Every finding on record at St. Juanita Retirement and Rehab

Based on observation, interview, and record review, the facility failed to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week in that: The facility had no RN coverage on 8/15/21 and 8/16/21. This failure could affect residents by putting them at risk of poor nursing care and assessment. The findings were:Observation on 8/15/26 at 2:38 p.m. through 8/15/26 8:20 p.m. revealed no RN in the building. Observation on 8/16/26 at 10:24 a.m. through 1:36 p.m. revealed no RN in the building. Interview on 8/15/26 at 3:27 p.m. CNA A stated there were two nurses on the day shift, but there was not an RN on duty. Interview on 8/15/26 at 3:58 p.m. CNA B stated the only RN the facility had was the DON. Interview on 8/16/26 at 12:02 p.m. LVN F said she thought there was no RN on site on 8/16/26 and she did not think there was an RN in the building on 8/15/26. Interview on 8/16/26 at 12:39 pm. the Administrator stated she did not know who the RN was on 8/15/26 or 8/16/26. Interview on 8/17/26 at 10:05 a.m. the DON stated the facility currently used a lot of LVNs. The DON stated if an RN applied the facility would accept them. The DON said she was aware of the RN 8 hours a day requirement, but she had a family emergency on the weekend of 8/15/26 and 8/16/26 and could not be at the facility. The DON said the facility needed RN coverage because only an RN could do certain care issues due to the scope of practice. The DON stated she did not start picking up shifts at the facility until the end of May 2026 and only became the DON two weeks ago. Review of the complete staff list, undated, provided on 8/17/26, revealed the DON was the only RN in the building. Review of the facility's policy on Staffing, undated, revealed: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. A registered nurse must be onsite 8 consecutive hours a day, 7 days a week.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #1) observed for infection control. The facility failed to ensure LVN C and CNA D used the required PPE (gown) for Resident #1 who was on enhanced barrier precautions due to her pressure ulcer wound care on 8/15/26.LVN C failed to provide wound care to Resident #1 in a manner that prevented cross-contamination by failing to use any hand hygiene, placing the uncovered wound on the bed, going over the wound multiple times while cleaning, and using the same gloves the entire wound care.The facility failed to ensure PPE was available for all staff who needed it to provide care to residents on EBP or isolation measures.LVN E turned off the faucet with her bare hands after washing her hands. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: Resident #1Review of Resident #1's admission Record, dated 8/15/26, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including diabetes and peripheral vascular disease (reduced blood flow to the extremities). Review of Resident #1's Care Plan Report, initiated 6/2/27, revealed:Resident#1 was a diabetic and was at risk for fluctuations in blood glucose (sugar) level, hypoglycemia (low blood sugar), frequent infections, etc.Goal: Resident #1's diabetic status would remain stable as evidenced by blood glucose level staying within normal limits over the next 90 days.Interventions: Observe for skin changes - redness, circulatory problems, breakdown - report to MD/NP Review of Resident #1's Order Summary Report, dated 8/15/26, revealed to cleanse left lateral heel (side) area with wound cleanser, apply collagen powder to wound bed followed by medi-honey then secure in place using a silicone foam dressing every day shift for wound care dated 8/8/26.There was no order for EBP. Review of Resident #1's Resident Alert History (Box on top of the Electronic Record documenting any specialized needs the Resident had for quick example such as directive, allergies.) did not show Resident #1 needed EBP status. Review of Resident #1's Wound Assessment Report, dated 8/4/26 revealed an order to change dressing daily, clean with normal saline, with primary treatment of collagen and honey with silicone bordered foam dressing. Review of Resident #1's Nurse's Notes dated 7/8/26revealed: Resident #1 had a skin alteration to the left heel. Upon assessment there was a blood blister measuring 1.5 cm x 1.5 cm. Interview on 8/15/26 at 4:39 p.m. LVN C stated she worked at the facility for 3 months. LVN C said she was designated as the Treatment Nurse. LVN C said no one gave her training on what was expected as the Treatment Nurse. LVN C stated she was learning what to do as she followed the doctor. Observation and interview on 8/15/26 at 6:48 p.m. revealed Resident #1 gave permission to watch the wound care. There was no wound care set up. CNA D put on gloves with no hand hygiene and wore no PPE. LVN C did not wear any PPE nor did she put on gloves. With her bare hands, LVN C took off Resident #1's sock and laid Resident #1's foot flat on the bed. LVN C put her hands into her pocket and pulled out iodine swabs out of her pocket and placed them onto Resident #1's bed. LVN C opened a bandage, placed it on the bed, then initialed it, and put it back on the bed. LVN C then told CNA D to hold Resident #1's leg up. LVN C put on gloves with no hand hygiene and took off Resident #1's bandage from Resident #1's foot and threw it into the regular trash. LVN C said the last time she saw Resident #1's wound it looked like a closed blood blister. LVN C described the wound as dime-sized, white and mushy on the outside and hard in the middle of the wound. The wound was observed to have a flap of skin over the wound bed. LVN C said she forgot something and told CNA D to put Resident #1's foot onto the bed, then left the room. LVN C returned holding stacked cups of dry gauze and wet gauze. LVN C placed the cups of gauze on the bedside table. CNA D picked up Resident #1's foot and while wearing the same gloves, LVN C cleaned the wound with the wet gauze explaining it was normal saline. LVN C picked up the iodine swab from the bed, opened it and went around the wound three times. LVN C took a stack of the dry gauze, and patted Resident #1's foot 12 times. LVN C took Resident #1's dressing and placed it on Resident #1's foot. Then put the dirty sock back on and took off her gloves. LVN C only wore one pair of gloves through the entire wound care. Interview on 8/15/26 at 7:17 p.m. LVN C stated she thought she did her best. LVN C said she wished she had a little more time to do the wound care. LVN C said since Resident #1's wound was open so she might have to change the treatment, and no one told her it had opened. LVN C said she did not perform hand hygiene. LVN C said she was not even thinking about it and she should have performed hand hygiene before, after and between wound care. LVN C said she should have performed hand hygiene when she returned into the room. LVN C said putting her hands in her pocket was a problem because of all the germs she had. LVN C said not performing hand hygiene could cause the spread of germs and infection. LVN C said it one thing the specialist physician did was make her sanitize her hands between residents to prevent cross contamination (the spread of germs). LVN C said she should have used a different bag for the dirty dressing. LVN C stated placing Resident #1's uncovered foot on the bed could be a problem because everything Resident #1 put there. LVN C said she needed to wash her hands more. LVN C said the only training she had on wound care was just what she picked up from the doctor. LVN C stated EBP was for any resident with a pressure ulcer, anything open such as a feeding tube, a colostomy bag (open means there is a way germs can directly access the inside of the body). LVN C said she thought Resident #1 needed to be on EBP and LVN C thought Resident #1 was not designated as needing EBP. LVN C thought Resident #2 should be on EBP and was not designated. LVN C stated she did not think there was any PPE in the building. At 7:44 p.m. LVN C showed the treatment storage closet and the storage closet for general staff. Neither had any gloves in it. Review of Resident #2's admission Record, dated 8/15/26, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including acute osteomyelitis (bone infection), Diabetes. Review of Resident #2's Baseline Care Plan, dated 7/30/26, revealed Skin Risk: Current / History of skin integrity issues was blank. Review of Resident #2's Residet Alert Box, reviewed 8/15/26, revealed no specialized care about her foot including EBP. Observation on 8/16/26 at 10:46 a.m. of the rooms with PPE carts in the hallways revealed the carts had no gowns or gloves in them. Resident #1 and Resident #2 did not have EBP cart with PPE in them outside the door at all. Observation on 8/16/26 at 11:32 a.m. revealed LVN E with no gloves cleaning a resident's arm with an alcohol swab, placing an insulin pen on the resident's arm and using it. LVN E did not clean the area after. LVN E washed her hands but turned the faucet off with her bare hands. Interview on 8/16/26 at 11:35 a.m. LVN F stated the facility used PPE when the facility had any kind of drain (a tube going into the body to help wound drainage leave a wound). LVN F stated the doors had to be labeled and anyone going into the room had to wear the PPE. LVN F said she thought the facility had enough supplies. Interview on 8/16/26 at 1:09 p.m. LVN C stated she had one wound care with PPE on once. LVN C said she did not remember the last time she did wound care with PPE on. She said she told the DON, but when the supply order arrived, the facility received a bunch of aprons instead of gowns. LVN C stated she thought the DON placed another order but was not sure. Interview on 8/17/26 at 10:05 a.m. the DON stated her expectation for wound care was it be completed. The DON said she was responsible for ordering PPE. The DON said she did not check the closet for the amount of PPE the facility had. The DON said she found out what needed to be ordered because the nurses would write on a list. The DON said she would have to look to see when the last time the nurses wrote down they needed gowns. The DON said she was not aware the nurses were out of gowns. The DON said the facility's supplier had gowns on back order for two or three weeks. The DON said the last time the facility got supplies, the facility's supplier sent aprons instead of gowns. The DON stated she had not done any training with the nurses for wound care nor had she completed any competency check-off. Interview and record review on 8/17/26 at 3:30 p.m. the DON showed she ordered gowns on 8/17/26 with the building's supplier and the representative took it out of the order because it was a non-contracted item and he never submitted it. The DON stated the representative was overnighting the gowns. The DON said on 8/12/26 when she ordered the gowns the facility had four boxes of 12 gowns each with a resident on isolation precautions. The DON stated the facility could not get any gowns from a sister facility because the closest sister facility was not close. The DON said she was not aware the facility had an incidental card that could be used. The DON stated the outcome of not using PPE was infection control, that it could go from one person to another. Review of the facility's policy on Personal Protective Equipment, revised 1/2012, revealed Personal Protective Equipment appropriated to specific task requirements is available at all times. Employees required to perform tasks that may involve exposure to blood/body fluids will be provided appropriated protective clothing and equipment. All tasks do not involve the same type or degree of risk and therefore will not all require the kind or extent of protection. The type of protective clothing and equipment is based on:The fluid or tissue to which there is a potential exposure;The likelihood of exposure;The potential volume of material;The probable route of exposure; andThe overall working conditions and job requirements.Protective clothing provided to our employees includes, but is not necessarily limited to,Gowns/aprons/lab coats (disposable, cloth, and/or plastic). A supply of protective clothing and equipment is maintained at each nurse's station.

Based on interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 2 of 5 residents (Resident #1, Resident #2) reviewed for medical records. The facility failed to ensure wound care assessments were completed for Resident #1 and Resident #2 The facility failed to document changes in condition for Resident #1's development of an ulcer and keeping the family informed. These failures could place residents at risk of records being inaccurate and not receiving potentially needed services due to documentation errors. Finding included Resident #1Review of Resident #1's admission Record, dated 8/15/26, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including diabetes and peripheral vascular disease (reduced blood flow to the extremities). Review of Resident #1's Order Summary Report, dated 8/15/26, revealed wound care dated 8/8/26. Review of Resident #1's Nurse's Notes, dated 7/8/26 it was documented Resident #1 had a skin alteration to the left heel. Upon assessment there was a blood blister measuring 1.5 cm x 1.5 cm. The MD was notified and a new order received to cleanse the area to the left heel with wound cleanser, pat dry, apply skin prep, and a foam dressing. Review of Resident #1's Weekly Skin Monitoring revealed: the only Skin Monitoring completed in July 2026 was on 7/31/26. The Skin Monitoring form revealed there was a wound on the left heel. Review of Resident #1's Wound Assessment Reports revealed they were completed on 7/21/26, 7/28/26, and 8/4/26. Review of Nurse's Notes, Wound Care notes, available skin assessments revealed no notification to the family about changes in treatment and/or progression of the wound. Resident #2Review of Resident #2's admission Record, dated 8/15/26, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including acute osteomyelitis (bone infection), Diabetes. Review of Resident #2's Baseline Care Plan, dated 7/30/26, revealed Skin Risk: Current / History of skin integrity issues was blank. Review of Resident #2's admission Summary Note, dated 7/30/26 revealed it was noted that the resident had presented to the hospital with a non-healing ulcer. The LVN noted that on the right foot that the right great toe and right second toe had been amputated. Review of Resident #2's Order Summary Report, dated 8/15/26, revealed orders:Medial and lateral ankle (middle and side): clean with Vashe (a type of wound cleanse) apply triple antibiotic ointment, cover with ABD and soft roll (of gauze), kerlix and netting. Change M, W, F and as needed for wound care. Start date 8/12/26.Right great toe wound: Clean and soak with Vashe Primary Dressing: Transfer Silver foam, secondary dressing ABD pad, secure with tape three times M, W, FSkin Assessment to be done weekly dated 8/7/26. Review of Resident #2's Residet Alert Box, reviewed 8/15/26, revealed no specialized care about her foot including EBP. (A way for staff to quickly know resident needs) Review of the Assessments in the electronic record revealed: Weekly Wound Monitoring were not found. Review of the Assessments in the electronic record revealed: Weekly Skin Monitoring was found for 7/31/26 and 8/14/26. Interview on 8/15/26 at 4:39 p.m. LVN C stated she worked at the facility for 3 months and was just designated as the treatment nurse. LVN C said the doctor did skin assessments and she just learned she was supposed to be putting the assessments into the clinical record. LVN C stated she was not able to put the information into some parts of the charting program so some of the tracking of skin issues was still on paper. LVN C said skin assessments were completed on admission and documented on the baseline assessment in the resident record. LVN C stated they just taught her about some new paperwork a couple of days ago. Interview on 8/17/26 at 10:05 a.m. the DON stated the skin assessments were completed on paper and the treatment nurse was responsible for it. The DON stated right now the skin monitoring process was half paper and half computer assessment. The DON said tracking of skin issues was done with the infection control tracking. The DON said trending was by using the weekly tool. Interview on 8/17/26 at 3:30 p.m the DON stated skin assessments were done weekly and the nurses should do it. The DON stated the skin assessments were in the facility's electronic records under skin assessments. The DON stated the program had weekly skin assessment that pops up. The DON stated wounds were documented differently. The DON stated she could not speak for the previous DON but it looked like it was not being monitored. The DON stated some Nurses do the assessments some don't. The DON said wound assessments were through the skin assessments and they should be measured by a nurse. The DON stated the current wound care nurse was stepping down. The DON said if a nurse did any documentation it was in the skin assessment, that there observation tools. The DON stated she did expect the nurses to write a note with any change of condition that had information containing when the physician and family was notified. Interview on 8/17/26 at 4:57 p.m. the Corportate Executive Officer stated the skin process was half on computer and half on paper and it was confusing. Review of the facility's policy and procedure on Charting and Documentation: Clinical Record, dated 2018, revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.The following information is to be documented in the resident medical record:Objective observations;Changes in the resident's condition;Events, incidents or accidents involving the resident; andProgress toward or changes in the care plan goals and objectives.Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Review of the facility's policy and procedures on Wound Monitoring Guidelines, undated revealed: It is the goal of the facility to maintain skin integrity. A resident who has developed or is admitted with a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new wounds from developing. Review of the in-service dated 6/16/26 revealed: Notifications to resident, Responsible Party, Primary Care Physician and administration. All changes in condition that require the eINTERACT Change In Condition Evaluation If the patient is transferred to ER for evaluation the eINTERACT TRANSFER FORM V5 needs to be completed.

Based on interview, and record review, the facility failed to allow the resident the right to be informed of, or participate in, his or her treatment for 3 (Resident #3, resident #4, Resident #6) of 6 residents reviewed for resident rights.The facility failed to inform the resident (Resident #6) and/or their RP/POA (Resident # 3, Resident #4), in advance, of the care to be furnished and the professional that would furnish the care.The facility failed to inform the resident (Resident #6) and/or their RP/POA (Resident # 3, Resident #4), in advance, by the physician or professional of the risks and benefits of proposed care, of treatment alternatives or treatment options he or she prefers.The facility failed to protect, promote, and respect the rights of each resident (Resident #3, Resident #4, Resident #6).The facility failed to maintain the residents' (Resident #3, Resident #4) freedom in exercising their rights to be free from interference, coercion, discrimination, or reprisal from the facility in exercising their rights.The facility failed to give the resident's (Resident #3, Resident #4) legal representative the same rights as the resident.This failure could result in a lack of knowledge, self-determination, and improper care. Findings included:1. Record review of Resident #3's face sheet reviewed on 7/11/2026 revealed a [AGE] year-old female, admitted [DATE], with diagnoses of dementia (decline in cognitive abilities severe enough to interfere with daily life), vascular dementia (decline in thinking and memory skills caused by conditions that block or reduce blood flow to the brain), generalized anxiety disorder (persistent, excessive, uncontrollable worry about everyday issues), chronic pain syndrome (pain that lasts for over 3 months and may feel that pain all of the time or it may come and go), diastolic (congestive) heart failure (heart can't pump blood well enough to give your body a normal supply), and presence of cardiac pacemaker (battery-powered device implanted under the skin to monitor heart activity and sends tiny electrical impulses to correct slow, irregular, or uncoordinated heart rhythms).In an interview on 7/11/2026 at 4:55 P.M. with the POA for Resident #3, she revealed that the facility was going to send Resident #3 to an intensive rehabilitative hospital for 2 weeks without her consent. The POA stated the facility sent a referral to the rehabilitative hospital without her knowledge or consent. The POA stated she did not feel this rehabilitation was appropriate for her mother because the therapy had specific criterion that Resident #3 did not meet. The POA stated the facility did not have the right to send a referral on Resident #3's behalf. The POA stated she had Resident #3 transferred to a different facility due to her feeling this action was fraudulent.Record review of Resident #3's medical record, reviewed on 7/11/2026, lacked consent for a referral to the rehabilitative hospital. The medical record lacked a physician's order for the referral.2. Record review of Resident #4's face sheet reviewed on 7/11/2026 revealed an [AGE] year-old female admitted [DATE], with diagnoses of dementia (decline in cognitive abilities severe enough to interfere with daily life), major depressive disorder (persistent sadness, emptiness, and loss of interest in activities), and osteoarthritis (when protective cartridge that cushions the ends of your bones wear down over time).In an interview on 7/11/2026 at 1:16 P.M. with the POA of Resident #4, revealed that the facility insisted Resident #4 go to an intensive rehabilitative hospital or she had to take her home, discharging from the facility. The POA cried during the interview and stated that she could not take care of her mother at home and was not given any choice. The POA stated her and her brother went to pick up Resident #4 because they could not afford to send Resident #4 to the rehabilitative hospital. She stated that her mother had dementia and could not consent or deny. The POA of Resident #4 stated when they were assisting Resident #4 in the car to discharge from the facility, ADM A approached them and stated she would try to figure something else out. The POA and ADM A went back inside the facility and called RBOM C and RBOM C stated Resident #4 had to transfer to the rehabilitative hospital. The POA stated she had no choice but to send her. The POA stated Resident #4 went to the rehabilitative hospital for two weeks before she could return to the facility. The POA stated it did not do her any good and created a lot of undue stress. The POA stated she could not say if it harmed Resident #4 because Resident #4 could not tell anyone and was uninterviewable. In an attempted interview on 7/11/2026 at 1:16 P.M. with Resident #4, she did not answer any questions or make any noted recognition of what was going on around her.Record review of Resident #4's medical record reviewed on 7/11/2026 lacked consent for a referral to the rehabilitative hospital.3. Record review of Resident #6's face sheet, dated ??, revealed a [AGE] year-old male, admitted [DATE], with diagnoses of polyneuropathy (damage to nerves of the peripheral nervous system or those outside the brain and spinal cord), radiculopathy (pinching of nerves at the root which can produce pain, weakness, and numbness), spinal stenosis (narrowing of the spaces between the spine), malignant melanoma of skin (dangerous skin cancer in which there is an uncontrolled growth of melanocytes). Resident #6 had a BIMS of 15 indicating cognition fully intact.In an interview on 7/11/2026 at 2:58 P.M. with Resident #6, he revealed that a representative from a rehabilitative hospital entered his room to evaluate him because they said they received a referral. Resident #6 stated he did not know or agree to a referral being sent to them. He stated he, Told the representative no and they left. Resident #6 stated he had cancer and would not do that. Resident #6 stated he did not know who sent the referral to the rehabilitative hospital.Record review of Resident #6's medical record reviewed on 7/11/2026 lacked consent for a referral to the rehabilitative hospital. The medical record lacked a physician's order for the referral to the rehabilitative hospital.In an interview on 7/12/2026 at 10:15 A.M. with OMB G, he revealed that if a resident went to the rehabilitative hospital, then Medicare would pay and when readmitted to the facility, the facility could send in a long-term care Medicaid application to get paid.In an interview on 7/12/2026 at 10:12 A.M. with ADM A, she stated that RBOM C would be able to answer my questions. ADM A stated MD E contacted the rehabilitative hospital, and referrals were decided before MD E got them. ADM A stated that the decision was from corporate, from RBOM C. ADM A stated Resident #4's POA and son were taking her out and were upset when she brought them back inside and called RBOM C. ADM A confirmed when they called RBOM C, she told them Resident #4 needs to go to the rehabilitative hospital. ADM A stated it could be handled differently where the family could decide but she would not comment on how this would impact a resident.In an interview on 7/12/2026 at 10:48 A.M. with LVN D, she revealed she was told on 6/11/2026 by other staff that Resident #4 was discharging, so she opened a discharge summary form in the medical file. LVN D stated then the family returned happy and in tears stating Resident #4 was going to stay.In an interview on 7/12/2026 at 10:59 A.M. with RBOM C, she stated MD E sent referrals to the rehabilitative hospital. RBOM C did not answer when asked who retrieved the consents for the referrals to the rehabilitative hospital. RBOM C stated she could not speculate on a negative impact on the residents if families were told the residents had to go to the rehabilitative hospital or leave the facility.In an interview on 7/12/2026 at 11:08 A.M. with MD E, he stated he was provided with the list of residents from RBOM C to send referrals to the rehabilitative hospital. He stated when he asked RBOM C about consent, she told him it was already done, and the families had been spoken to. MD E stated he had heard of residents and/or their families being told they had to send the resident to the rehabilitative hospital or they had to discharge from the facility. He stated he believed there to be a payer source issue. MD E stated he believed the rehabilitative hospital could benefit the residents and the facility was helping the residents and families. MD E stated he was provided with a list and was told they had consent already. He stated that was not typical because he would usually get consent first but was told it was already done by RBOM C. MD E stated he had not seen any negative impact on the residents going to the rehabilitative hospital. MD E did not comment on the negative impact on the residents if they did not have consent prior to sending the referral.In an interview on 7/12/2026 at 11:48 A.M. with ADON F, she revealed it was required for the facility to get consent from the resident or their RP before sending a referral out for any reason. ADON F stated she was informed of Resident #3 discharging from the facility due to the POA being upset that she was not consulted, or provided approval, for a referral to the rehabilitative hospital. ADON F stated a negative impact on the residents might be that they were not aware and might become upset.In an interview on 7/12/2026 at 3:36 P.M. with DON B, she stated that the facility lost Resident #3 over not getting consent for the referral to a rehabilitative hospital. She stated the daughter of Resident #3 got upset and took her out of the facility. DON B stated she was not aware until Resident #3's daughter told her and then she told the daughter that was not standard practice, and the facility should have contacted her first to get consent. DON B stated a negative impact on the resident or family would be stress and worry because the family needed to know where the resident might go.Record review of the facility policy titled, Resident Rights, dated 2016, revealed, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to: a. dignified existence; b. be treated with respect, kindness, and dignity.e. self-determination.g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. be supported by the facility in exercising his or her rights; i. exercise his or her rights without interference, coercion, discrimination or reprisal from the facility; be informed about his or her rights and responsibilities.p. be informed of, and participate in, his or her care planning and treatment.s. choose an attending physician and participate in decision-making regarding his or her care.

Based on interview and record review, the facility failed to ensure it received registry verification that the individual met competency for 1 (CNA C) of 3 employees reviewed for registry verification. The facility failed to ensure CNA C had a current nurse aide certification prior to providing care for residents. This failure could place residents at risk for being provided with care by staff who have not provided documentation of training and competency in providing care. Findings included: A record review on [DATE] of CNA C's personnel file revealed a date of hire of [DATE]. The last Employability Status Check Search was completed on [DATE] reflected CNA C's NAR status expired [DATE]. A record review on [DATE] of Employe Time Clock details, dated [DATE], revealed CNA C clocked in and worked 6:00 p.m. - 6:00 a.m. on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE],[DATE], [DATE],[DATE], [DATE], [DATE], and [DATE]. During an interview on [DATE] at 1:45 p.m., CNA C stated t she was aware that her NAR status had expired. CNA C stated she was aware that it was her responsibility to renew it through TULIP. CNA C stated she told the HR Coordinator it was expired and she needed help to renew it because she did not know how and the HR Coordinator told her he was busy and could not help her. During an interview on [DATE] at 2:12 p.m., the HR Coordinator stated he was not aware CNA C's NAR status was expired, but he knew it was getting close to expiring because she had come by a couple of times for him to help her and they kept missing each other. The HR Manager stated CNA C's certificate in the NAR was expired. The HR Manager said CNA C was instructed that she would have to renew her NAR status through TULIP herself but that he would help her. The HR Coordinator stated it was his responsibility to ensure that EMR/NAR checks were conducted annually to ensure all staff working had updated certifications. The HR Manager stated that it was the staff's responsibility to keep their own certifications current. The HR Coordinator said that if staff did not keep their certifications updated, it could lead to increased falls, accidents, abuse allegations, and infection control issues. During an interview on [DATE] at 2:30 p.m., the DON stated t it was the HR Coordinators' responsibility to ensure that the EMR/NAR checks were conducted annually for all CNAs and medication aides. The DON stated no one monitored this system to ensure that all certified nurse aides' and medication aides' certifications were active. The DON said that if certified nurses aides' and medication aides' certifications were not active, it could lead to incorrect procedures. During an interview on [DATE] at 2:52 p.m., the Corporate Quality Assurance Nurse stated that EMR/NAR were supposed to be checked by the HR Coordinator annually and upon hire. The Corporate Quality Assurance Nurse said that it was the Administrator's responsibility to monitor the process but right now they did not have an Administrator. The Corporate Quality Assurance Nurse also stated that there was potential for harm to a resident when no EMR/NAR checks are completed on hire or annually. Record review of the facility's policy, undated, titled, Credential Verification During Hiring and Employment, reflected the following: PolicyAll applicants and employees must have current and valid credentials required for their position before beginning work and throughout their employment with the facility. The Human Resources Department is responsible for verifying and maintaining documentation of all required credentials, licenses, certifications, and exclusion checks in employee personnel files.Ongoing Monitoring:Facility HR must:Complete yearly EMR exclusion checks for all employees.Maintain updated copies of all renewed credentials in personnel files.Non-Compliance:Employees with expired licenses, certifications, or failed exclusion checks:Must be removed from the work schedule.May not return to work until compliant documentation is received and verified.

Based on observation, interview, and record review, the facility failed to post the daily nurse staffing information with the current date, resident census, and the total number of staff and actual hours worked at the beginning of each shift for 1 of 1 facility reviewed for nurse staffing. The facility failed to update and post the daily nurse staffing information from 5/10/2026-5/26/2026. This failure could place residents at risk of not having access to information regarding the numbers of staff caring for the residents each shift and the facility census.Findings included: During an observation and interview on 05/26/2026 at 11:32 A.M., the daily staffing posting was not hanging at the nurse's station, only an assignment sheet for staffing. The Corporate Quality Assurance Nurse said the daily staffing was completed by the DON. The Corporate Quality Assurance Nurse stated the new DON just started on Monday 5/25/2026 and they were changing the way the daily staffing was completed. She said the daily staffing posting should be completed daily so that everyone knew how much staff were supposed to be in the facility to care for the residents. During an interview on 05/26/2026 at 11:42 A.M., the DON said the night shift nurses completed the daily staffing posting. The DON said she would be responsible for ensuring the daily staffing was posted. The DON said the daily staffing should be posted to keep up with the number of staff in the building. During an interview on 05/26/2026 at 11:44 A.M., the Corporate Quality Assurance Nurse said they changed the person responsible for staffing and the nurse taking over the staffing position would be responsible for completing the daily staffing. She stated she would start in-services and education regarding the changes. The Corporate Quality Assurance Nurse said she presumed it was not completed since 05/9/2026 because they had just hired a new DON on 5/25/2026. Record review of the facility's policy titled, Direct Care Daily Staffing Numbers, dated July 2016, indicated, Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents.

Based on interview and record review the facility failed to ensure, before a resident was transferred or discharged , the resident and the resident's representative was notified of the transfer or discharge and the reason for the move in writing and in a language and manner they understood for 1 of 3 residents (Resident #1) reviewed for transfer and discharge rights.The facility failed to notify Resident #1's representative of the transfer with the reasons for the move in writing in a language and manner they understand. This failure could place residents at risk of not receiving an advocate who could inform them of their options, rights, and the added protection from being inappropriately transferred or discharged . Findings include: Record review of Resident #1's face sheet, dated 1/29/26, revealed a [AGE] year old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Cerebral infarction (a type of ischemic stroke caused by a blockage in blood vessels supplying the brain, leading to tissue death (necrosis) due to oxygen deprivation), Alzheimer's disease, and hypertensive heart/chronic kidney disease. discharge date revealed 1/24/26, length of stay 1 day, discharge to Facility B with hospice services. Record review of Resident #1's Progress Notes revealed, effective date of discharge 1/24/26, discharge transportation method to Facility B: ambulance picked up Resident #1 from the facility and transported to Facility B. During an interview on 1/29/26 at 10:15 AM, Family Member #2 stated she did not sign any documents or agree to have Resident #1 moved to another facility. She stated the hospice company called her on 1/24/26 and stated Resident #1 was to be moved to another facility. She stated Facility #2 never called her or let her know. She stated she worked with the hospice company regarding the transfer. During an interview on 1/29/26 at 12:55 PM, the Administrator stated Resident #1 was due to come into the facility as dually certified and he would be on the skilled side. He stated once Resident #1 got to the facility an assessment was completed, and they found that Resident #1 did not meet qualifications for receiving hospice and physical therapy services, which changed their services provided to Resident #1. He stated on the evening of 1/23/26, he spoke with the hospice company and Resident #1 could not stay at the facility. He stated he did not have any documentation from a physician order for the transfer. He stated he did not have any family approval documentation for the transfer. He stated he did not have the documentation because he believed HL should have handled everything including the documentation. During an interview on 1/29/26 at 1:25 PM, the HL stated she went to the facility the day Resident #1 was admitted . She stated everything was set up and everything was ready for Resident #1 to stay at the facility receiving end of life services through the hospice company. She stated on 1/24/26 she received multiple calls from the administrator stating that due to Resident #1 not meeting for qualifications for both hospice and physical therapy services the hospice company must get Resident #1 out of his facility. She stated she told the administrator it was not that simple and there was a process to moving Resident #1 to another facility. She stated the administrator did not care and it was their responsibility to get Resident #1 out. She stated the only reason the hospice company set up to get Resident #1 out of the building was because the administrator began to yell and cuss at not only herself but her nurse. She stated the process was not followed, but Resident #1 was moved for the safety of Resident #1 and his family. Record review of the, undated, Facility policy, Your Rights and Protections as a nursing home resident revealed: the nursing home has to safely and orderly transfer or discharge you and give you proper notice of bed-hold and/or readmission requirements.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to prevent dishes and utensils from being stored face up (open to air contamination).The facility failed to remove potatoes in the dry storage when they were beginning to show signs of rot.These failures could place residents who received prepared meals from the kitchen at risk of food borne illness and cross-contamination. The findings included:During the initial tour of the kitchen on 12/23/25 at 8:15 AM the following observations were revealed: The top plate in the plate warmer faced up and was not covered. Cooking and serving utensils hanging above a food preparation table were not covered. Silverware in bins was not covered. A plastic container of red potatoes had sprouting potatoes in it. A food grater was on a shelf and not covered.In an interview with the Dietary Manager (DM) on 12/23/25 at 5:16 PM, the DM said a cover for the plate warmer has been ordered. The DM said she was not aware of the need for utensils to be covered. The DM said she will remove the red potatoes with sprouts. She said the facility has not used them due to having only three residents in the facility. The DM said these things could cause the residents to get sick and could prevent the facility from becoming certified.In an interview on 12/23/25 at 5:30 PM, the administrator said the builder was experienced in building nursing facilities and knew the state and federal requirements. The administrator said the racks for hanging the cooking and serving utensils were installed by the builder. The administrator said he assumed the racks met government requirements and followed facility policy. The administrator agreed that the sprouting potatoes should not be used and should have been removed to prevent resident illness. Review of facility policy Food Storage, dated 2023, revealed, in part, Racks and other storage services should be clean and protected from splashes, overhead pipes or other contamination (ceiling sprinklers sewer/waste disposal pipes, vents, etc.).Review of Food Code 2022 Recommendations of the United States Public Health Service Food and Drug Administration revision date 01/18/2023 revealed, in part:4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 med rooms. that had Tuberculosis solution that was not labeled with an open date.The facility failed to ensure one Tuberculosis solution was labeled with the open date in Medication room [ROOM NUMBER].This failure could place residents at risk of adverse medication reactions.Findings included:Observation on 12/23/2025 at 10:30 AM revealed the refrigerator in Medication room [ROOM NUMBER] had the following opened medications with no open date labeled:1. Aplisol Tuberculin solutionInterview on 12/23/25 at 10:31 AM with DON, she said once Tuberculosis solution was opened, they need to be dated with open dates. She stated tuberculosis solutions are good for 28 days after opening. She stated the risk of not having an open date was that they would not be able to know when they expire, and they will not be effective.Interview on 12/23/25 at 12:36 PM with the DON revealed she said tuberculosis solution when opened should be dated. She stated it was the responsibility of nursing management to check and audit the carts and medication rooms after the nurses. The DON said the nurses were responsible for dating the medication when opened. She stated tuberculosis solution was good for 28 days and should be dated once the vial was opened.Record review of the Recommended Medication Storage policy, undated, reflected the following:Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.