Every finding on record at Sterling Care Riverside

Based on record review and interview, it was determined that the facility failed to make readily available a place for written grievances to be submitted anonymously. This deficient practice has the potential to impact all the residents. The findings include:Facility policy : Resident and Family Grievances- Policy Explanation and Compliance Guidelines: 1. [NHA (Nursing Home Administrator #1] has been designated as the Grievance Officer and can be reached at [email address] . 3. Notices of resident's rights regarding grievances will be posted in prominent locations throughout the facility.6. Information on how to file a grievance or complaint will be available to the residents. Information may include, but is not limited to: a. The admission liaison provides the residents with a welcome packet that has a copy of the grievance form and the process is explained. 8. A grievance may be filed anonymously. (date reviewed/revised 1/2026).A review of Resident #1's electronic medical record (EMR) on 8/11/26 at 9 AM revealed Resident #1 was admitted on [DATE] to the facility.During a telephone interview on 8/11/26 at 10:15 AM while investigating Complaint #3095070, Resident #1's family member stated, .My mom complained about her bed not going all the way down so she could lie flat and that her wheelchair was broken. She did not know how to file a grievance. They never told her how to do that.The surveyor toured the facility hallways on 8/11/26 at 1:30 PM, the surveyor found a poster Resident Rights which stated that residents have a Right to Raise Grievances- present grievances without discrimination. prompt efforts by the facility to resolve grievances, and provide a written decision upon request, and to file a complaint with the long-term care Ombudsman's program or the state agency. There was no other signage posted that mentioned grievance/concerns or its process within the facility.During an interview on 8/11/26 at 11:39 AM, NHA #1 stated, The grievances forms are on the table in the front lobby. The Liaison handles grievances. We give residents a Welcome packet on admission that has information about concerns. I will bring one to you.On 8/11/26 at 12 :00 PM, the surveyor toured the front lobby and confirmed there was a bin with concern forms; however, there was no explanation of the grievance process. The surveyor was not able to locate a secure box, in which completed concern forms could be submitted anonymously.During an interview on 8/12/26 at 10:10 AM, SW (Social Worker) #7 stated, When there is a complaint, I take the verbal grievance and put it on the concern form. I don't call it a grievance. I call it a concern and I put it on a form so we can address it. Our goal is to address the concern as soon as possible. I do circle back to the complainant and tell them what we found out about their complaint. [NHA #1] is the grievance officer. There used to be a mailbox outside my office door for residents to file a concern anonymously. I think it got knocked off the wall. So now the residents can just slide it under my door if they want to file it anonymously. I am not sure if there is a poster that explains the process posted in the facility. I would have to look.While reviewing the grievance log on 8/12/26 at 11:10 AM, there was evidence of concern forms dated 2/25/26 and 2/26/26 regarding Resident #15's concerns about his/her incontinence care and wound care, which had been verbally told to SW #7.A review of Resident #15's EMR on 8/12/26 at 11:20 AM revealed he/she was admitted on [DATE] with diagnoses including but not limited to, spina bifida and paraplegia.During an interview for complaint #3124871 on 8/12/26 at 1:15 PM, Resident #15 stated, I have heard the word grievance but I am not sure what it is about. I tell my issues to the social worker. I did not know there was a process. It is notable that Resident #15 has been residing in this facility for six years and was unable to articulate the facility's grievance process.During an interview on 8/12/26 at 2:34 PM, NHA #1 stated, We have our policy on grievances. I believe in the admission packet there is information in the resident rights section regarding grievances.On 8/12/26 at 3:30 PM, the surveyor reviewed the admission Welcome packet that is given to the resident on admission. There was a blank Concerns/issues form in the packet. However, there were no instructions regarding whom to return the completed form to or where to submit it if the resident wanted to file the concern anonymously. Additionally, no where in the provided documents or in signage in the facility was there notice of the contact information including name, email, business address and business phone number of the facility Grievance Officer, information about the process of how to file a concern anonymously or the expected time frame for resolution of the concern. It should be noted the facility did have a poster with the Corporate Compliance Hotline as an option to file a concern. While the facility policy stated, 8. A grievance may be filed anonymously, no where in the facility or in the documents provided could the surveyor find instructions on how to file a grievance anonymously.

Based on facility documents and interviews, it was determined that the facility failed to maintain the facility's emergency electrical power system (generator) to manufacturer's recommendations . This has the ability to affect all residents. The findings include:During an investigation of complaint #3075629, the surveyor became aware that the facility lost utility power on the evening of 7/4/26 at approximately 9 PM and the emergency generator failed to initiate backup power.During an interview on 8/10/26 at 3:36 PM, the NHA (Nursing Home Administrator) confirmed that there was a power outage on the evening of 7/4/26, in which the generator did not immediately come on.During an interview on 8/11/26 at 12:50 PM, MD (Maintenance Director) #4 also confirmed there was a utility power outage on 7/4/26. MD #4 stated, The notification came to me around 9 PM. I went to the facility and was there by 9:05 PM. Everything in the facility was off. there was no power to anything whatsoever. This would also put out the fire system.the generator being down. I called the [generator maintenance contractor]. they had a guy out around 10:30 PM. He (the generator service technician) got the system running. He said there was a fuse blown and a valve got stuck.We (the maintenance department) run a generator system check every Tuesday. It had worked during the previous Tuesday check.The surveyor reviewed the [generator maintenance contractor] call summary paperwork for 7/4/26, which documented that building in an outage upon arrival. Gen (generator) in fault for aux fault, air damper. Also annunciator fuse is blown. Replaced annunciator fuse. Lubricated the air damper mechanism and moved back and forth a few times to free it up. Started and ran the generator.Generator is now shutting down on low oil pressure. Gauge is reading about 50 PSI while running, this is normal. Unplugged the low oil pressure shutdown switch and tried again. This time the unit does not shut down. Gen is now backing up the building. Explained to the customer that the gen will run without the low oil pressure sensor, but the gen will not shut down like it should , in the event of the engine actually having low oil pressure. Now there is still a pre-low oil pressure fault that will give them a warning only, not a shut down. Customer understands the risk and will monitor oil pressure closely. Will be sending a quote to replace oil pressure sender.During an 8/14/26 telephone interview at 8:48 AM, GMCSM #14 (Generator Maintenance Contractor Service Manager) stated, My tech was in their building by 10:54 PM that night, I am looking at the call service documentation. I absolutely believe that the power was back on by midnight. A sensor went bad. You can't really test them (the sensors) at a maintenance call. This is one of our better customers regarding maintenance. They have a meeting with us every year to make sure that they are on top of everything with their HVAC and generator.The facility provided the Logbook Documentation of the diesel emergency power generator in-house inspection dated 6/29/26 at 10:28 AM and was completed by MD #4. In-house Inspections- Emergency Power Generators.STEPS: . Execute prestart checklist: 1. Refer to your generator's Owner's Manual for specifics on your model's requirements.The surveyor requested a copy of the facility's emergency generator manual, which was not provided by the facility. However, [facility emergency diesel generator] Owner's Manual was obtained from the internet. The following maintenance was listed in the Owner's Manual. For the [facility's emergency generator], the air damper is part of the air intake system and is critical for regulating airflow into the engine. Proper maintenance ensures optimal performance, fuel efficiency, and engine protection. Preventive Maintenance Schedule: Every 500 hours of operation or every 6 months (whichever comes first): inspect and clean the air damper, Every 1000 hours: replace worn seals or O-rings. The low oil pressure sensor on you [facility emergency generator] is a critical safety device that monitors oil pressure and triggers an alarm if it drops below a safe threshold. Keeping it in good condition prevents engine damage from running on low oil.3. Testing the Low Oil Pressure Sensor: You can verify the sensor's function: 1. Locate the sensor near the oil pan (may require removing a panel) 2. Disconnect the sensor wire from the control circuit 3. Turn the generator on and observe the Low Oil indicator 4. If the indicator goes off, the sensor is working correctly. 5. If the indicator stays on, the sensor may be faulty or the wiring may be loose.4. Preventing Sensor-Related Issues:. replace the sensor if it fails the test or shows signs of damage.On 9/1/26, the surveyor reviewed the Logbook Documentation of the diesel emergency power generator in-house inspection dated 6/29/26. The inspection failed to document the time of the last preventative maintenance for the air damper, seals and O-rings as recommended by the Owner's Manual. The inspection also failed to document the date of the last oil and filter changes as recommended by the Owner's Manual.

Based on record review and interviews, it was determined the facility failed to consult with the responsible party of a resident incapable of making medical decisions regarding advance directive status, consent for treatments, and immunization status. This was evident for 1 resident (Resident #3) of 3 residents reviewed for advance directives during the complaint survey. The findings include:On 08/10/2026 at approximately 10:00 AM, a review of intake #3075629 revealed a concern related to the complainant being the medical power of attorney, and there was no notification regarding a fall that led to a transfer to the emergency room. The Minimum Data Set (MDS) is a required assessment for all residents in Medicare- or Medicaid-certified nursing homes. It evaluates each resident's health and functional status to help staff identify issues and determine resident care decisions. Assessments are conducted at admission, at regular intervals, and at discharge following set guidelines.The Brief Interview for Mental Status (BIMS) is a mandatory screening tool used upon admission to long-term care facilities to assess a resident's cognitive condition. Typically administered by a social worker, the assessment uses numerically scored questions totaling 0 to 15 points to categorize cognitive status into three groups: Intact (13 to 15: normal thinking and memory), Moderate (8 to 12: moderate problems), and Severe (0 to 7: severe problems). Rather than diagnosing illnesses like dementia or Alzheimer's, it helps staff detect early symptoms and identify the need for further evaluation.Under the health care decisions acts a power of attorney for health care is part of an advance directive. It is legally defined as the written appointment of an adult agent (or proxy) given the authority to make medical and health care decisions on behalf of a patient if they become incapable of making an informed decision. On 08/10/2026 at 1:38 PM, a review of Resident #3 medical records revealed a 06/02/2026 Social History noting no for both advance directives and whether paperwork was provided or offered. Additionally, there was no evidence of documentation related to inquiring with Resident 3's representative regarding an advance directive.On 08/12/2026 at 10:24 AM, during an interview, the Director of Social Work stated that advance directive status is inquired about and a BIMS assessment is completed upon admission. An advance directive is offered if the resident is capable; otherwise, staff contacts the family, with documentation kept in progress notes. The Director of Social Work noted they only received power of attorney documentation after the resident's hospital transfer and had no documented conversations with their representative.On 08/10/2026 at 1:42 PM, a review of Resident #3's admission MDS dated [DATE] was conducted. Section C revealed a BIMS score of 5.On 08/10/2026 at 1:30 PM, a review of Resident #3's closed medical record revealed two physician certifications regarding decision-making capacity that indicated Resident #3 lacked capacity due to dementia. These documents were completed by a physician on 06/12/2026 and another certifying practitioner on 06/19/2026.On 08/10/2026 at 3:05 PM, further review of Resident #3's closed record revealed a treatment consent form signed by Resident #3 on 06/01/2026. Additional signed consent forms by Resident #3 were found for influenza, RSV, and COVID-19 vaccinations (all dated 06/01/2026), as well as an undated consent for the pneumococcal vaccine.On 08/10/2026 at 3:11 PM, during an interview, the Administrator and Director of Nursing (DON) explained the standard procedure: the social worker performs an initial assessment and completes a Brief Interview for Mental Status (BIMS). If the resident is determined to be incapable, staff then consults with the family regarding advance directives. Furthermore, the Administrator concurred that if Resident #3 was incapable of understanding the paperwork, they should not have signed admission consents.

Based on record review and interview, it was determined the facility failed to provide residents with a written notice and reason for the room change before the resident was moved. This was evident for 3 (Residents #3, Resident#4 and Resident #5) of 4 residents reviewed for room change during the complaint survey. The findings include: On 08/10/2026 at approximately 9:00 AM, a review of intake #3110287 revealed a complainant's concern that a resident was placed in unsafe conditions due to a room change. 1) On 08/10/2026 at 10:41AM, a review of Resident #3's census record indicated a room change from 122-B to 221-A on 06/04/2026. However, a further review of Resident #3's medical record contained no evidence of a written notice explaining the room change. 2)On 08/10/2026 at 11:41 AM, a review of Resident #4's census record indicated a room change from 118-A to 126-A on 07/17/2026. However, a further review of Resident #4's medical record contained no evidence of a written notice explaining the room change. On 08/10/2026 at 3:11 PM, during an interview, the Administrator and Director of Nursing (DON) stated that the room change process involves notifying families, informing the receiving roommate, and documenting this in a progress note or completion of a room change assessment. At this time the concerns were shared with the DON. 3. While investigating complaint # 3095070 on 8/10/26 at 11:30 AM, a review of Resident #5's electronic medical record (EMR) revealed that he/she was admitted on [DATE] for rehabilitation services. Further record review revealed that on 7/29/26 , Resident #5 was moved to another room on the same hallway; however, there was no evidence that the facility notified the resident or responsible party of that room change or documented the reason for the room change prior to the move. On 8/10/26 at 3:14 PM, DON #2 stated that for room changes the facility lets the resident, family and roommate know about the room change. DON#2 stated, It is documented in the progress notes and in the assessment section of the [EMR], under a title, Room Change. After surveyor intervention, the facility presented the surveyor on 8/11/26 at 9:30 AM a document signed by Resident #5 stating that he/she requested and agreed to a room change from [room number] to [room number]. When asked, DON #2 stated that the facility had Resident #5 read and sign that document on the afternoon of 8/10/26.

Based on record review and interview, it was determined that the facility failed to monitor and document treatment and services to promote healing of residents' wounds. This was evident for 2 (Resident #5 and Resident #7) of three residents reviewed for wound care. The findings include:Facility's Wound Treatment Management policy stated to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standard of practice and physician orders. Policy explanation and Compliance Guidelines: . 6. Treatments will be documented on the Treatment Administration Record (TAR) or in the electronic health record. (Date reviewed/revised 1/2026).1.) On 8/10/26 at 10:15 AM while investigating Complaint #3095070, a review of Resident #5's electronic medical record (EMR) revealed that Resident #5 was admitted on [DATE] with diagnoses, including but not limited to, osteomyelitis of left ankle and foot, peripheral vascular disease (PVD) and bacteremia. Further review of Resident #5's EMR revealed a wound care order written by MD (medical doctor) #15 on 8/3/26, that stated Wound care: cleanse left foot 3rd toe amputation site with wound cleanser, pat dry, wrap with kerlix (a type of medical gauze for wounds), and then wrap with ace bandage every other day for wound care.A review of Resident #5's August 2026 TAR on 8/10/26 at 10:40 AM revealed no documentation on 8/8/26 for Resident #5 for left foot 3rd toe amputation site wound care. On 8/11/26 at 12:25 PM, during an interview, DON (Director Of Nursing) #2 confirmed that there was no documentation that Resident #5's wound care had been performed on Saturday, 8/8/26. DON #2 stated, [LPN ( Licensed Practical Nurse) #16] works the weekend option program so he/she is here on the weekends for a double shift, days and evenings.He/she is usually pretty good.2.) On 8/10/26 at 10:45 AM while investigating Complaint #3095070, a review of Resident #7's EMR revealed that Resident #7 was admitted on [DATE] with diagnoses, including but not limited to, cellulitis of right lower extremity and sepsis. Further review of Resident #7's EMR revealed several wound care orders for Resident #7's right heel wound written by MD #15. On 7/23/26, MD #15 ordered Wound care: Right heel- cleanse with clorpactin. Apply clorpactin moist 4X4 gauze to wound bed. Cover with absorbent pad (ABD), rolled gauze and medipore tape every day and evening shift. On 7/27/26, MD #15 ordered Wound care: Right heel- cleanse with clorpactin. Apply collagen and calcium alginate to wound and cover with silicone bordered gauze every day shift for wound care.A review of Resident #7's July 2026 and August 2026 on 8/10/26 at 10:55 AM revealed there was no sign off for the wound care on 7/26/26 and 8/9/26.On 8/11/26 at 12:25 PM, during an interview, DON #2 confirmed that there was no documentation that Resident #7's wound care had been performed on Monday, 7/27/26 and Sunday, 8/9/26.

Based on observations, record review, and interview, it was determined that the facility failed to implement interventions, determined to be necessary, for residents identified as fall risks. This was evident for 2 (Resident #12 and #13) of 3 residents reviewed for accidents during the complaint survey.The findings include:In the State Operations Manual, Appendix PP, the Centers for Medicare and Medicaid Services (CMS) indicated that an avoidable accident results from a facility's failure to identify environmental hazards and/or assess individual resident risk (including supervision and assistive device needs); evaluate, analyze, and eliminate/reduce hazards/risks; implement interventions (supervision, assistive devices) consistent with needs, goals, care plan, and professional standards; and/or monitor intervention effectiveness, modifying the care plan as necessary.A comprehensive care plan is a detailed, individualized document that outlines a resident's medical, nursing, and psychosocial needs, along with the specific treatments and activities planned to meet those needs. It is created through a collaborative process involving the residents, family, and a multidisciplinary team, ensuring care is coordinated, patient-centered, and focused on achieving both short- and long-term goals. On 08/10/2026 at approximately 9:00 AM, a review of intake #3110287 revealed a complaint that fall interventions were not in place, which resulted in a fall with major injury.1) On 08/11/2026 at 9:35 AM, during an observation, Resident #12 was lying in bed, and there were no fall mats placed on either side of the bed, nor were any present in the room.On 08/11/2026 at 9:30 AM, a review of Resident #12's medical record showed a 07/23/2026 physician order for bilateral bedside fall mats. Further review of Resident #12's medical record revealed a fall care plan (initiated 02/10/2022) that noted a history of falls and ongoing risk due to confusion, deconditioning, gait/balance issues, poor communication/comprehension, safety unawareness, and wandering, with an intervention of bilateral fall mats added on 05/20/2026.On 08/11/2026 at 9:50 AM, during a second observation accompanied by the Director of Nursing (DON), it was confirmed no fall mats were on either side of Resident #12's bed.2) On 08/10/2026 at 9:43 AM, during an observation, Resident #13 was in a wheelchair near the doorway of the room without a soft protective cap on her head.On 08/10/2026 at 9:20 AM, a review of Resident #13's medical record revealed a 05/12/2026 physician order for a soft cap on the head as tolerated. Further review of Resident #13's medical record revealed a care plan that noted an actual fall and fall risk due to generalized weakness, disease process, medication side effects, fall history, and gait/balance issues (Initiated: 10/23/2025; Created: 05/07/2026). Interventions, including a soft cap to the head as tolerated, were added on 05/12/2026. On 08/10/2026 at 9:55 AM, during an observation and interview, Staff #3, a Licensed Practical Nurse (LPN), searched Resident #13's room in all areas and confirmed that the soft cap was not present. Staff #3 stated that fall interventions specified in physician orders and care plans would be accessible in the room and properly implemented. There was no evidence of documentation that indicated Resident #13 was unable to tolerate the soft cap.On 08/11/2026 at 12:28 PM, during an interview, the Director of Nursing (DON) stated that fall interventions should be implemented and accessible whenever ordered.

Based on record review and interview, it was determined that the facility failed to ensure that resident medications were administered as ordered by the physician. This was evident for 1 (Resident #14) of 3 residents reviewed for medication administration during the complaint survey.The findings include:On 08/11/2026 at approximately 2:15 PM, a review of Intake #3132187 revealed the complainant for Resident #14 had concerns related to Resident #14 not receiving his/her medications as prescribed for many illnesses.On 08/12/2026 at 9:49 AM, a review of Resident #14's July 2026 medication administration record (MAR) revealed multiple instances where medications were not administered in accordance with physician orders:-Digoxin (125 MCG): Ordered every other day for heart failure, this medication was documented as administered on both 07/30/2026 and 07/31/2026. This indicates the resident received daily doses for two consecutive days instead of the prescribed schedule of every other day.-Anastrozole (1 MG daily) prescribed for breast cancer: With a start date of 07/30/2026 at 0900, the dose was omitted on 07/30/2026. Progress notes showed no follow-up that day. On 07/31/2026, the administration was marked as 5, and a nurse's note recorded at 6:32 PM stated the medication was awaiting the pharmacy, confirming the resident did not receive the medication for 2 consecutive days as prescribed.-Warfarin Sodium: Prescribed for blood clot prevention, the 5 mg dose (1 tablet daily Tue, Thu, Sat, Sun; start date 07/30/2026 at 0900) was omitted on Thursday, 07/30/2026. The 2.5 mg dose (1 tablet daily Mon, Wed, Fri; start date 07/31/2026) was omitted on Friday, 07/31/2026. As a result, Resident #14 missed blood clot prevention therapy for two consecutive days.-Yupari (Revefenacin) (175 mcg/3 mL): Ordered for oral inhalation daily for Chronic Obstructive Pulmonary Disease (COPD) with a start date of 07/30/2026 at 0900; the scheduled dose was omitted on 07/30/2026. This indicated Resident #14 did not receive the medication as prescribed by the physician.-Formoterol Fumarate Inhalation Solution (20 mcg/2 mL): Prescribed at 2 mL twice daily at 9:00 AM and 5:00 PM for COPD with a start date of 07/30/2026 at 9:00 AM. An omission was recorded for the 9:00 AM dose on 07/30/2026, indicating Resident #14 did not receive the medication as prescribed by the physician.-Insulin Lispro Prot & Lispro Suspension (75-25) (100 UNIT/ML): Ordered for diabetes management at 11 units subcutaneously twice daily before breakfast (8:00 AM) and dinner (5:00 PM), with a start date of 07/30/2026 at 0800. The 0800 dose on 07/30/2026 was omitted. The 5:00 PM dose was marked 12, accompanied by a nursing note at 11:28 PM stating that the dose was held due to a blood sugar reading of 147 and that the resident remained stable. These entries confirm Resident #14 did not receive the medication twice daily as ordered on 07/30/2026.On 08/12/2026 at 11:35 AM, during an interview the Director of Nursing explained the protocol for medication administration and medication errors. The process requires completing an incident report in the event of an error. A medication error is defined as administering the wrong medication, administering medication to the wrong patient, giving an incorrect dose, or failing to administer medication as prescribed. At this time the concern was shared.

Based on record review, observation and interviews, it was determined that the facility failed to maintain an infection control program by donning the appropriate personal protective equipment for Enhanced Barrier precautions. This was evident for two (Residents #6 and #15) out of three residents reviewed for infection control.The findings include:Facility's Enhanced Barrier Precautions policy states Enhanced Barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of MultiDrug-Resistant Organisms (MDROs) that employs targeted gown and gloves us during high contact resident care activities.2. Initiation of enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g. chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g. central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a multi-drug resistant organism (MDRO). ii. Infection or colonization with a CDC (Centers for Disease Control)- targeted MDRO when Contact precautions do not otherwise apply.3. Implementation of Enhanced Barrier Precautions: b. PPE (personal protective equipment) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room.4. High-contact resident care activities include: . g. device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes.6. MDROS for which EBP applies are based on local epidemiology. At minimum, they should include resistant organisms targeted by the CDC but can also include other epidemiologically important MDROs.7. Examples of MDROs targeted by the CDC include: a. pan-resistant organisms, b. Carbapenemase-producing carbapenem-resistant Enterobacterales. 8. Additional epidemiologically important MDROs may include, but are not limited to: a. Methicillin-resistant Staphylococcuse aureus (MRSA), b. ESBL( extended-spectrum-beta-lactamase)- producing Enterobacterales, c. Vancomycin-resistant Enterococci (VRE). Date reviewed/revised 3/25/251.) A review of resident #15's electronic medical record (EMR) on 8/12/26 at 11:20 AM revealed that he/she was admitted on [DATE] with a diagnoses, including but not limited to, spina bifida and paraplegia. Resident #15's EMR medical diagnoses list was updated on 11/29/19 to include the diagnosis of methicillin resistant staphylococcus aureus (MRSA) infection. Further review of Resident #15 EMR revealed the medical diagnoses list was updated on 12/11/24 with the diagnosis of pressure ulcer of the sacrum.Ongoing review of Resident #15's EMR on 8/12/26 at 11:20 AM revealed an order from MD (medical doctor) #15 on 8/5/26 stating, Enhanced Barrier precautions due to wounds, supra-pubic catheter, H/O (history of) ESBL, MRSA, CRE/CRO (carbapenem-resistant Enterobacterales/ Carbapenem- resistant organism), VRE. Wear a gown and gloves during high touch Activities every shift. There was also an order dated 8/10/26 stating Place a midline (a thin medical catheter placed in an upper arm vein for medication or fluid infusion) for IV (intravenous) infusion. Additionally, Resident #15's EMR contained an order that was written on 8/10/26 for Cefepime solution 1 gram intravenously every 8 hours for 14 days.While investigating Complaint #3124871 on 8/11/26 at 3:55 PM, the surveyor observed LPN #11 come into Resident #15's room and disconnect the cefepime IVSS (intravenous soluset antibiotic) from Resident #15's left upper extremity midline with only gloves on. LPN #11 did not have on the appropriate PPE (gown) for this high contact task. Additionally, LPN #11 came back in the room and placed the green catheter cap on Resident#15's midline with his/her bare hand. LPN #11 was not wearing gloves for this task.On a tour of the facility on 8/11/26 at 9:26 AM, the surveyor noted that Resident #15's room had both an EBP sign on the room door and a small orange dot on Resident #15's name plate next to the door. There was a bin with EBP supplies outside Resident #15's door.During an interview on 8/12/26 at 10:30 AM, LPN #9 stated, The orange dot on the name plate means that the resident is on EBP precautions and you should wear gloves and a gown for high-contact activities.2.) A review of resident #6's EMR on 8/12/26 at 2:20 PM revealed that he/she was admitted on [DATE] with a diagnoses, including but not limited to, osteomyelitis and bacteremia.Ongoing review of Resident #6's EMR on 8/12/26 at 2:20 PM revealed an order from MD #15 on 6/23/26 stating, Enhanced Barrier precautions due to Hickman catheter. Wear a gown and gloves during high touch Activities every shift. There was also an order dated 6/24/26 stating Flush [NAME] at right chest with 10 ml (milliliters) of normal saline every shift. Additionally, Resident #6's EMR contained an order that was written on 7/25/26 for Cefazolin solution 2 grams intravenously every 8 hours for MSSA (methicillin- sensitive staphylococcus aureus) bacteremia until 8/13/26.On 8/12/26 at 12:40 PM, the surveyor observed LPN #13 hang cefazolin IVSS via Resident #6's right chest Hickman catheter with only gloves on. The surveyor noted that Resident #6 had an EBP sign on the room's door and his/her hallway name plate had the orange dot on it. There was a bin with EBP supplies outside Resident #6's room.On 8/12/26 at 3:30 PM, the surveyor brought these occurrences to the attention of the CON #2, who stated that she had already initiated more EBP training that morning.

Based on observation and interview it was determined the facility failed to ensure sanitary practices were followed in accordance with professional standards for food service safety, and ensure the dishwasher reached adequate temperature according to the manufacturer's guideline. This was evident during the surveyor's tour of the facility's kitchen and 1 out of 1 nutrition room observed by the surveyor on the first floor of the facility during the survey. The findings include: 1. During the surveyor's tour of the facility's kitchen on 8/14/25 at 8:57AM the surveyor observed a closed container with a clear lid on it, of thickener powder in which a plastic handled scooper was observed laying within the thickener powder with the handle of the scooper touching the thickener powder. At the time of the observation, the surveyor informed the facility's Director of Dining Services #30 who, after surveyor intervention, observed and acknowledged the surveyor's concern and was then observed reaching into the container and they removed the scooper. At this time, the surveyor conducted an interview with Director of Dining Services #30 who confirmed with the surveyor that the handle of the scoop should not be touching the food container contents and showed the surveyor where the scoops were to be hung, at which time, other scoops for other similar containers were observed to be hanging. After surveyor intervention, Director of Dining Services #30 reported to the surveyor that they would begin educating the facility kitchen staff regarding not leaving the handled scoop in the container. On 8/15/25 at 1:55PM the surveyor shared concerns with the facility's Administrator and the Director of Nursing who acknowledged understanding of the surveyor's concern. On 8/15/25 at 2:16PM the surveyor observed the first floor nutrition room refrigerator which contained a carton of creamer with a plastic bag on it observed to have spots of dark green matter/growth on it which was sitting next to a tray of peanut butter and jelly sandwiches. On 8/15/25 at 2:16PM the surveyor requested a dual observation of the concern with Unit Manager #26, who observed and acknowledged the surveyor's concern and stated the following to the surveyor: Okay, I'll take care of it. After surveyor intervention, Unit Manager #26 was then observed removing the carton of creamer with the plastic bag and throwing it away into the trash can. On 8/19/25 8:19AM the Director of Dining Services #30 informed the survey team of the following information with the facility's Director of Nursing present: We committed an error with the scooper and the handle so I just wanted to show you that we corrected this by in-servicing the staff and the thickener, I threw away and more thickener was ordered. 2. On 8/19/25 2:04PM the surveyor conducted an observation of the conveyor dishwashing process, at which time the surveyor observed dishwashing staff on the dirty side of the dishwashing area continuing to push dirty dishes through, and no staff was present on the receiving side of the dishwashing line to receive dishes after sanitization. At this time, the surveyor observed the dishwashing process in operation, and the wash temperature gauge was observed to not be moving and displayed 138F, and the rinse temperature gauge was observed to be at 154F. Observation of the manufacturer placard on the machine stated the following information: This machine is currently in hot water sanitizing mode, Hot water sanitizing: 160F minimum wash temperature, 180F minimum final rinse temperature. The dishwashing line was further observed to be backing up with dishes due to no one being on the receiving side of the dishwashing line, dishes were observed stuck and unable to appropriately move through the machine due to there being no room to leave the dishwasher. Upon further observation of the receiving side of the dishwasher line, food debris was observed on the designated clean side where the dishes were sitting after they had been through the dishwashing process. On 8/19/25 at 2:05PM the surveyor requested a dual observation with Director of Dining Services #30, who reported to the surveyor: The dishwashing company was here this morning and everything was fine. Regarding the food debris, Director of Dining Services #30 reported to the surveyor that the food debris just happened, and they were sure that Dietary Aide #31 would know that the food debris sitting there had just happened. At this time, orange food debris was additionally observed by the surveyor within the clean rack of dirty dishes that had been through the dishwashing process, and at this time, the surveyor shared their observation with Director of Dining Services #30. On 8/19/25 at 2:06PM the surveyor conducted an interview and dual observation of the concern with Dietary Aide #31 and inquired as to how long the food debris had been present on the receiving end of the dishwashing line, to which they replied: That's been here since I came in, I keep telling them not to put food over there, it was there since after lunch. After surveyor intervention, Director of Dining Services #30 was observed removing the dishes from the receiving side and and placing them on the other side to be put through the dish machine again, and poured sanitizer over the area where the food debris was. Director of Dining Services #30 reported to the surveyor that the temperature of the dish machine was not rising because it was full of dishes and no one to remove the clean dishes coming out. Director of Dining Services #30 stated to the surveyor: I will re-wash the dishes. On 8/19/2025 at 2:14PM the surveyor observed the dish machine log for August 2025 which revealed the dish machine log temperatures on the dates of 8/10 and 8/11/25 were crossed out and written over with the following information written: Repaired and was good! Ecolab was called 8/10/25. On 8/19/25 at 2:19PM the Director of Dining Services stated to the surveyor that the food debris observed was not food. At this time, the surveyor observed the dishwashing machine process and observed the wash temperature gauge was not moving during the process and read 132F. On 8/19/2025 2:21PM the surveyor conducted another observation of the dishwashing machine process and the was temperature gauge was again, observed to be at 132F. On 8/19/25 at 2:40PM the surveyor requested and conducted a dual observation of the dishwashing temperature concern with the facility's Administrator during the dishwashing process and the wash temperature gauge dial was observed to not be moving and read 130F. On 8/19/25 at 2:47PM the surveyor conducted an interview and shared concerns with the facility's Administrator who acknowledged and confirmed understanding of the surveyor's concerns. On 8/19/2025 at 2:54PM, after surveyor intervention, the facility Administrator informed the surveyor: The three compartment sink will be utilized and the dishwasher will be taken out of service and signs for out of use will be placed.

Based on interviews, medical record reviews, and observations it was determined that the facility failed to provide dignity and respect to residents dependent for activities of daily living assistance. This was evident for two residents (#7 and #43) out of 8 residents observed at mealtimes during the recertification survey.The findings include:On 08/14/25 at 0745 AM the surveyor initiated a tour of the second floor clinical unit. Resident#43 was observed at 08:35 AM eating breakfast in bed without staff assistance. Resident #43 had pureed and ground food items on the tray. There was a black handled adaptive spoon in the resident's contracted right hand. The surveyor observed the Resident #43 using the utensil to feed themself however, the resident was also spilling some food on her/his neck and chest. Resident #43 did not have any protective clothing covering the resident's neck, chest and/or bedsheets from spills. At the time of the observation there were no nursing clinical staff in Resident #43's room or in the hallway available to assist the resident. On 08/14/2025 at 08:39 AM the surveyor observed Resident #7 being spoon fed by GNA, #8. Additionally, GNA #8 was standing at the residents bedside while feeding the resident. There was guest chair available in the resident's room at the time of the observation. At 08:49 AM on 08/14/2025 the second-floor unit manager, RN #6 was interviewed by the surveyor and was informed of the surveyor's observations related to Resident #7 and Resident #43 in regard to staff assistance with residents meals and resident dignity. RN #6 stated that she would address the issues with the staff and that nursing staff are expected to sit while feeding residents. On 08/14/2025 at 1:10 PM a review of the electronic medical record revealed that Resident #43 had a diagnosis of status post cerebral infarction, hemiplegia, and right arm contracture. Additionally, Resident #43's Activities of Daily Living care plan included the intervention of nursing staff to assist with feeding the resident at mealtimes.On 08/18/2025 at 08:30 AM the surveyor observed Resident #43 with a pillowcase under their chin. Resident #43 stated that she/he had just finished breakfast. The surveyor observed that crumbs and bits of food were on the resident's face and neck, and the breakfast tray had been removed from the resident's room.

Based on observations and interview it was determined the facility failed to ensure a homelike environment and maintain the resident environment in a safe, clean, and homelike manner. This was evident for 1 out of 1 outdoor resident patio spaces and 5 of 15 resident rooms observed during the facility's recertification survey. The findings include: 1.) On 8/15/25 at 14:07PM the surveyor conducted an observation of the facility's first floor dining room at which time the surveyor observed from the dining room, two metal beds and two bed headboards sitting within the outdoor patio space and various weeds and overgrowth of plants protruding through the fence surrounding the outdoor patio space. Weeds were observed protruding upward from sections of the cement in the outdoor patio space. An overgrowth of weeds along the front parking area spaces was additionally observed by surveyors. On 8/15/25 at 14:09PM the surveyor requested a dual observation with the Director of Nursing (DON) and observed and shared the concerns with them. At this time the surveyor conducted an interview of the DON who confirmed with the surveyor that the outdoor patio space was utilized by residents of the facility for activities and for sitting out to get fresh air and for family visits with residents. At this time the DON acknowledged the surveyor's concerns and reported the following information to the surveyor regarding the weeds and metal beds and headboards: I will get someone to take care of that. The surveyor subsequently shared the concern with the facility's Administrator who acknowledged the surveyor's concerns and confirmed that they had made contact with a lawn company prior to the survey for a quote, however, nothing had been scheduled yet for the care of the weeds or removal of the bedframes and head boards. On 8/19/25 at 12:28PM the surveyor conducted an interview with a facility visitor who communicated to the surveyor that the parking lot was observed by them to be overgrown by weeds during previous times they had visited the facility. On 8/25/25 at 2:01PM the surveyor again shared the concern during the facility's exit conference. 2.) On 8/14/2025 at 7:49AM, during the initial tour of the unit, observations revealed that 5 of 15 resident rooms had damaged walls, including unpainted portions and unsanded drywall patches. These areas were visibly unfinished and detracted from providing a clean, homelike environment for the residents. The rooms with damaged walls were 118, 123,125.127, and 128. On 08/14/2025 at 1:35 PM, the Nursing Home Administrator (NHA) and Regional Director were made aware of the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (Resident #10) out of 5 residents reviewed for pressure ulcers during the facility's recertification survey. The findings include: On 8/21/2025 at 8:06AM the surveyor observed LPN #22 perform a dressing change for Resident #10 for their pressure ulcers. On 8/21/2025 at 10:57AM the surveyor conducted a review of Resident #10's medical record which revealed an admission date to the facility in December 2024, and admission history documented by Physician #23 which indicated Resident #10 was admitted to the facility with a pressure ulcer. On 8/21/2025 at 10:57AM during the surveyor's review of Resident #10's medical record it was observed that an admission MDS assessment was completed for Resident #10 in December 2024 indicating under Section M- skin conditions, that the resident had pressure ulcers present. MDS section M0100 Determination of Pressure Ulcer/Injury Risk, question A asks the following information: Resident has a pressure ulcer/injury, a scar over bony prominence or a non-removable dressing /device and directs the person completing to select all that apply. Resident #10's MDS section M0100 question A was observed to coded with no documented as signed by Staff #24. On 8/21/2025 at 10:57AM during the surveyor's review of Resident #10's medical record it was observed that a quarterly MDS assessment was completed for Resident #10 in May 2025 and then again in August 2025 which were both documented as signed by MDS Coordinator #25. Section M- skin conditions, was observed to be documented that Resident #10 had pressure ulcers present. MDS section M0100 Determination of Pressure Ulcer/Injury Risk, question A asks the following information: Resident has a pressure ulcer/injury, a scar over bony prominence or a non-removable dressing /device and directs the person completing to select all that apply. Resident #10's MDS section M0100 question A was observed to coded with no documented as signed by MDS Coordinator #25. On 8/21/25 at 11:53AM the surveyor conducted an interview with MDS Coordinator #25 who confirmed they had completed the May and August 2025 MDS section M0100 for Resident #10 and acknowledged the surveyor's concern and stated the following to the survey team: This was a mistake, and yes it should be coded, it was an oversight on my part. On 8/21/25 at 11:54AM the surveyor shared the concern with the facility's Director of Nursing who stated the following to the survey team in response to the surveyor's concern: There will be an audit of the MDS to review for accuracy. On 8/25/25 at 2:01PM the surveyor again shared the concern during the facility's exit conference.

Based on interview and record review it was determined the facility failed to ensure medications were timely administered to a resident (#68). This was evident during the surveyor's review of a complaint during the facility's recertification survey. The findings include: On 8/14/25 at 1:26PM a review of complaint 357933 that was received by the State Survey Agency, alleged that Resident #68's medications were delayed several hours. During an interview 8/18/25 at 2:43PM conducted by the surveyor of the facility's Director of Nursing (DON), they stated the following information to the surveyor regarding Resident #68: No, I am not aware of any issues relating to medication administration. On 8/19/25 at 8:47AM the surveyor conducted an interview with the DON who reported they were not aware of any med pass delays regarding Resident #68, at which time the surveyor requested the Medication Administration Audit Report for Resident #68 to be provided for 6/18/24 and 6/19/24. On 8/19/25 at 13:55PM the surveyor was provided with the Medication Administration Audit Report for 6/18/24 and 6/19/24 for Resident #68 by the DON. On 8/20/2025 at 7:30AM the surveyor conducted a review of the Medication Administration Audit Report for 6/18/24 and 6/19/24 which revealed documentation indicating the following medications were not timely administered to Resident #68:1.) Oxycodone HCI Oral Tablet 10MG scheduled for 12:00PM on 6/18/24 with an administration time of 15:39PM by Licensed Practical Nurse (LPN) #29,2.) Oxycodone HCI Oral Tablet 10MG scheduled for 18:00PM on 6/18/24 with an administration time of 20:55PM by LPN #29,3.) Alprazolam Oral Tablet 0.25mg scheduled for 9:00AM on 6/19/24 with an administration time of 13:27PM by LPN #29,4.) Oxycodone HCI Oral Tablet 10mg scheduled for 12:00PM on 6/19/24 with an administration time of 14:52PM by LPN #29,5.) Gabapentin Oral Capsule 100MG scheduled for 17:00PM on 6/19/24 with an administration time of 19:02PM by LPN #29,6.) Alprazolam Oral Tablet 0.25MG scheduled for 17:00PM on 6/19/24 with an administration time of 22:57PM by LPN #29,7.) Oxycodone HCI Oral Tablet 10MG scheduled for 18:00PM on 6/19/24 with an administration time of 19:02PM by LPN #29,8.) Oxycodone HCI Oral Tablet 10MG scheduled for 00:00AM on 6/18/24 with an administration time of 1:16AM by Registered Nurse (RN) #10,9.) Oxycodone HCI Oral Tablet 10MG scheduled for 00:00AM on 6/19/24 with an administration time of 2:27AM by RN #10. On 8/20/25 at 7:40AM the surveyor conducted an interview of the DON who reported to surveyors that their expectation is for nurses to document at the time of medication administration to the resident, and nurses have one hour before, up until one hour after the scheduled medication order time to be considered passing the meds timely. At this time, the surveyor shared the concerns and observed the concerns with the DON on the Medication Administration Audit Report to which the DON replied: They should not be waiting until the end of their shift to sign medications off, we might have some medication administration timing audits to show you. On 8/20/25 at 9:37AM the surveyor conducted an interview with the DON who acknowledged and confirmed understanding of the surveyor's concerns. At this time the DON reported to the surveyor that the facility pulls reports of late medication administration for review. When the surveyor inquired to the DON as to how the facility determines if the medication pass was late, they stated to the survey team that they go by the scheduled time and compare it to the documented administration time, and showed the surveyor the Oxycodone order scheduled and administration times on the Medication Administration Audit Report.

Based on observation and staff interviews, it was determined that the facility failed to ensure that all residents were free from accident hazards and supervision. This was evident for 4 (Resident #2, 4, 73, and 22) out of 4 residents observed in the dining room area after breakfast time during the survey.The findings include:On 8/14/2025 at 8:47 AM, during the initial observation of the second floor, the surveyor went to the dining area and saw that there were several residents in the area talking amongst themselves. One of the residents (Resident #73) had finished their breakfast at the table and was trying to eat the aluminum lid from their apple juice container. As the surveyor was looking around, they heard a residents say, Don't eat that baby. You're not supposed to eat that. I don't know why they are eating that. Another resident (Resident #22) did not have any socks on and was in their wheelchair, moving around, using their feet to maneuver. The surveyor looked around the room to see if any staff were available to assist the residents. However, the surveyor did not see anyone in the room. The surveyor checked the nurse's station, which was right next to the room, but the nurse's station was empty at that time. The surveyor then looked down the hall to see if they could find a staff member to assist. The surveyor waved to a staff member (LPN #14) down the hall and asked them to come to the dining area. LPN #14 came and was notified that Resident #73 was eating an aluminum lid from their apple juice container. LPN #14 stopped the resident from eating the lid. LPN #14 was then asked if it was normal for residents to roam the hall in their bare feet. LPN #14 replied, No, I don't know why they don't have any socks on. LPN #14 was then asked if it was customary for the residents to be in the dining area without any supervision. LPN #14 replied that the staff were bringing the residents to the dining area for their coffee social hour and that someone from activities would be in there with them.

Based on observation, interview and record review it was determined the facility failed to: 1.) follow an active medical order in place for continuous oxygen for a resident, 2.) ensure the resident's care reviewed by the physician reflected the medical order in place, and 3.) ensure the respiratory care plan accurately reflected the medical order for oxygen. This was evident for 1 out of 1 resident (Resident #68) reviewed for respiratory care during the surveyor's review of a complaint and during the facility's recertification survey. The findings include: During the surveyor's review of investigation into a complaint, Resident #68 was observed by the surveyor on 8/18/25 at 10:53AM laying in bed with their oxygen concentrator on and set at 5 liters being delivered via nasal cannula to the resident. Review of the medical record at this time revealed Resident #68 had the following active medical order dated as beginning on 5/1/25: Respiratory: Oxygen- Continuous 4L via NC (nasal cannula), every shift. On 8/18/25 at 10:54AM the surveyor requested a dual observation of the concern with Unit Manager #26 who observed the oxygen concentrator of Resident #68 set at 5 liters, acknowledged the surveyor's concern, and after surveyor intervention, Unit Manager #26 was observed turning the oxygen concentrator from 5 liters down to 4 liters. On 8/18/25 at 10:56AM the surveyor shared the concern with the facility's Director of Nursing who acknowledged understanding of the concern. On 8/18/25 at 12:30PM the surveyor reviewed the medical record which revealed a progress note for Resident #68 documented by Nurse Practitioner #27 which indicated the resident was on oxygen via nasal cannula as needed on physical exam, and documented that the resident's assessment and plan included the resident being on chronic oxygen via nasal cannula at 3 Liters. On 8/18/25 at 12:30PM the surveyor reviewed the medical record which revealed a progress note for Resident #68 documented by Nurse Practitioner #27 which indicated the resident was on oxygen via nasal cannula as needed on physical exam, and documented that the resident's assessment and plan included the resident being on chronic oxygen via nasal cannula at 3 Liters. On 8/18/25 at 12:45PM the surveyor reviewed the care plan of Resident #68 and observed the following two simultaneous care plan interventions: 1.) Oxygen settings: 02 via 4L via NC, and 2.) Oxygen Settings: Humidified 02 via nasal prongs 3 L continuously. On 8/18/25 at 12:54PM the surveyor shared concerns with the Director of Nursing who acknowledged and confirmed understanding of the surveyor's concerns.

Based on record review and staff interview, it was determined that the facility failed to ensure the services of a registered nurse were provided for at least 8 consecutive hours a day, 7 days a week. This deficient practice was evident on 1 of 8 days reviewed (08/10/2025) during the recertification survey.On 08/15/2025 at 1:07 PM, record review of staffing schedules and assignments revealed that no registered nurse was scheduled or present to provide coverage for the facility on 08/10/2025 for an 8-hour consecutive period.At 1:26 PM, during an interview with the Director of Nursing (DON), she confirmed there was no nurse coverage for the entire building during the overnight shift on August 9 and all day on August 10. She stated she lives close by and could come in if needed but was not in the facility.

Based on observation and interview, it was determined that the facility failed to post nurse staffing information in a clear and visible manner as required. This deficient practice was evident for 1 of 2 floors during the recertification survey.The findings include:On 08/14/2025 at 7:39 AM, during observation of the first floor unit staffing board, the surveyor noted there was no clearly visible posting of the staff-to-resident ratio. The information could not be readily located or reviewed by residents, visitors, or staff. On 08/14/2025 at 1:35 PM, the Nursing Home Administrator (NHA) and Regional Director were made aware of the findings.

Based on observations and staff interviews, it was determined that the facility failed to ensure that all items in the medication storage rooms were free from expired expiration dates. This was evident for 1 out of 2 medication storage rooms.The findings include: On [DATE] at 12:50 PM, the Surveyor arrived on the first floor to observe the medication storage room. A nurse (LPN #13) was asked for the location of the med room and to unlock it for them. LPN #13 had to first locate the person with the keys for the medication room to unlock the door. LPN #13 stood in the doorway while the surveyor reviewed the medications and supplies. It was noted that blue laboratory tubes for blood collection had expiration dates on them for [DATE] and [DATE]. The Eswab Collection & Transport System for Aerobic, Anaerobic & Fastidious bacteria had expiration dates on them for [DATE], and a Luer Lock Disposable syringe with 25G X 0.625 needles had expiration dates for [DATE], and [DATE]. All items were shown to LPN #13. She then stated that they would go through and make sure all expired items were removed from the medication storage rooms. On [DATE] at 1:30 PM, the DON #2 was notified of the findings and was shown the things found that had expired expiration dates on them.

Based on observations, record review, and staff interview, it was determined that the facility failed to ensure accurate information was placed in residents' records. This was evident for 2 (Resident #2 and #132) residents reviewed during the survey. 1) On 8/21/2025 at 2:13 PM, the surveyor spoke with the DON #2 and asked the question, Who is responsible for reviewing and implementing orders from the doctor after a doctor's appointment? DON #2 explained that the nurse should review the visit summary and update the orders when the resident returns, and the unit manager should also follow up to make sure that the orders are completed. DON #2 was notified that during the surveyor's record review, for Resident #2, there was no documentation of when the Foley was ever changed. DON #2 stated that she is not sure how they document it and that she would get back to the surveyor. When the DON #2 returned, she had brought the ADON #3 back with her. The ADON #3 explained that she had documented on 7/1/25 how Resident #2 had dislodged the Foley, and they needed to replace it after doing a bladder scan that showed a significant amount of urine in the Resident #2's bladder. However, her documentation was noted in the Care Plan Notes section and not under nursing or treatments. The surveyor then asked the ADON #3 to show the surveyor where the documentation would be for this task, of when the Foley should be changed or has been changed. The DON #2 left and returned 20 minutes later with an SBAR note of when the resident had his Foley changed on 6/30/25, and it was not noted on the TAR or the MAR. Further record review, revealed that the facility was documenting to change the Foley as needed on the Care Plan and in the resident's order summary. However, the orders from the Urologist on 7/16/25 and 8/13/25 stated that the Foley should be changed monthly. The progress notes dated 8/14/25, 8/8/25, and 7/31/25, all stated to change the Foley catheter every 3 weeks. 2) On 8/14/25, the surveyors received a copy of the matrix for the facility. During the record review, it was noted that Resident #132 was in room [ROOM NUMBER] A; however, while during the surveyor's initial observation, the resident was actually in room [ROOM NUMBER] A. The documentation was incorrect on the matrix. The DON was notified and asked to give a corrected matrix with accurate information for all residents.

Based on observation and interviews the facility failed to: 1.) maintain optimal infection control and prevention precautions in one area of the laundry room and maintain a clean environment around the eye wash station and the laundry hopper, and ensure water pipes were not left exposed in the area next to and above the laundry hopper. This was evident for 1 out of 1 laundry area observed; 2.) ensure proper infection control/sanitization for any medical equipment that was shared among residents. This was evident for 1 out of 2 medication administration observations; and 3.) ensure oxygen equipment was properly dated to prevent potential infection control risks. This was evident for 1 (Resident #101) of 2 residents reviewed for oxygen use during the facility's recertification survey. The findings include: 1.) On 8/25/25 at 11:32AM the Administrator and the surveyor agreed to tour the laundry room on the ground floor of the facility. Laundry Supervisor #20 accompanied the surveyor and the Administrator into the dirty side of the laundry room. The surveyor observed that the laundry room's eye wash station was located next to the hopper bowl that is used to rinse off soiled clothing, linens, towels, etc. The eye wash/hand wash sink and the hopper were dirty and with areas of brown rust like material present on the sink, inside the sink, and on the outside and the inside of the hopper. Above the hopper the wall was exposed, a large portion of drywall was not present and the shut off valves were without knobs. On 8/25/25 at 11:52AM Maintenance Director #21 stated that maintenance department was responsible for the removal and replacing the portion of the drywall that normally covers the shut-off valves. On 8/25/25 at 11:54AM Maintenance Director #21, with Laundry Supervisor #20 present, stated that the plumbing for the building was [AGE] years old. Maintenance Director #21 stated that he was aware that the interior wall should not be left exposed but he was waiting to figure out where he could order the replacement parts for the shut off valve knobs. Maintenance Director #21 stated that currently the hose for the hopper has a mixture of hot and cold water that is adjusted with a plumber's wrench to maintain a warm temperature. 2.) On 8/19/25 at 9:30AM the surveyor asked to observe Licensed Practical Nurse (LPN) #17 while he started his medication administration. LPN #17 was observed reviewing the first resident's medications in the computer. LPN #17 unlocked his medication cart and checked to see if he had all the medications that he needed for the resident needed first. LPN #17 noted that he was missing Ensure Max. LPN #17 walked with the surveyor to the medication room to see if any were in there, but none were. LPN #17 walked with the surveyor to the kitchen to see if any were there, however, the kitchen attendant stated that they should be on the unit. Then LPN #17 asked a coworker if they could assist him with finding some. LPN #17 then returned to the medication cart and sanitized his hands first and then stated that he needed to check the resident's blood pressure before he gave them their blood pressure meds. LPN #17 and the surveyor walked to the resident's room, and the nurse introduced himself and asked if he could check his blood pressure. LPN #17 checked the resident's blood pressure and stated that the blood pressure was good and okay to give them their blood pressure medication. LPN #17 walked with the surveyor back to the med cart, which was outside the resident's room, and LPN #17 began to pull the resident's medications. LPN #17 returned to the resident and told him which medication he/she was receiving and administered the medications. LPN #17 then left the resident's room and returned to the medication cart with the blood pressure machine. LPN #17 sanitized his hands again and returned to the computer to see the next resident. LPN #17 saw that he needed to check the next resident's blood pressure prior to administering their meds. The surveyor followed LPN #17 to the next resident's room, where he introduced himself and asked to check their blood pressure. LPN #17 checked their blood pressure; however, he did not sanitize the blood pressure machine. When LPN #17 returned to the medication cart to pull the medications, the surveyor asked what the policy was for using the medical equipment between residents. LPN #17 replied, I was supposed to clean the blood pressure machine between each resident. During this observation of medication administration, it was noted that LPN #17 failed to sanitize the blood pressure cuff between residents who needed their blood pressures completed before the administration of blood pressure medications. 3.) On 8/14/25 at 7:53AM, Resident #101 was observed to be using oxygen tubing that was not dated. At 7:56AM, Registered Nurse (RN) #10 was located and confirmed that the tubing and humidifier bottle were undated. RN #10 stated it was the responsibility of the registered nurse to ensure oxygen equipment was dated. RN #10 subsequently obtained new tubing and humidifier bottle for Resident #101 and ensured the date was applied. On 8/14/2025 at 1:35PM, the Nursing Home Administrator and Regional Director were made aware of the findings.

Based on review of facility investigation, review of the medical record, and staff interviews, it was determined that facility staff failed to protect a resident (Resident#2) from abuse. This resulted in harm to the resident when the resident was dragged against their wishes down the hall and sustained skin tears (actual pushing back of tissue) when forced into their bed. This was evident for 1 of 6 residents reviewed during a complaint survey. The findings include: Resident #2 who has dementia but was able to make his/her wishes known was asked on 2-5-18 after dinner by Geriatric Nursing Assistant #1 (GNA#1) if he/she could put him/her to bed. Resident #2 said he/she was not ready to go to bed. GNA #1 then dragged Resident #2 backwards in the wheelchair down the hall while Resident #2 was yelling help. GNA #1 then forced Resident #2 into the bed while Resident #2 was yelling for help and Resident #2 sustained 2 skin tears. One skin tear was on the left upper wrist 4 cm long and one below the left wrist was 5cm long. Both skin tears were treated with steri strips. GNA #1 left Resident #2 in the bed with the lights out and reported to the nurse on duty that the resident had sustained new skin tears. Resident #2's skin tears were immediately treated. The evening nursing supervisor was immediately notified and Resident #2 was made safe by removing GNA #1 from his care. Family and physician were notified. GNA #1 was asked to make a written statement which was not done, was suspended and sent home. The full investigation on 2-6-18 included video evidence of GNA #1 dragging Resident #2 in the wheelchair down the hall backwards, Resident #2 stating to the Director of Nursing he/she (GNA #1) pulled me and made me go to bed and that GNA #1 grabbed his/her arm and pushed him/her into the bed. He stated he was mad but felt safe at facility GNA #1's employment was terminated. The incident was reported to the police and the [NAME]land Board of Nursing was notified of GNA #1's actions. Facility staff re-education on resident rights and abuse was done.