, state, federal, and other regulatory guidelines. Ensure a safe, clean, and comfortable environment for residents, visitors and staff. The job description for the Director of Nursing, undated, listed under Job Function Supervising clinical nurses and nurse techs and carrying out the resident care policies established by this facility. Duties and Responsibilities included assurance with resident rights policies and work to resolve resident grievances. 43857

Based on observation, staff interviews, resident interviews, and quality assurance performance improvement plan (QAPI) review, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to ensuring an adequate supply of clean linens was readily available for resident use and care; ongoing housekeeping and maintenance issues throughout the facility; maintaining essential equipment (washing machines) in good operating order; and infection control processes and training related to laundry processing. Concerns were previously identified with clean linen availability, broken laundry equipment and the QAPI processes during a complaint investigation ending a year ago on 2/02/2023 [refer to the Statement of Deficiencies, Form CMS-2567, Survey Event ID # 8Q7X11. Citations were issued at F584 (Environment) and F867 (QAPI). The facility had 2 commercial grade washing machines, one broke in December 2022 and the second broke on or before November 2023 (exact dates could not be determined). Soiled laundry (linens, towels, resident clothing, mop heads, rags etc) was being transported to a local laundromat in a pick-up truck bed. Soiled linens were visibly soiled contaminated with feces and urine. The laundromat used both large capacity front loading washing machines and typical household style top-loading washing machines. No information was provided that the washing machines had an extractor (device that removes larger debris). The facility ran out of commercial laundry detergent on 1/28/24 and was observed to be substituting consumer products. The wet laundry was placed in clear plastic bags and transported back to the facility in the same vehicle where it remained bagged until a dryer was available, often the next day. Clean wet linen was observed stored in containers labeled for soiled linen on the clean side of the laundry room (by the dryers). Clean wet linen was also observed in clear bags stored outside on facility grounds. Cross reference to F835, F880, F908 and F945. This situation resulted in a finding of Immediate Jeopardy at a scope and severity of widespread, (L). The facility's Administrator was notified of the Immediate Jeopardy on 2/02/2024 at 5:20 PM. The Immediate Jeopardy was determined to have begun on 2/01/2024. At the time of the survey exit on 2/02/2024, the Immediate Jeopardy was ongoing. The findings include: Previous Complaint Survey from 2/2/2023 [refer to the Statement of Deficiencies, Form CMS-2567, Survey Event ID # 8Q7X11]: During a previous complaint survey conducted on 1/31/23 through 2/2/23, the facility was cited for noncompliance at F584 and F867 for a lack of available linen supply due in part to broken laundry equipment. During the survey, observations of the linen supply closets on 1/31/23 at approximately 11:05 AM found no clean sheets, washcloths, or towels available. Interviews with 4 staff members and 5 residents identified a lack of linens as a concern. On 1/31/23 at approximately 11:18 AM, the Environmental Services Director stated the facility had 1 out of 2 washing machines not functioning. She stated that the facility had ordered parts for the machine. During a follow-up interview on 1/31/23 at approximately 11:51 AM, the Environmental Services Director stated the washing machine had not been functional since about the last week of December 2022. The administrator at that time stated that parts were ordered for the broken washing machine on 1/9/2023. See Statement of Deficiencies Form CMS-2567 dated 2/02/2023, Survey Event ID #8Q7X11. As of the current survey ending 2/02/2024, the facility was unable to provide evidence that the washing machine has been fixed or functioning since December 2022. Current Survey, ending 2/2/24: During the initial tour, 4 residents were observed without pillowcases on their pillows and 2 without sheets on their bed. Cleanliness and maintenance issues were identified in numerous resident rooms, 3 residents and/or family members described laundry concerns (cross reference F908, F584 and F880). Both facility washing machines had been broken since at least November 2023, and the facility was transporting soiled laundry to a local laundromat and then transporting the clean, wet linen back to the facility for drying (cross reference F908). An observation of laundry processes on 2/1/2024 beginning at 10:21 AM, which found the laundry area disorganized and evidence of cross contamination was observed. Some of the concerns included soiled linen piled on the concrete floor and in bags in both the soiled area and outside on the grounds. Clean wet linens were bagged up and placed in bins labeled Soiled Linen, and piled outside on a wooden pallet awaiting to be dried (cross reference F880). A lack of staff training related to laundry procedures was identified (cross reference F945). On 02/02/24 at 1:29 PM, an interview regarding Quality Assurance and Program Improvement (QAPI) processes was conducted with the Administrator and the Director of Nursing (DON), who stated the QAPI team meets quarterly and as needed, with the most recent meeting on 1/16/24. The sign in sheet was provided. The Administrator stated the Maintenance and Housekeeping staff responsible for laundry attend each meeting as well. When asked how the QAPI process is implemented in order to resolve an issue, the DON stated they do ad hoc QAPI meetings and create a performance improvement plan, and the plan stays open until the issue is resolved. The DON stated if the issue is not resolved, then they add additional interventions and extend the date of completion. The QAPI team was asked what has been done to address the issue of not having laundry services available in the building. The staff replied that the facility has hired additional laundry staff and created a different drop time schedule so they could provide linen at different times throughout the day. She stated they do audits of laundry in the clean linen room as to what linens are available and communicate with the Environmental Director, who tells us what she ordered as far as linens each month and orders more. The QAPI team was asked about the issues with washing the linens, and they replied that they have been working with corporate to get the part for the washer that has been broken for over a year and have finally purchased a refurbished washing machine to replace the second and final washer. In the meantime, they have been transporting the clothes and linens to the local laundromat. The QAPI team was asked to provide evidence that the laundry issues had been discussed in QAPI since December 2022. The Administrator stated that the previous owner would not cooperate with purchasing the equipment or share any information related to previous QAPI meetings/discussions. The Administrator was asked about the part for Washer 1 that was supposed to arrive back in December 2023; the Administrator replied that the wrong part arrived and they had to again order the correct part, which still has not been delivered. The Administrator provided meeting minutes from 1/16/24, which revealed the QAPI team discussed linen inventory, were notified by Corporate that the washing machine was ordered and a check was cut on 1/15/24 for the new machine. There were no other details about the status of the washing machine purchase and the purchase of the part for the first washer that had been inoperable since December 2022. Review of the invoice dated 1/15/24 revealed a Certified Used Washer was purchased for $6989.99 with anticipated deliver in February 2024. Review of an email dated 11/30/23 at 9:19 AM revealed order #1000729908 for the part to fix Washer 1 was paid via credit card in the amount of $1596.45 with an expected delivery between 12/11/23 and 12/18/23. This part had not yet arrived. The Administrator and DON confirmed the QAPI process for ensuring the laundry equipment was addressed failed. The Administrator was unable to provide any QAPI agendas or other QAPI evidence from monthly QAPI meetings between February 2023 and January 2024.

Based on observation of laundry storage and laundry procedures, staff interviews, review of facility laundry policy, facility laundry inservices, and a review of the Centers for Disease Control (CDC) guidelines, the facility failed to ensure that facility textiles and resident clothes were stored, sorted, processed and transported in a manner to prevent cross-contamination in accordance with facility policy and recommendations by the CDC. The facility failed to ensure that the facility's Infection Preventionist had oversight of the laundry procedures. The facility failed to update their laundry procedures to ensure hygienic laundry after both facility washing machines failed, and the facility made the determination to utilize a local laundromat. This failure had the potential to affect all 68 residents at the time of the survey. Additionally, the facility failed to ensure appropriate infection control practices were followed for 1 of 1 fingerstick blood glucose checks observed (Resident #10). The facility had 2 commercial grade washing machines, one which became non-functional in December 2022 and the second which became non-functional in November 2023. Soiled laundry (linens, towels, resident clothing, mop heads, rags, etc.) were observed being transported to a local laundromat in the bed of a pick up truck. Soiled linens were visibly contaminated with feces and urine. The laundromat had both large capacity front loading washing machines and typical household style top loading washing machines. No information was provided that the washing machines had an extractor (device that removes larger debris). The facility ran out of commercial laundry detergent on 1/28/24 and was observed to be substituting consumer household-grade products. The wet laundry was placed in clear plastic bags and transported back to the facility in the same vehicle where it remained bagged until a dryer was available, often the next day. Clean wet linen was observed stored in containers labeled for soiled linen on the clean side of the laundry room (by the dryers). Clean wet linen was also observed in clear bags stored outside on facility grounds. The laundry situation resulted in a finding of Immediate Jeopardy at a scope and severity of widespread, (L). The facility's Administrator was notified of the Immediate Jeopardy on 2/02/2024 at 5:20 PM. The Immediate Jeopardy was determined to have begun on 2/01/2024. At the time of the survey exit on 2/02/2024, the Immediate Jeopardy was ongoing. Cross reference to F835, F867, F908 and F945. The findings include: On 1/29/24 at approximately 12:10 PM, during the initial facility tour, soiled wet towels were observed on the floor in the shower room. The shower room was not in use at the time. (Photographic evidence obtained) On 1/29/24 at approximately 12:42 PM, an interview was conducted with the Maintenance Supervisor, who stated that facility textiles and resident laundry was being processed at a local laundromat [by facility staff]. He stated that this has been going on for a long time, at least 3 months. He stated that he has been helping with processing laundry on the weekends. He stated, It is disgusting but it has to be done. The Maintenance Supervisor indicated that they had been waiting for an ordered part to arrive for about 9 months for a washer. When the second machine went out about November of 2023, the facility was left with no operating washing machines. The surveyor asked how he ensured that the laundry is properly cleaned. The Maintenance Supervisor explained that the laundry gets washed. He did not express any knowledge of chemical detergents or water temperature requirements for properly laundering resident clothing and linens. On 1/31/24 at approximately 11:00 AM, an interview was conducted with an anonymous direct care staff member. The employee indicated that she did not want her name to be revealed due to fear of retaliation. She indicated that the linen supplies at the facility have been inadequate. Frequently there are piles of soiled linens waiting to be washed and left-over wet linens waiting to be dried. She indicated that laundry is not processed after 6:00 PM. The facility often runs out of linen on a daily basis and it has been a problem for months. On 2/1/24 at approximately 10:00 AM, during a resident care observation, staff did not have a clean fitted sheet to apply to the bed for Resident #9. The surveyor followed Licensed Practical Nurse D (LPN D) to each of the two indoor laundry storage rooms. Each of the 2 indoor clean linen storage areas had very little clean laundry available. The shelves were mostly bare and there were no fitted sheets in any of the indoor storage areas to apply to Resident #9's bed. On 2/1/24 at approximately 10:21 AM, Certified Nursing Assistant (CNA) F then escorted the surveyor outside of the facility to check for clean linen in the facility laundry room. Laundry Worker A was observed sitting on a bucket sorting loose linen that was saturated with urine and feces. The linen was piled on the concrete floor in the soiled linen room. Laundry Worker A was wearing gloves, but had no other personal protective equipment (PPE) over her clothing. There was another large pile of resident clothes mixed with soiled linen lying on the concrete floor in the corner behind Laundry Worker A and 4 bags of soiled linen in front of her. There was a portable rack that had both hanging clothes and partially folded clothes in an attached metal linen basket in the soiled laundry room. The hanging and partially folded clothes were clean. The small sink in the room was surrounded by laundry and inaccessible for handwashing. Used gloves were laying on the concrete floor next to the soiled laundry. Outside of the soiled laundry room there were 2 bins labeled soiled laundry containing bags of soiled laundry. There were 11 clear garbage bags of soiled laundry on the ground extending out the open laundry door to the outdoors. Also outdoors, approximately 8 bags containing clean wet linen were observed stacked on a wooden pallet. Additional unbagged linens were observed on top of the bagged linen. There was a broom and a trashcan lid resting on the linen, a box of clean gloves sitting on the pallet and 2 used gloves on the ground next to the pallet along with multiple tree leaves. (photographic evidence obtained) The Environmental Services Manager was in the area at the time of the laundry room observation, and an interview was conducted during the observation. She explained that they had been transporting the laundry to the laundromat in the back of a pickup truck that was parked nearby. The pickup truck bed was observed with dirt and debris, used gloves and had multiple bottles of Tide Simply All in One and household bleach containers. Some of the chemical containers were empty. The Environmental Services Manager explained that the washers have not been working at the facility for several months. She indicated that the facility has had trouble maintaining both washers and dryers over the past year. Since the washers broke, they have been taking laundry to the local public laundromat to wash. The facility will then bring the wet laundry back to the facility to dry 7 days a week. The Environmental Services Manager explained that they ran out of commercial laundry detergent on 1/28/24. They have since been using 1/2 cup of Tide [detergent] and 1/2 cup of bleach per load in the washers at the laundromat. She was unable to verbalize how those amounts were determined. She indicated that the laundromat washers might have a 35-gallon capacity. The surveyor asked if the facility has run out of commercial detergent and laundry sanitizer in the past. The Environmental Services Manager replied yes, and stated they have had to utilize the Tide and bleach in the past when they had run out of commercial detergent and sanitizer. She was asked to describe the type and capacity of the washers at the laundromat. The manager was unable to provide specific information regarding type, manufacture, or recommendations for detergent and/or hot water temperatures for washers at the laundromat. On 2/1/24 at Approximately 10:29 AM, when the surveyor entered the clean side of the laundry area where the dryers were located, there were 4 bins of wet laundry waiting to be dried. The bins were labeled Soiled Linen. Clean and dry linen and clothes were being sorted and folded in the same room where these 4 bins were located. The surveyor asked how long those linens have been waiting to be dried. The Environmental Services Manager said they were left over from yesterday at approximately 6:00 PM. Clean resident clothes were folded and sorted on a table that did not have a barrier present. Outside the laundry area, there was a bin marked trash stored next to a cart where clean dry resident clothes were stored. Tree leaves were observed to be underneath the linen. (Photographic evidence was obtained) On 2/1/24 at about 1:20 PM, the surveyor observed the washed wet bagged laundry loaded in the back of the same pickup truck upon return from the laundromat. There was no indication that the bed of the truck had been cleaned after the soiled linen was transported and before the wet washed laundry was loaded. The bed of the truck appeared the same as the prior observation, with dirt, debris, and empty bleach and detergent containers. The Environmental Services Manager was asked about cleaning the truck bed. She indicated that they are wiping out the truck bed using a small bottle of Broadside sanitizer spray. The Environmental Services Manager was asked to provide a list of employees that were assisting with processing laundry. She explained that she, Laundry Worker A, Maintenance Worker K, and the Maintenance Supervisor were assisting with transporting and processing soiled linens at the laundromat. The Environmental Services Manager was asked to provide evidence of training for the employees who were processing laundry for the facility. Evidence of a flash in-service training entitled Infection Control in Laundry dated 4/17/23 (several months before the facility was using the local laundromat) was provided. The accompanying training materials were based on CDC guidance. Three employees signed that they completed the training. Laundry Worker A, another employee who was no longer employed, and Housekeeping Staff Member P were listed as attending these inservices. Maintenance Worker K and the Maintenance Supervisor did not sign that they had received the training. Per the in-service materials, to prevent microbial contamination of laundry equipment staff should: -remove solids such as feces or vomit before the wash/dry cycle. -follow manufacturer recommended temperature, detergent and laundry additive guidelines. -do not leave damp textiles in machines overnight. The inservice advised that a temperature of at least 160 degrees Fahrenheit for a minimum of 25 minutes was commonly recommended for washing laundry. Chlorine bleach becomes activated at water temperatures of 135-145 degrees Fahrenheit. On 2/1/24 at approximately 2:30 PM, during a second interview with the Maintenance Supervisor, he indicated that he had training regarding processing laundry but could not recall exactly when the training occurred or give details related to the training. On 2/1/24 at approximately 3:00 PM, an interview was completed with the Infection Prevention Nurse (IP). She was asked if she does infection prevention rounds around the facility to ensure compliance with infection control processes. The IP explained that she does not do rounds. She explained that the Director of Nursing (DON) normally does infection control rounds. The DON has been out from work for several weeks on extended leave. She mentioned the Environmental Services Manager was in charge of ensuring infection control processes are followed when it comes to handling and laundering linen. She was asked how long the facility has had trouble with the laundry equipment. The IP indicated that the facility has had trouble with laundry equipment for over a year. First the dryers were broken and now the washers were not working. She was asked if anyone has made her aware that the facility is out of commercial laundry detergent. The IP indicated that she had not been notified and was not aware. She indicated that there was one small household sized functional washer in the shower room that was purchased previously and she did not know how the washer was currently being utilized. She was asked if anyone at the Health Department was notified that the facility was laundering their textiles and resident clothing at a local laundromat. She reported that the health department had not been notified. The IP nurse was also asked who was responsible for providing education regarding handling laundry. The Infection Control Nurse indicated that she was unsure who did the training, but it was probably the Environmental Services Supervisor. The IP nurse was shown images of bins labeled soiled linen which contained clean wet laundry that had waited all night before being placed in dryers. The Infection Control Nurse indicated that clean linen should never be stored in bins that are labeled soiled linen and that clean linen should be processed in an area that does not contain contaminated laundry. An interview was conducted with the facility Administrator on 2/1/24 at approximately 3:42 PM. She stated she started working at the facility in December of 2023. The washing machines were not working when she started the position. She stated that parts were ordered. She was unable to verbalize when the second washer broke. On 2/1/24, a review of the Laundry Services Policy (dated 12/8/23) was conducted. The policy stated soiled and clean linen should be separated at all times. The policy directed staff not to place clean linen in contaminated areas or transport clean linen in containers designated for soiled linen. The policy directed staff to wash their hands after handling soiled linen and before handling clean linen. Staff should consider all soiled linen to be potentially infectious and handle it with standard precautions. All soiled linen should be placed directly into covered containers designated for soiled linen. Handle soiled linen as little as possible and prevent agitation. Employees sorting or washing linen must wear a gown and gloves. The policy directed employees to not leave damp linen in laundry machines overnight. The policy recommended that staff follow manufacturer instructions (instructions from equipment, detergent, rinses etc.) for all laundry processing. The policy directed staff to keep soiled and clean linen and their respective hampers and laundry carts separated at all times. Mops are to be washed separately from linens and kept in separate laundry carts. Staff processing clean linens were directed to place a barrier on the sorting folding table before placing any clean linen or clothing items. The laundry services policy did not address any procedures regarding utilizing the local laundromat. On 2/1/24 a review of the job description for laundry services workers, undated, was conducted. The job description stated that laundry workers should participate in an in-service training program prior to performing tasks that involve potential exposure to blood, body fluids, or hazardous chemicals. A review of the Infection Control Guidelines policy, dated April 2013, was conducted. The policy directed staff members to wear personal protective equipment as necessary to prevent exposure to body fluids and other potentially infectious materials. A review of Policies and Practices-Infection Control (dated October 2018) was conducted. The policy indicated that infection control policies and practices apply equally to all personnel. Objectives of infection control policies and practices are to prevent, detect, and control infections in the facility and maintain a safe sanitary and comfortable environment for personnel residents visitors and the general public. The policy stated that all personnel with be trained on infection control policies and practices upon hire and periodically thereafter including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of resident contact and job responsibilities. The administrator or governing board, through Quality Assurance and Performance Improvement and the Infection Control Committee, has adopted the infection control policies and practices. Inquiries concerning infection control policies or facility practices should be referred to the Infection Preventionist or the Director of Nursing Services. A review was conducted of the Centers for Disease Control and Prevention (CDC) laundry guidelines, Appendix D - Linen and laundry management, accessed on 2/2/24. https://www.cdc.gov/hai/prevent/resource-limited/laundry.html. Under the section, Best practices for linen (and laundry) handling: -If there is any solid excrement on the linen, such as feces or vomit, scrape it off carefully with a flat, firm object and put it in the commode or designated toilet/latrine before putting linen in the designated container. -The effectiveness of the laundering process depends on many factors, including: time and temperature; mechanical action; water quality (pH, hardness); volume of the load; extent of soiling model/availability of commercial washers and dryers -Always use and maintain laundry equipment according to manufacturer's instructions. -Best practices for personal protective equipment (PPE) for laundry staff: a. Practice hand hygiene before application and after removal of PPE. b. Wear tear-resistant reusable rubber gloves when handling and laundering soiled linens. c. If there is risk of splashing, for example, if laundry is washed by hand, laundry staff should always wear gowns or aprons and face protection (e.g., face shield, goggles) when laundering soiled linens. Best practices for laundering soiled linen: a. Follow instructions from the washer/dryer manufacturer. b. Use hot water (70-80 C for 10 minutes) [158-176 F]) and an approved laundry detergent. c. Disinfectant are generally not needed when soiling is at low levels. d. Use disinfectant on a case by case basis, depending on the origin of the soiled linen (e.g., linens from an area on contact precautions). e. Dry linens completely in a commercial dryer. Best practices for management of clean linen: a. Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items. b. Each floor/ward should have a designated room for sorting and storing clean linens. c. Transport clean linens to patient care areas on designated carts or within designated containers that are regularly (e.g., at least once daily) cleaned with a neutral detergent and warm water solution. 30584 43857 Blood Glucose Monitoring: On 1/30/24 at 11:30 AM, Registered Nurse O (RN O) was observed performing a blood glucose check on Resident #10. RN O was observed washing her hands, then touching the bathroom door and then donning gloves. After gloves were donned, RN O touched the diabetic flow sheet, gathered alcohol wipes, glucometer strip, gauze and lancet, and placed them on top of a paper towel. She wiped the glucometer with disinfectant wipes, placed the glucometer on top of the paper towel, and then used gauze to dry the glucometer within a few seconds of wiping the glucometer with the disinfectant. She doffed gloves, followed by donning new gloves and grabbed the glucometer, alcohol wipe, lancet and glucometer strip. She entered the resident's room and placed the glucometer on the resident's bed cover. On 01/30/24 at 11:40 AM, an interview was conducted with RN O regarding infection control concerns observed during the blood glucose check. RN O stated she should have been careful not to touch the bathroom door after washing her hands, or wash her hands again before donning gloves. She further stated she should have left the glucometer air dry instead of using the gauze and she should have not left the glucometer on top of the resident's bed cover, instead, she should have used a clean surface. A review of disinfectant product instruction found a recommended 3 minute wet contact time. A review of the facility's skill competency assessment for glucometer, undated, stated to inspect, clean and disinfect the glucometer utilizing disinfectant wipe per manufactures recommended wet time.

Based on observations, resident interviews, staff interviews, ombudsman interview, and review of facility provided documentation, the facility failed to maintain 2 of 2 laundry washing machines in good repair. Both of the facility washing machines have been non-functional since at least November 2023 (exact date could not be determined). The first washing machine became non-functional in the month of December 2022 (exact date could not be determined) and remained broken. Staff were unable to demonstrate the specific date the second washing machine broke. Invoices indicated that parts were ordered both in September 2023 and November 2023. Observations found a lack of readily available linens in 2 of 2 linen closets, resident beds with missing sheets and pillowcases, residents observed without a change of clothing in their closets, and residents wearing hospital gowns. This failure had the potential to affect all 68 residents residing in the facility at the time of the survey. Due to the lack of washing machines, facility staff were transporting soiled laundry to a local laundromat for washing, then bringing the wet laundry back to dry. However, not all the wet laundry could be dried at once, so some of the clean wet laundry was stored wet, often overnight. The laundry was not being handled, stored, processed, and transported in a manner to prevent the spread of infection. Soiled laundry was observed on the ground and in bins in facility shower rooms and in the dirty side of the laundry room. Soiled laundry was also observed in clear plastic bags in both the laundry room and outside on facility grounds waiting transport to the laundromat. Soiled linens were visibly contaminated with feces and urine. Washed linen was placed in clear plastic bags for transport back to the facility for drying. The bags of wet washed linen were observed inside containers labeled for soiled linen on the clean side of the laundry room (by the dryers). Clean wet linen was also observed in clear bags stored outside on facility grounds. The lack of washing machines has affected the quality of life for residents, in that they have to wear hospital gowns and/or the same personal clothing on repeated days because their personal clothing has not returned from the laundry timely. Additionally, the residents showering frequency was affected by the availability of clean linens in the facility. This situation resulted in a finding of Immediate Jeopardy at a scope and severity of widespread, (L). The facility's Administrator was notified of the Immediate Jeopardy on 2/02/2024 at 5:20 PM. The Immediate Jeopardy was determined to have begun on 2/01/2024. At the time of the survey exit on 2/02/2024, the Immediate Jeopardy was ongoing. Cross reference to F835, F867, F880 and F945. The findings include: Previous Complaint Survey from 2/2/2023 [refer to the Statement of Deficiencies, Form CMS-2567, Survey Event ID # 8Q7X11]: During a previous complaint survey conducted on 1/31/23 through 2/2/23, the facility was cited at for noncompliance at F584 for a lack of available linen supply. During the survey, observations of the linen supply closets on 1/31/23 at approximately 11:05 AM found no clean sheets, washcloths, or towels available. Interviews with 4 staff members and 5 residents identified a lack of linens as a concern. On 1/31/23 at approximately 11:18 AM, the Environmental Services Director stated the facility had 1 out of 2 washing machines not functioning. She stated that the facility had ordered parts for the machine. During a follow up interview on 1/31/23 at approximately 11:51 AM, the Environmental Services Director stated the washing machine had not been functional since about the last week of December 2022. See survey Statement of Deficiencies Form CMS-2567 dated 2/2/2023, Survey Event ID # 8Q7X11. Current Survey, 2/2/2024: On 1/29/24 between 11:15 AM and 11:50 AM, during an initial tour of the facility, linen issues were observed. Resident #54 had no pillowcase on the pillow, and the pillow fabric cover was shredded. Resident #16's bed sheet appeared dirty with a grainy like matter and there was no pillowcase on the pillow. Resident #30 had a pillow without a pillowcase. Resident #45 had no pillowcases on the pillows. Residents #1, #9, and #211 were observed to be wearing hospital style gowns. Resident #9 preferred to wear their own clothing; however, their personal clothes were not returned from the laundry. Additionally, Resident #9 had no pillowcases on his pillows and no bottom sheet on his bed. Instead, Resident #9, who had a history of pressure ulcers, was observed laying on top of a blanket without bed sheets on the bed. Resident #211 had no sheets on their bed. During the observations, a resident in the hallway could be heard asking staff if today was the day that he could wash his clothes, and a staff member was heard asking another staff member if they would go check in the outside storage area to bring in more sheets. On 1/29/24 at 12:00 PM, an interview was conducted with Resident #46. She stated her only concern was related to the non-functional washing machines. She further stated sometimes it took 10 days to get back her clothes and, because of that, she had to wear the same clothes a couple of extra days. On 1/29/24 at approximately 12:42 PM, an interview was conducted with the Maintenance Supervisor. He indicated that facility textiles and resident laundry was being processed at a local laundromat [by facility staff]. He mentioned that he has been helping with processing laundry on the weekends, and that the task is disgusting but has to be done. He indicated that the facility has had issues with processing laundry for a long time, at least 3 months, ever since the only remaining working washing machine went down. Prior to this, the facility had another washing machine that went down, and they had been waiting on a part they ordered to arrive for about 9 months. When the second machine went out, the facility was left with no operating washing machine, since about November of 2023. On 1/29/24 at approximately 2:50 PM, an interview was conducted with Resident #9, who had been observed during the initial tour. Resident #9 continued to have a blanket under him instead of a sheet, and he was wearing a hospital gown. Resident #9 stated that the facility often runs out of sheets. He said the church gave him sheets to use, but the facility does not keep up with laundry. He indicated that he does not like wearing the gown and wanted staff to assist him to change into his clothes. The next day, on 1/30/24 at approximately 10:00 AM, Residents #1, #9, and #211 were again observed wearing hospital gowns. Residents #9 stated he preferred to wear his own clothing; however, his personal clothes had not returned from the laundry. On 1/31/24 at 9:34 AM, an interview was conducted with Staff B, a Licensed Practical Nurse (LPN). She stated she had concerns about the lack of linens. She states it had been going on for a long time. On 1/31/24 at 9:49 AM, an interview was conducted with Staff N, a Registered Nurse (RN). She stated the facility had been saying they were going to fix the washing machines before the new company took over, but it was not being done. She further stated it used to take 3 days to turn around laundry and now was 1 to 2 weeks. On 1/31/24 at approximately 11:00 AM, an interview was conducted with an anonymous direct care staff member. The employee indicated that she did not want her name to be revealed due to fear of retaliation. She indicated that the linen supplies at the facility have been inadequate. Frequently there are piles of soiled linens waiting to be washed and left-over wet linens waiting to be dried. She indicated that laundry is not processed after 6:00 PM. The facility often runs out of linen on a daily basis and it has been a problem for months. On 01/31/24 at approximately 2:30 PM, an interview was conducted with the significant other of Resident #211. She was asked if the resident preferred to wear a patient gown. She indicated that he prefers to wear his own clothing. The surveyor inquired about the pillows without pillowcases and mattress without a sheet on it. Resident #211's significant other indicated that the facility has seemed to be short on linen since he was admitted about 3 weeks earlier. On 1/31/24 at approximately 4:50 PM, neither Residents #23 nor Resident #47 had a change of clothes available in their wardrobes. On 2/1/24 at approximately 9:00 AM, Residents #23 and #47 were observed wearing the same clothes as the previous day. On 2/1/2024 at 7:44 AM, the local Long Term Care Ombudsman reported laundry issues at the facility during visits on 1/5/2024 and 1/11/2024. During the visit on 1/05/2024, Resident #13 reported that the facility did not have enough clean linens. Resident #13 reported that the lack of linens was reducing the number of showers, and caused issues getting back to bed because they had to wait on linens. During her visit of 1/05/2024, the Ombudsman assisted Resident #13 in filing a grievance. During a follow-up visit on 1/11/2024, neither the Administrator nor the Director of Nursing could find the grievance, so the Ombudsman assisted Resident #13 on completing them a second time. On 2/01/24 at 9:24 AM, two days after the initial tour, Resident #16 was again observed to have pillows without pillowcases and Resident #45 had 2 pillows placed on top of a wheelchair without pillowcases. On 2/1/24 at approximately 10:00 AM during a resident care observation, staff did not have a clean fitted sheet to apply to the bed for Resident #9. The surveyor followed Licensed Practical Nurse D (LPN D) to each of the two indoor laundry storage rooms. Each of the 2 indoor clean linen storage areas had very little clean linens available. The first indoor storage room had about 4 bed pads, three top sheets, 3 bed spreads, 15 towels, 1 patient gown and a stack of wash cloths. The other indoor linen storage area had about 5 patient gowns, about 30 towels, three bed spreads, 1 stack of bed pads and about 15 flat sheets. The shelves were mostly bare and there were no fitted sheets in any of the indoor storage areas to apply to Resident #9's bed. (photographic evidence obtained). An interview was conducted with the facility Administrator on 2/1/24 at approximately 3:42 PM. She stated she started working at the facility on December of 2023. The washing machines were not working when she started the position. She stated that parts were ordered. The Administrator was unable to provide exact dates for when each washer became non-functional. She was asked to provide dates that machines broke along with invoices regarding repairs. The Administrator provided some emails indicating the status of machine part orders. The first email was dated 9/21/23 to the previous administrator stating a screen kit, washer extractor keyboard, mini switch, microswitch drive and a fuse had been delivered. On 10/9/23 there is an email indicating that a 3-inch drain valve was shipped to the facility. An email on 11/14/23 indicating parts on backorder. There was also an invoice for a certified used washer ordered on 1/15/24. 43857

Based on observation of laundry storage and laundry procedures, staff interviews, review of facility laundry policy, and facility laundry staff training, the facility failed to ensure that staff were trained in infection control processes related to the laundering of linens and resident clothing to prevent cross-contamination. Both of the facility laundry machines (2 of 2) have been non-functional since at least November 2023. Facility staff are transporting soiled laundry to a local laundromat for washing, then bringing the wet laundry back to dry. However, not all the wet laundry could be dried at once, so some of the clean wet laundry was stored wet, often overnight. The laundry was not being handled, stored, processed, or transported, in a manner to prevent the spread of infection. On 2/1/2024, clean wet linens were observed in clear plastic bags that were stored inside bins labeled Soiled Linen and clean wet linens were observed outside stacked on a wooden pallet. Dirty linens were observed on the floor in both a shower room, and piled on the floor on the dirty side of the laundry room, and in clear bags both inside the laundry room and outside on the facility grounds awaiting transport to the laundromat. The facility failed to ensure that the facility Infection Preventionist had oversight and provided training for laundry procedures. This failure had the potential to affect all 68 residents at the time of the survey. This situation resulted in a finding of Immediate Jeopardy at a scope and severity of widespread, (L). The facility's Administrator was notified of the Immediate Jeopardy on 2/02/2024 at 5:20 PM. The Immediate Jeopardy was determined to have begun on 2/01/2024. At the time of the survey exit on 2/02/2024, the Immediate Jeopardy was ongoing. Cross reference F835; F867; F880 and F908. The findings include: On 1/29/24 at approximately 12:10 PM, soiled wet towels were observed on the floor in the shower room. The shower room was not in use at the time. (Photographic evidence obtained) On 1/29/24 at approximately 12:42 PM, an interview was conducted with the Maintenance Supervisor who stated that facility textiles and resident laundry was being processed [by facility staff] at a local laundromat. He stated this has been going on for a long time, at least 3 months. He stated that he has been helping with processing laundry on the weekends. He stated, It is disgusting, but it has to be done. The Maintenance Supervisor indicated that they had been waiting for an ordered part to arrive for about 9 months for a washer. When the second machine went out, the facility was left with no operating washing machine since about November 2023. The surveyor asked how he ensured that the laundry is properly cleaned. The Maintenance Supervisor explained that the laundry gets washed. He did not express any knowledge of chemical detergents or water temperature requirements for properly laundering of resident clothing and linens. On 2/1/24 at approximately 10:21 AM, Certified Nursing Assistant (CNA) F escorted the surveyor outside of the facility to the facility laundry room. Laundry Worker A was observed sitting on a bucket sorting loose linen that was saturated with urine and feces. The linen was piled on the concrete floor in the soiled linen room. Laundry Worker A was wearing gloves, but had no other personal protective equipment (PPE) over her clothing. There was another large pile of resident clothes mixed with soiled linen lying on the concrete floor in the corner behind Laundry Worker A and 4 bags of soiled linen in front of her. There was a portable rack that had both hanging clothes and partially folded clothes in an attached metal linen basket in the soiled laundry room. The hanging and partially folded clothes appeared clean. The small sink in the room was surrounded by laundry and inaccessible for handwashing. Used gloves were laying on the concrete floor next to the soiled laundry. Outside of the soiled laundry room there were 2 bins labeled soiled laundry containing bags of soiled laundry. There were 11 clear garbage bags of soiled laundry on the ground extending out the open laundry door to the outdoors. Also outdoors, approximately 8 bags containing clean wet linen were observed stacked on a wooden pallet. Additional unbagged linens were observed on top of the bagged linen. There was a broom handle resting on both the bagged and unbagged linen, a trash can lid resting on the bagged linen, a box of clean gloves sitting on the pallet and 2 used gloves on the ground next to the pallet along with multiple tree leaves. The Environmental Services Manager was at the time of the laundry room observation, and an interview was conducted during the observation. She explained that they had been transporting the laundry to the laundromat in the back of the pickup truck that was parked nearby. The pickup truck bed was observed with dirt and debris, used gloves and had multiple bottles of Tide Simply All in One and household bleach containers. Some of the chemical containers were empty. The Environmental Services Manager explained that the washers have not been working at the facility for several months. She indicated that the facility has had trouble maintaining both washers and dryers over the past year. Since the washers broke, they have been taking laundry to the local public laundromat to wash. Then bringing the wet laundry back to the facility to dry 7 days a week. The Environmental Services Manager explained that they ran out of commercial laundry detergent on 1/28/24. They have since been using 1/2 cup of Tide [detergent] and 1/2 cup of bleach per load in the washers at the laundromat. She was unable to verbalize how those amounts were determined. She indicated that the laundromat washers might have a 35-gallon capacity. The surveyor asked if the facility has run out of commercial detergent and laundry sanitizer in the past. The Environmental Services Manager replied yes, and stated they have had to utilize the Tide and bleach in the past when they had run out of commercial detergent and sanitizer. She was asked to describe the type and capacity of the washers at the laundromat. The manager was unable to provide specific information regarding type, manufacture, or recommendations for detergent and/or hot water temperatures for washers at the laundromat. On 2/1/24 at Approximately 10:29 AM, when the surveyor entered the clean side of the laundry area where the dryers were located, there were 4 bins of wet laundry waiting to be dried. The bins were labeled Soiled Linen. Clean dry linen and clothes were being sorted and folded in the same room where these 4 bins were located. The surveyor asked how long those linens have been waiting to be dried. The Environmental Services Manager said they were left over from yesterday at approximately 6:00 PM that had not yet been dried. Clean resident clothes were folded and sorted on a table that did not have a barrier present. Outside there was a bin marked trash stored next to a cart where clean dry resident clothes were stored outside. Tree leaves were observed to be underneath the linen. (photographic evidence was obtained). On 2/1/24 at about 1:20 PM, the surveyor observed the washed wet bagged laundry in the back of the same pickup truck after return from the laundromat. There was no indication that the bed of the truck had been cleaned after the soiled linen was transported and before the wet washed laundry was loaded. The bed of the truck appeared the same as the prior observation, containing dirt, debris, and empty bleach and detergent containers. The Environmental Services Manager was asked about cleaning the truck bed. She indicated that they are wiping out the truck bed using a a small bottle of Broadside sanitizer spray. The Environmental Services Manager was asked to provide a list of employees that were assisting with processing laundry. She explained that she, Laundry Worker A, Maintenance Worker K, and the Maintenance Supervisor were assisting with transporting and processing soiled linens at the laundromat. The Environmental Services Manager was asked to provide evidence of training for the employees who were processing laundry for the facility. On 2/1/24 at approximately 4:00 PM, a follow-up interview was conducted with the Environmental Services Supervisor who is also the Housekeeping Supervisor. She provided the latest training regarding handling infectious laundry, dated 4/25/2023. Three employees signed that they completed the training. Laundry Worker A, another employee who was no longer employed and Housekeeping Staff Member P. Maintenance Worker K and the Maintenance Supervisor did not sign that they had received the training. Per the in-service materials, to prevent microbial contamination of laundry equipment staff should: -remove solids such as feces or vomit before the wash/dry cycle. -follow manufacturer recommended temperature, detergent and laundry additive guidelines. -do not leave damp textiles in machines overnight. The inservice advised that a temperature of at least 160 degrees Fahrenheit for a minimum of 25 minutes was commonly recommended for washing laundry. Chlorine bleach becomes activated at water temperatures of 135-145 degrees Fahrenheit. The training materials were based on the Centers for Infection Control and Prevention (CDC) guidance. On 2/1/24 at approximately 2:30 PM, during a second interview with the Maintenance Supervisor, he indicated that he had training regarding processing laundry but could not recall exactly when the training occurred or give details related to the training. On 2/1/24 at approximately 3:00 PM, an interview was completed with the Infection Prevention (IP) Nurse who stated that the Environmental Services Manager was in charge of ensuring infection control processes are followed when it comes to handling and laundering linen. The IP nurse was asked who was responsible for providing education regarding handling laundry. The Infection Control Nurse indicated that she was unsure who did the training, but it was probably the Environmental Services Supervisor. The IP nurse was shown images of bins labeled soiled linen which contained clean wet laundry that had waited all night before being placed in dryers. The Infection Control Nurse indicated that clean linen should never be stored in bins that are labeled soiled linen and that clean linen should be processed in an area that does not contain contaminated laundry. On 2/1/24 at approximately 4:36 PM, an interview was conducted with the Administrator. She was asked who provides the education for laundry serves. The Administrator explained that she would find out who is responsible. The Administrator was asked when she last toured laundry area, and replied that she toured the laundry when she first came on board (in December). She stated that nothing caught her eye that was off. The Administrator was shown photographs of laundry on the ground being sorted out of bags. The Administrator stated that it should not be like that, and that she would find out who is responsible for education. On 2/1/24, a review of the Laundry Services Policy dated 12/8/23 was conducted. The policy stated soiled and clean linen should be separated at all times. The policy directed staff not to place clean linen in contaminated areas or transport clean linen in containers designated for soiled linen. The policy directed staff to wash their hands after handling soiled linen and before handling clean linen. Staff should consider all soiled linen to be potentially infectious and handle it with standard precautions. All soiled linen should be placed directly into covered containers designated for soiled linen. Handle soiled linen as little as possible and prevent agitation. Employees sorting or washing linen must wear a gown and gloves. The policy directed employees to not leave damp linen in laundry machines overnight. The policy recommended that staff follow manufacturer instructions (instructions from equipment, detergent, rinses etc.) for all laundry processing. The policy directed staff to keep soiled and clean linen and their respective hampers and laundry carts separated at all times. Mops are to be washed separately from linens and kept in separate laundry carts. Staff processing clean linen were directed to place a barrier on the sorting folding table before placing any clean linen or clothing items. The laundry services policy did not address any procedures regarding utilizing the local laundromat. On 2/1/24 a review of the job description for laundry services workers, undated, was conducted. The job description stated that laundry workers should participate in an in-service training program prior to performing tasks that involve potential exposure to blood body fluids or hazardous chemicals.

Based on observations, resident interviews, staff interviews and clinical record review, and the facility failed to provide necessary care and services to ensure that a resident maintains or improves abilities in activities of daily living (ADL) for 1 of 2 residents sampled for ADL care, #9. The facility failed to provide bathing and dressing assistance in accordance with the resident's abilities and preferences. The facility failed to assist with mobility (walking) and transfers out of bed since November 2023. During the survey, when the facility did assist resident #9 out of bed on 1/31/24, Resident #9 was left in a wheelchair for about 10 hours. The facility failed to provide timely incontinence care for 12 hours the evening/night of 1/31/24 and morning of 2/1/24. This failiure resulted in the discovery of a new buttocks wound on 2/1/24. The findings include: Resident #9 On 1/29/24 at approximately 11:50 AM, Resident #9 was observed asleep in the bed. The bed was raised all the way up to the highest position. Resident #9 was on a pressure reducing mattress with no sheet and a grooved blanket under him. He had a patient gown on and the area around him smelled strongly of urine. On 1/29/24 at approximately 2:50 PM, Resident #9 was awake. He had a patient gown on and smelled strongly of urine. His bed did not have a sheet on it and he laid on a grooved blanket. An interview was conducted with the resident. Resident #9 immediately said that he wanted to get up out of the bed to his wheelchair. He explained that he has not seen his wheelchair for months and has been told that it is missing. He said he cannot remember the last time he was out of bed, but that it was definitely more than 2 weeks ago. He explained that he asked his Certified Nursing Assistant (CNA) if he could get up and walk yesterday, but no one ever got him up. He explained that his back is sore and his feet are swollen. He said he asked Nurse D, a Licensed Practical Nurse (LPN) in Restorative for shoes to use so he can get up in the shower chair to take showers, but has never gotten a response. He explained he has been getting bed baths since then, instead of getting him up to the shower chair. The resident explained that he almost never gets a response to his requests. On 1/30/24 at approximately 9:18 AM, a follow up interview with Resident #9 occurred. He said that the staff did not get him out of bed all day. He said he told CNA L that he wanted to get out of bed. CNA L never came back to assist him out of bed. The resident explained that, if staff comes in and you are asleep, they will mark that you refused to get out of bed. He indicated that if staff comes in and wants to get him up out of bed and he asks to do it at a later time, they will also mark that he refused. Resident #9 indicated that he wants to get up. He reports he can use a trapeze bar to move himself around in the bed and help staff when they move him. On 1/30/24 at approximately 4:00 PM, Resident #9 was in the bed asleep. On 1/31/24 at approximately 9:18 AM, Resident #9 stated that they did not get him out of bed yesterday. On 1/31/24 at approximately 10:23 AM, an interview was conducted with Nurse B, an LPN, who was asked why Resident #9 had not been gotten out of bed all week. She explained that the resident is supposed to be getting out of bed, but often refuses. The surveyor asked to observe treatment of his dressing and areas. LPN B indicated that she would let the surveyor observe the application of Nystatin powder to his skin folds as ordered on the Treatment Administration Record (TAR) and wound care. LPN B did not check into why Resident #9 had not been assisted out of bed. She also did not contact the surveyor to conduct observation of application of the Nystatin powder to the resident. On 1/31/24 at approximately 10:30 AM, Staff F, a CNA, was notified that Resident #9 had been asking to get out of bed since Monday 1/29/24 and that he said he wants to get up to his wheelchair now. CNA F said therapy was supposed to work with him to get a new wheelchair because his knees don't bend and they can't be placed on the foot rests. CNA F said, I can't put him in the wheelchair. It takes a Hoyer lift and two people. He has needed new leg rests for over a month. She explained that she was told a new piece was getting ordered for the leg rests months ago because he had the money in his account to buy the pieces of equipment. She explained it has been awhile and she has heard nothing more. She said it has been awhile since he has been gotten out of bed. CNA F was asked how long it had been since Resident #9 got out of bed, and replied that Resident #9 had not been up since November of 2023. She explained that staff often has to wake him up to get him out of bed as well. She also said that it was hard to get him rolled and changed in the bed. She was asked where his wheelchair was. CNA F and the surveyor went to find the wheelchair in storage, but the wheelchair could not be located anywhere. On 1/31/24 at 10:50 AM, LPN D approached the surveyor with a bariatric wheelchair with a padded seat. She indicated that she found Resident #9's wheelchair. She said that Resident #9 will say he wants to get up but often refuses. She explained that she has been working on getting the resident to get up on a weekly basis. The surveyor pointed out to LPN D that the care plan does not indicate that Resident #9 refuses frequently. CNA H and CNA F accompanied LPN D to the bedside of Resident #9 to assist him out of the bed. On 1/31/24 at 11:00 AM, an interview was conducted with CNA H. She was asked if she can recall the last time Resident #9 was assisted out of bed. She explained that she cannot recall specifically but said it was a long time ago. She indicated that she has trouble bending his legs and putting his legs in the wheelchair foot rests as well. On 1/31/24 at 11:49 AM, Resident #9 was seated at a table in the cafeteria conversing with another resident. He was dressed in his clothes and he no longer smelled of urine. He was up in a wheelchair with his legs in leg rests and shoes on. The resident expressed his sincere gratitude for being allowed to get up out of bed. The resident said it had been months since he has been up. He said he asked his CNA if he could get up Monday but the CNA did not respond. Resident #9 said he asked to get up last week and the week before and no one assisted him out of bed. On 1/31/24 at 11:55 AM, CNA J had been talking to the resident. She said it has been a long time since she has seen in up in his wheelchair. CNA J was asked about the last time Resident #9 was observed out of bed. She explained that she cannot recall the last time she last saw him up. On 2/1/24 at approximately 8:30 AM, an interview was conducted with Resident #9. He said they left him up in the wheelchair all day yesterday until about 9:00 PM. He said he was hurting, but looking forward to getting out of bed next time. He indicated he might not ask to get up today because he was sore. On 2/1/24 at approximately 9:24 AM, an interview was conducted with CNA L. He was asked if he was assigned to care for Resident #9 on Monday 1/29/24. He stated the he was. He was asked why he did not get Resident #9 up on Monday. CNA L indicated that did not recall Resident #9 asking to get out of bed. He explained that he had only worked at the facility for 2 weeks and had not seen Resident #9 out of bed previously. On 2/1/24 at approximately 10:10 AM, CNA I was assisting Resident #9 with oral care. The resident smelled of urine. His brief was soaked with urine and feces. The dressing on his underpad was soaked with urine. His sheets were wet. The area smelled strongly of urine and feces. CNA I removed the soaked brief and proceeded to clean him up. Resident #9 said he had not been assisted with changing his brief since about 10:00 PM last evening. CNA I was asked if she assisted Resident #9 with changing his brief yet today. CNA I indicated that she had not checked or offered to assist Resident #9 with peri care yet today. There was a dressing over an area on the buttock and there was another open area lateral to the dressing on the upper right buttock. CNA I was asked if she had seen that open area before. CNA I reported that she had not seen the area before. On 2/1/24 at approximately 1:00 PM, Nurse B, a, LPN, was notified that there was an additional open area observed during peri care. LPN B indicated that she had not previously been notified of the area. LPN B was asked if that was a new area. LPN B said she was not sure and that she will have to talk to Nurse N, a Registered Nurse (RN) Unit Manager. She came back a few minutes later and confirmed that this is a new wound. On 2/1/24 at approximately 9:00 AM, the Facility Administrator (FA) was notified that, based on interviews with staff and residents, there were concerns that Resident #9 had not been out of bed to the wheelchair since November 2023. A copy of a Physical Therapy Assessment Form dated 12/7/23 noted no decline noted at the time. The Physical Therapy Assessment form dated 1/31/24 noted Resident #9 was currently in a 23-inch manual wheelchair with a 3-inch cushion. The wheelchair was listed in working condition and it was noted that the patient was able to reach the wheelchair brakes and both brakes are listed as working. The form stated no modifications to the chair were necessary. On 2/1/24 at approximately 3:30 PM, an interview and medical record review was conducted with Nurse N, the RN Unit Manager. She was notified that, during an observation of peri care at approximately 10:00 AM, Resident #9 was noted to be soaked with urine and feces. The resident reported that he had not been assisted with changing his brief since about 10:00 PM the night before (about 12 hours). A new open area was found on his right outer buttock. Unit Manager N indicated that the area was a new open area. There were no new orders, documentation, or care plan revision regarding the new open area on Resident #9's buttocks. Unit Manager N indicated that the physician had not yet been notified. Unit Manager N explained that Resident #9 has a history of getting open areas on his buttocks. She indicated that he does not like to turn and often refuses. The surveyor asked Unit Manager N to point out where the care plan has been updated to include that Resident #9 refuses to turn and get out of bed. Unit Manager N reviewed the plan and stated she does not see refusals included on the care plan. Unit Manager N indicated that Resident #9 does not have much mobility. Unit Manager N was notified that an interview with several CNA staff revealed that the last time he might have been gotten out of bed to the wheelchair was in November. Unit Manager N agreed that November probably was the last time he was up. She was asked why Resident #9 had not been put in his wheelchair since November 2023. Unit Manager N said she did not know why. She explained that Nurse D, the Restorative LPN, used to get him up at least three times a week. She explained that Resident #9 can be difficult at times. He becomes agitated and yells at the staff sometimes. Resident #9 has a couple of days every month or so when he is more confused. Unit Manager N was asked if Resident #9 is getting what he needs for his nursing care and psychosocial needs. The nurse indicated that the resident was not getting his needs met. She indicated that the therapy department takes measurements and makes decisions about the type of wheel chair. She indicated that if the facility had social services in place, there might have been more assistance with the wheelchair. A review of the quarterly Minimum Data Set (MDS) information was conducted for Resident #9. On 12/7/23, the resident's Brief Interview for Mental Status (BIMS) score was 12. Section F0500 of the MDS states that it is somewhat important to go to outside and get fresh air when the weather is good. On 1/31/24 at approximately 2:00 PM, a review of the medical record for Resident #9 was conducted. Resident #9 diagnoses included: Chronic Kidney disease, Hypertension, Diabetes Type II, Morbid obesity, vertigo, hyperlipidemia, neuropathy, and cognitive communication deficit. The narrative, check lists, nurses notes, and progress notes showed no documentation that the resident had been gotten out of bed at any time. A review of the care plan (last updated 12/6/2023) for Resident #9 was conducted. The care plan indicated that Resident #9 needed extensive assistance with activities of daily living (ADL) transfers, ambulation, locomotion, dressing, eating, toileting, personal hygiene, and bathing. Goals: The resident would not develop complications related to ADL performance. Resident will maintain ADL self-performance levels as evidenced by no decline in stated ADL levels through the next review date. Interventions: Staff will encourage participation in care as appropriate. Staff will ensure all needs are met. Staff will ensure the resident is dressed and groomed as appropriate. Staff will utilize task segmentation as indicated to help improve participation in ADL performance. Staff will get the resident out of bed as tolerated. Staff will encourage group exercises. The care plan indicated that Resident #9 was at risk for skin breakdown or wounds related to decreased mobility and incontinence. Goal: Resident will be free from skin breakdown or pressure by implementing prevention measures. Interventions: Completion of weekly skin assessments. Report any changes in skin status. Staff will notify the nurse immediately of any new skin breakdown, redness, bruises, blisters, or discoloration during daily care. Staff will to assist to reposition or shift weight to relieve pressure as needed. Staff will provide a pressure reduction mattress, provide incontinence care after incontinent episodes, and apply barrier cream as needed. Staff was directed to assist the resident to avoid prolonged periods of skin-to-skin contact.

Based on observations, resident interviews, staff interviews, and clinical record review, the facility failed to implement the care plan for 2 of 2 sampled residents with Activity of Daily Living Care concerns (Resident #9 and #45). The facility identified that resident #9 needed extensive assistance with transfers, ambulation, dressing, toileting, and bathing. The facility failed to provide bathing in accordance with the resident's abilities and preferences. The facility failed to assist with ambulation (walking) and transfers out of bed since November 2023 for Resident #9. The resident was observed dressed in a hospital style gown. The facility failed to provide timely incontinence care for 12 hours the evening/night of 1/31/24 into the morning of 2/1/24. The morning of 2/1/24, during incontinence care, a new buttocks wound was discovered for Resident #9. The facility failed to provide wound care for 7 days in accordance with the care plan for resident #45. The skin around the wound was missing and yellow exudate and redness were present. The findings include: Resident #9 A review of the care plan (last updated 12/6/2023) for Resident #9 was conducted. The care plan indicated that Resident #9 needed extensive assistance with activities of daily living (ADL) transfers, ambulation, locomotion, dressing, eating, toileting, personal hygiene, and bathing. Goals: The resident would not develop complications related to ADL performance. Resident will maintain ADL self-performance levels as evidenced by no decline in stated ADL levels through the next review date. Interventions: Staff will encourage participation in care as appropriate. Staff will ensure all needs are met. Staff will ensure the resident is dressed and groomed as appropriate. Staff will utilize task segmentation as indicated to help improve participation in ADL performance. Staff will get the resident out of bed as tolerated. Staff will encourage group exercises. The care plan indicated that Resident #9 was at risk for skin breakdown or wounds related to decreased mobility and incontinence. Goal: Resident will be free from skin breakdown or pressure by implementing prevention measures. Interventions: Completion of weekly skin assessments. Report any changes in skin status. Staff will notify the nurse immediately of any new skin breakdown, redness, bruises, blisters, or discoloration during daily care. Staff will assist to reposition or shift weight to relieve pressure as needed. Staff will provide a pressure reduction mattress, provide incontinence care after incontinent episodes, and apply barrier cream as needed. Staff was directed to assist the resident to avoid prolonged periods of skin-to-skin contact. On 1/29/24 at approximately 11:50 AM, Resident #9 was observed asleep in the bed. The bed was raised all the way up to the highest position. Resident #9 was on a pressure reducing mattress with no sheet and a grooved blanket under him. He had a patient gown on and the area around him smelled strongly of urine. On 1/29/24 at approximately 2:50 PM, Resident #9 was awake. He had a patient gown on and smelled strongly of urine. His bed did not have a sheet on it and he laid on a grooved blanket. An interview was conducted with the resident. Resident #9 immediately said that he wanted to get up out of the bed to his wheelchair. He explained that he has not seen his wheelchair for months and has been told that it is missing. He said he cannot remember the last time he was out of bed, but that it was definitely more than 2 weeks ago. He explained that he asked his Certified Nursing Assistant (CNA) if he could get up and walk yesterday, but no one ever got him up. He explained that his back is sore and his feet are swollen. He said he asked Nurse D, a Licensed Practical Nurse (LPN) in Restorative for shoes to use so he can get up in the shower chair to take showers, but has never gotten a response. He explained he has been getting bed baths since then, instead of getting him up to the shower chair. The resident explained that he almost never gets a response to his requests. On 1/30/24 at approximately 9:18 AM, a follow up interview with Resident #9 occurred. He said that the staff did not get him out of bed all day. He said he told CNA L that he wanted to get out of bed. CNA L never came back to assist him out of bed. The resident explained that, if staff comes in and you are asleep, they will mark that you refused to get out of bed. He indicated that if staff comes in and wants to get him up out of bed and he asks to do it at a later time, they will also mark that he refused. Resident #9 indicated that he wants to get up. He reports he can use a trapeze bar to move himself around in the bed and help staff when they move him. On 1/30/24 at approximately 4:00 PM, Resident #9 was in bed asleep. On 1/31/24 at approximately 9:18 AM, Resident #9 stated that they did not get him out of bed yesterday. On 1/31/24 at approximately 10:23 AM, an interview was conducted with Nurse B, an LPN, who was asked why Resident #9 had not been out of bed all week. She explained that the resident is supposed to be getting out of bed, but often refuses. The surveyor asked to observe treatment of his dressing and areas. LPN B indicated that she would let the surveyor observe the application of Nystatin powder to his skin folds as ordered on the Treatment Administration Record (TAR) and wound care. LPN B did not check into why Resident #9 had not been assisted out of bed. She also did not contact the surveyor to conduct observation of application of the Nystatin powder to the resident. On 1/31/24 at approximately 10:30 AM, Staff F, a CNA, was notified that Resident #9 had been asking to get out of bed since Monday 1/29/24 and that he said he wants to get up to his wheelchair now. CNA F said therapy was supposed to work with him to get a new wheelchair because his knees don't bend and they can't be placed on the foot rests. CNA F said, I can't put him in the wheelchair. It takes a Hoyer lift and two people. He has needed new leg rests for over a month. She explained that she was told a new piece was getting ordered for the leg rests months ago because he had the money in his account to buy the pieces of equipment. She explained it has been awhile and she has heard nothing more. She said it has been awhile since he has been out of bed. CNA F was asked how long it had been since Resident #9 got out of bed, and replied that Resident #9 had not been up since November of 2023. She explained that staff often has to wake him up to get him out of bed as well. She also said that it was hard to get him rolled and changed in the bed. She was asked where his wheelchair was. CNA F and the surveyor went to find the wheelchair in storage, but the wheelchair could not be located anywhere. On 1/31/24 at 10:50 AM, LPN D approached the surveyor with a bariatric wheelchair with a padded seat. She indicated that she found Resident #9's wheelchair. She said that Resident #9 will say he wants to get up but often refuses. She explained that she has been working on getting the resident to get up on a weekly basis. The surveyor pointed out to LPN D that the care plan does not indicate that Resident #9 refuses frequently. CNA H and CNA F accompanied LPN D to the bedside of Resident #9 to assist him out of the bed. On 1/31/24 at 11:00 AM, an interview was conducted with CNA H. She was asked if she could recall the last time Resident #9 was assisted out of bed. She explained that she cannot recall specifically but said it was a long time ago. She indicated that she has trouble bending his legs and putting his legs in the wheelchair foot rests as well. On 1/31/24 at 11:49 AM, Resident #9 was seated at a table in the cafeteria conversing with another resident. He was dressed in his clothes and he no longer smelled of urine. He was up in a wheelchair with his legs in leg rests and shoes on. The resident expressed his sincere gratitude for being allowed to get up out of bed. The resident said it had been months since he has been up. He said he asked his CNA if he could get up Monday but the CNA did not respond. Resident #9 said he asked to get up last week and the week before and no one assisted him out of bed. On 1/31/24 at 11:55 AM, CNA J had been talking to the resident. She said it has been a long time since she has seen in up in his wheelchair. CNA J was asked about the last time Resident #9 was observed out of bed. She explained that she cannot recall the last time she last saw him up. On 2/1/24 at approximately 8:30 AM, an interview was conducted with Resident #9. He said they left him up in the wheelchair all day yesterday until about 9:00 PM. He said he was hurting, but looking forward to getting out of bed next time. He indicated he might not ask to get up today because he was sore. On 2/1/24 at approximately 9:24 AM, an interview was conducted with CNA L. He was asked if he was assigned to care for Resident #9 on Monday 1/29/24. He stated he was. He was asked why he did not get Resident #9 up on Monday. CNA L indicated that did not recall Resident #9 asking to get out of bed. He explained that he had only worked at the facility for 2 weeks and had not seen Resident #9 out of bed previously. On 2/1/24 at approximately 10:10 AM, CNA I was assisting Resident #9 with oral care. The resident smelled of urine. His brief was soaked with urine and feces. The dressing on his underpad was soaked with urine. His sheets were wet. The area smelled strongly of urine and feces. CNA I removed the soaked brief and proceeded to clean him up. Resident #9 said he had not been assisted with changing his brief since about 10:00 PM last evening. CNA I was asked if she assisted Resident #9 with changing his brief yet today. CNA I indicated that she had not checked or offered to assist Resident #9 with peri care yet today. There was a dressing over an area on the buttock and there was another open area lateral to the dressing on the upper right buttock. CNA I was asked if she had seen that open area before. CNA I reported that she had not seen the area before. On 2/1/24 at approximately 1:00 PM, Nurse B, a, LPN, was notified that there was an additional open area observed during peri care. LPN B indicated that she had not previously been notified of the area. LPN B was asked if that was a new area. LPN B said she was not sure and that she will have to talk to Nurse N, a Registered Nurse (RN) Unit Manager. She came back a few minutes later and confirmed that this was a new wound. On 2/1/24 at approximately 9:00 AM, the Facility Administrator (FA) was notified that, based on interviews with staff and residents, there were concerns that Resident #9 had not been out of bed to the wheelchair since November 2023. A copy of a Physical Therapy Assessment Form dated 12/7/23 noted no decline noted at the time. The Physical Therapy Assessment form dated 1/31/24 noted Resident #9 was currently in a 23-inch manual wheelchair with a 3-inch cushion. The wheelchair was listed in working condition and it was noted that the patient was able to reach the wheelchair brakes and both brakes are listed as working. The form stated no modifications to the chair were necessary. On 2/1/24 at approximately 3:30 PM, an interview and medical record review was conducted with Nurse N, the RN Unit Manager. She was notified that, during an observation of peri care at approximately 10:00 AM, Resident #9 was noted to be soaked with urine and feces. The resident reported that he had not been assisted with changing his brief since about 10:00 PM the night before (about 12 hours). A new open area was found on his right outer buttock. Unit Manager N indicated that the area was a new open area. There were no new orders, documentation, or care plan revision regarding the new open area on Resident #9's buttocks. Unit Manager N indicated that the physician had not yet been notified. Unit Manager N explained that Resident #9 has a history of getting open areas on his buttocks. She indicated that he does not like to turn and often refuses. The surveyor asked Unit Manager N to point out where the care plan has been updated to include that Resident #9 refuses to turn and get out of bed. Unit Manager N reviewed the plan and stated she does not see refusals included on the care plan. Unit Manager N indicated that Resident #9 does not have much mobility. Unit Manager N was notified that an interview with several CNA staff revealed that the last time he might have been gotten out of bed to the wheelchair was in November. Unit Manager N agreed that November probably was the last time he was up. She was asked why Resident #9 had not been put in his wheelchair since November 2023. Unit Manager N said she did not know why. She explained that Nurse D, the Restorative LPN, used to get him up at least three times a week. She explained that Resident #9 can be difficult at times. He becomes agitated and yells at the staff sometimes. Resident #9 has a couple of days every month or so when he is more confused. Unit Manager N was asked if Resident #9 is getting what he needs for his nursing care and psychosocial needs. The nurse indicated that the resident was not getting his needs met. She indicated that the therapy department takes measurements and makes decisions about the type of wheel chair. She indicated that if the facility had social services in place, there might have been more assistance with the wheelchair. A review of the quarterly Minimum Data Set (MDS) information was conducted for Resident #9. On 12/7/23, the resident's Brief Interview for Mental Status (BIMS) score was 12. Section F0500 of the MDS states that it is somewhat important to go outside and get fresh air when the weather is good. On 1/31/24 at approximately 2:00 PM, a review of the medical record for Resident #9 was conducted. Resident #9 diagnoses included: Chronic Kidney disease, Hypertension, Diabetes Type II, Morbid obesity, vertigo, hyperlipidemia, neuropathy, and cognitive communication deficit. The narrative, check lists, nurses notes, and progress notes showed no documentation that the resident had been gotten out of bed at any time. 43857 Resident #45: On 1/29/24 at 11:33 am, during the initial tour, Resident #45 was observed with abrasions on the right side of face that were open to the air. Layers of skin were observed missing and yellow exudate and redness were noted. A review of Resident #45's medical record was conducted. Resident # 45's care plan was updated on 1/22/24 and stated that new orders to soak open area with 1 part water to 3 parts vinegar, cover, apply Vaseline, xeroform, non-adherent dressing twice a day and as needed. The medical record contained an undated form with education about a biopsy, aftercare instructions, and a hand-written list indicating treatment for wound care. A review of Resident #45's Treatment Administration Record (TAR) also stated to soak all areas open to bilateral arm, neck and face with 1 part water, 3 parts vinegar, pat dry, apply Vaseline, xeroform, non-adherent dressing twice a day and as needed. The TAR had a start date of 1/23/24 and has not been documented from 1/22 until 1/29. On 1/31/24 at 09:39 am, an interview was conducted with Unit Manager N who was also the facility's Infection Preventionist. During the interview, she reviewed Resident #45's TAR. Unit Manager N stated honestly, nurses are not doing the treatments. Unit Manager N further stated she was aware of treatments not being done and she would like to do wound care, but she was in charge of Infection control and also a unit manager. She further stated the facility was going to start monitoring compliance with treatments, she would be checking the records, provide some education, and start writing up staff that would not comply.