Every finding on record at Stone Mountain Run of Journey LLC

Based on observations, staff interviews, and review of the facility policy titled, Food Safety Requirements, the facility failed to maintain the cleanliness of the facility minimizing the risk of food-borne illness and to promote safe food handling practices. The deficient practice had the potential to place 27 of 27 residents who received an oral diet at risk of foodborne illness.Findings Include:Review of the facility policy titled Food Safety Requirements revealed under Policy Explanation and Compliance Guidelines: .7. Staff shall adhere to safe hygiene practices to prevent contamination of foods from hands or physical objects. 8. Additional strategies to prevent foodborne illness include, but are not limited to: . e. Cleaning and sanitizing the internal components of the ice machine according to manufactures guidelines.Observation on 05/04/26 at 10:40 AM of the ice machine located in the kitchen revealed that the unit had a build-up of a tan like thick substance attached to the top and bottom of the inside of the ice machine. There was an off white, tan drip on the front lid's left side.An interview on 05/04/2026 at 10:45 AM with the Dietary Manager confirmed the build-up inside the unit. She reported that maintenance cleaned the ice machine.An observation and interview on 05/05/2026 at 10:30 AM with the District Manager confirmed the build-up on the inside of the unit.An observation on 05/05/2026 at 10:35 AM revealed the ice machine had been cleaned of the build-up.Observation on 05/04/2026 at 10:50 AM of the portable air conditioners in the kitchen. Two units were in use with a thick black flaky substance blowing from the unit. The build-up/substances on one of the units was blowing toward the food line.An interview on 05/04/2026 at 10:55 AM with the Dietary Manager confirmed the build-upon the portable air conditioners and the unit blowing toward the food line. The units were turned off and taken to be cleaned by maintenance.An interview on 05/05/2026 at 10:35 AM with the Dietary Manager confirmed the picture of the unit had a build-up of a black flaky substance blowing toward the food tray line.

Based on observations and staff interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment were clean and free from dusty grayish build up including on packaged terminal air conditioner (PTAC) in air conditioner (AC) units on six of six halls (100 Hall, 200 Hall, 300 Hall, 400 Hall, 500 Hall and 600 Hall) in 18 resident rooms (Rooms 201,208, 221, 316, 401, 405, 407, 411, 413, 507, 508, 511, 512, 602, 606, 611, 701, and 713), The deficient practice had the potential to cause respiratory issues for residents residing in the affected rooms Findings include:A review of facility documentation titled Direct Supply TELS (building management platform) dated 02/28/2026 revealed Instructions on HVAC (PTAC), due 05/31/2026: Clean air filter. Step 1. Remove or open access cover. 2. Remove air filter and inspect for cleanliness. If filter is dirty, either wash or replace depending on type of filter. Observation on 05/04/2026 during Initial screening starting at 10:47 AM till 1:33 PM on the 200, 300, 400, 500, 600 and 700 hall revealed an excessive amount of gray fuzzy substance on pull out vent filters in the following rooms: room [ROOM NUMBER]room [ROOM NUMBER] room [ROOM NUMBER] room [ROOM NUMBER] room [ROOM NUMBER] room [ROOM NUMBER] room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]room [ROOM NUMBER]During a tour starting on the 200 hall on 05/04/2026 at 4:52 PM with the Regional [NAME] President of Operations (RVPO) and the Administrator confirmed that the PTAC air conditioning unit in room [ROOM NUMBER] exhibited a grayish buildup on the filter. Both parties acknowledged this issue and agreed that cleaning would be performed right away; however, they declined to continue the tour of the other rooms mentioned. The Administrator indicated that the PTAC units were inspected weekly and cleaned monthly but noted that the condition of the filter posed a risk of respiratory complications for residents.An interview and observation on 05/05/2026 at 9:42 AM with the Regional Maintenance Director (RMD), who was shown several images via phone showing dust accumulation on PTAC units in rooms 201, 208, 221, 401, 405, 407, and 606. The RMD confirmed that the dust buildup was present for two to three months. He disclosed that he performed cleaning on 02/26/2026 but acknowledged that he did not believe he was able to clean the PTAC units during the task log that was marked as completed on time for Category HVAC PTACs.

Based on observations, staff and resident interviews, record review, and review of the facility policies titled, Comprehensive Care Plan and Oxygen Administration, the facility failed to develop a comprehensive care plan for two of 59 sampled residents (R) (R101 and R108). Specifically, R101 was receiving continuous oxygen, and it was not addressed on the care plan and R108 had communication concerns that were not addressed on the care plan. The deficient practice had the potential for R101 and R108 not to receive needed care and services.Findings include:Review of policy titled, Comprehensive Care Plans revised 3/20/2025 revealed under Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.Review of the policy titled Oxygen Administration, revised 02/01/2024, revealed under Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Under Policy Explanation and Compliance Guidelines: . 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: a. The type of oxygen delivery system. b. When to administer, such as continuous or intermittent and/or when to discontinue. c. Equipment setting for the prescribed flow rates. d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. e. Monitoring for complications associated with the use of oxygen.Review of the electronic medical record (EMR) revealed R101 was admitted to the facility on [DATE] with pertinent diagnoses including, but not limited to, hypertension, respiratory failure, generalized anxiety, and seizures.Review of R101's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicates R101 has moderate cognitive impairment. Section GG, Functional Status, revealed R101 required setup/cleanup assistance with eating and oral hygiene, moderate assistance with personal hygiene, and maximal assistance with all other ADLs (activities of daily living) and with mobility. Section I, Active Diagnosis, revealed respiratory failure. Section J, Health Problems, revealed shortness of breath when lying flat. Section O, Special Treatments, Procedures, and Programs, did not include that resident is receiving oxygen.Review of R101's care plan initiated on 01/24/2026 with last review history dated 03/31/2026 did not indicate any respiratory issues although the resident is on oxygen and receiving nebulizer treatments.Review of the Physician's Orders for R 101 included but was not limited to:Order dated for 02/04/2026 Pulmicort Suspension 0.5 MG/2ML (milligrams per milliliter) (Budesonide)2 ml inhale orally via nebulizer every 12 hours for SOB (shortness of breath) Supplementary Documentation Codes: Pre and Post Tx (treatment) Lung Sounds C = Clear O = Other (see progress note) Pre and Post Tx - P (pulse), R (respirations) and O2 (oxygen) Sat (saturation) results MNS - Enter the number of minutes of nurse time for the administration.Order dated 03/19/2026, BusPIRone HCl Tablet 5 MG, Give 1 tablet by mouth two times a day for anxietyObservation and interview on 05/06/2026 at 3:57 PM with Registered Nurse (RN) II while standing in room [ROOM NUMBER] confirmed that R101 was receiving oxygen at 3 LPM (liters per minute). RN II confirmed that the resident did not have an order for oxygen. RN II stated that the doctor's order would tell you how much oxygen to give. RN II confirmed that the resident was on oxygen continuously.Interview on 05/06/2026 at 4:08 PM with the Director of Nursing (DON) revealed expectations were when a resident was on oxygen that an order was placed in the system and that the care plan should include oxygen.An interview on 05/06/2026 at 4:10 PM with the Administrator revealed that if a resident was on oxygen, it should be on the care plan. Review of the EMR revealed R108 was admitted to the facility on [DATE] with pertinent diagnoses including, but not limited to, encephalopathy, muscle wasting and atrophy, and cerebral infarction. Review of R108's admission MDS assessment dated [DATE] revealed a BIMS score of 6, which indicates R108 has severe cognitive impairment. Section GG, Functional Status, revealed R108 required/was independent/minimum/extensive assistance for ADLs with one/two or more-person assistance.Review of R108's care plan did not indicate that the resident had communication needs.Observation on 05/04/2026 at 2:14 PM revealed when Certified Nursing Assistant (CNA) NN was asked how she communicated with R108, she stated that he didn't talk much but he understood. CNA NN also pointed to and stated that they have a communication line if needed. Observation on 05/05/2026 at 1:45 PM with CNA FF revealed R108 spoke Vietnamese and that he could say some words in English.Interview on 05/06/2026 at 3:21 PM with the Social Worker (SW) revealed that communication should be on R108's care plan.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Activities of Daily Living (ADLs), the facility failed to ensure ADL care related to nail grooming was provided for four of eight sampled residents (R) (R44, R77, R124, and R144). This failure had the potential to cause the affected residents to harbor bacteria, increasing the risk of physical injury and the spread of infection, as well as causing them to feel self-conscious of their appearance.Findings include:Review of the policy titled Activities of Daily Living (ADLs), revised 3/20/2025 revealed, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; 2. Transfer and ambulation. 3. Toileting. 4. Eating to include meals and snacks; and 5. Using speech, language or other functional communication systems. Further review of the policy revealed, .4. a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.1. A review of the facility's admitting records revealed that R44 was admitted to the facility on [DATE] with diagnoses that include, but are not limited to muscle weakness, unspecified lack of coordination, unspecified dementia, and behavioral disturbances.A review of R44's Quarterly Minimum Data Set (MDS) for R44 dated 04/27/2026, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Section B revealed the resident makes himself understood and he has the ability to understand others. Section E (Behavior) revealed no documentation indicating rejection of ADL care during the lookback period. Section GG (Functional Abilities and Goals) documented that R44 requires partial to moderate assistance with personal hygiene ADLs.A review of the Care Plan for R44 revealed a focus area of .at risk for an ADL self-care deficit due to his diagnosis. The goal stated that R44 will appear clean, well-groomed and dressed.During an observation and interview on 05/04/2026 at 12:45 PM, R44 was observed in bed with fingernails that were long, jagged, and with visible dark black/brown debris (dirty). R44 stated, I would trim them myself if I could. They don't usually do it for me.Subsequent observations and interviews on 05/05/2026 at 12:15 PM and 05/06/2026 at 9:35 AM revealed that the condition of the resident's nails remained unchanged: they were excessively long and jagged, with visible dark debris (dirty). R44 stated he would allow the staff to provide nail care and does not recall the last time he had his nails groomed.Review of R44's ADL Certified Nursing Assistant (CNA) task sheets for April 04/24/2026 through 05/07/2026 revealed no documentation of resident refusal for personal hygiene. Further review of the record revealed documentation of daily finger pulse oximetry oxygen (O2) saturation assessments.During an observation and interview on 05/06/2026 at 9:40 AM, CNA AA revealed that for residents with diabetes, staff report nail care needs to the nurse; otherwise, CNAs trim nails during showers if the resident allows. She confirmed that R44's nails were long, jagged, and dirty with an accumulation of a dark brown/black substance.2. A review of the facility's admitting records revealed that R77 was admitted to the facility on [DATE] with diagnoses that include but are not limited to unspecified cerebrovascular disease affecting left non-dominant side, contracture left wrist, other reduced mobility, muscle wasting and atrophy, and unspecified lack of coordination.A review of R77's Quarterly MDS dated [DATE], revealed Section C documented a BIMS score of 12, indicating moderate cognitive impairment. Section B revealed the resident makes himself understood, and he has the ability to understand others. Section E revealed no documentation indicating rejection of ADL care during the lookback period. Section GG documented that R77 requires partial to moderate assistance with personal hygiene ADLs.A review of the Care Plan for R77 revealed a focus area of ADL.requires assistance with ADL related to stroke. The goal stated that R77 will appear clean, well-groomed and dressed.During an observation and interview on 05/04/2026 at 12:45 PM, R77 was observed in the main dining room with fingernails that were long, jagged, and with visible dark brown/black debris (dirty). R77 stated, They won't do them for me, and I can't do them by myself. The resident states he cannot remember when they were last cleaned and trimmed.Subsequent observations on 05/05/2026 and 05/06/2026 revealed that the condition of the resident's nails remained unchanged: they were excessively long and jagged, with visible dark debris (dirty). R77 stated he would allow staff to provide nail care and does not recall having rejected it in the past. He stated he would like them to be groomed as soon as possible.Review of R77's ADL, CNA task sheets for April 04/23/2026 through 05/06/2026 revealed no documentation of resident refusal for personal hygiene. Further review of the record revealed documentation of daily finger pulse oximetry oxygen (O2) saturation assessments.3. A review of the facility's admitting records revealed that R124 was admitted to the facility on [DATE] with diagnoses that include, but are not limited to, other sequelae of cerebral infarction, unspecified lack of coordination, need for assistance with personal care, muscle weakness (generalized), and other lack of coordinationA review of R124's MDS dated 0 3/17/2026, revealed that Section C documented a BIMS score of 10, indicating moderate cognitive impairment. Section B revealed that the resident makes himself understood, and he has the ability to understand others. Section E revealed no documentation indicating rejection of ADL care during the lookback period. Section GG documented that R124 is dependent on staff for personal hygiene ADLs.A review of the Care Plan for R124 revealed a focus area of ADL.has an ADL self-care deficit due to his overall Disease process.Total assistance with Dressing, Bathing/Showering.Personal Hygiene. The goal stated that R124 will appear clean, well-groomed and dressed.During an observation and interview on 05/04/2026 at 10:45 AM, R124 was observed in bed with excessively long, jagged fingernails and visible dark brown/black debris (dirty). R124 stated that staff generally cared for his needs but could not recall the last time his nails were cleaned and trimmed. He stated that he would like his nails to be groomed.Subsequent observations on 05/05/2026 and 05/06/2026 revealed that the condition of the resident's nails remained unchanged: they were excessively long and jagged, with visible dark debris (dirty). R124 stated he would allow the staff to provide nail care.Review of R124's ADL, CNA task sheets for April 04/22/2026 through 05/05/2026 revealed no documentation of resident refusal for personal hygiene.4. A review of the facility's admitting records revealed that R144 was admitted to the facility on [DATE] with diagnoses that include but are not limited to, need for assistance with personal care, muscle weakness (generalized), quadriplegia unspecified, multiple sclerosis, and cognitive communication deficit.A review of R144's Quarterly MDS dated [DATE], revealed Section C documented a Brief Interview for BIMS score of 10, indicating moderate cognitive impairment. Section B revealed that the resident makes herself understood, and he has the ability to understand others. Section E revealed no documentation indicating rejection of ADL care during the lookback period. Section GG documented that R144 requires substantial assistance with personal hygiene ADLs.A review of the Care Plan for R144 revealed a focus area of ADL. has self-care deficit with ADL r/t (related to) dx (diagnosis) of MS (multiple sclerosis), Wounds and Muscle Weakness. R144 is provided with Total care for Bed Mobility, Transfers with lift and Toileting. Extensive assistance with Dressing, Showering per her preference and Personal Hygiene. The goal stated that R144 will appear clean, well groomed and dressed as per preferences through next review date.During an observation and interview on 05/04/2026 at 10:45 AM, R144 was observed in bed with fingernails that were excessively long, jagged, and with visible dark brown/black debris (dirty). R144 initially stated she could try to trim her nails if the staff would bring her the supplies to do so. She promptly corrected herself and stated, I don't know why I said that. I cannot do them on my own. She stated she cannot clean or trim them and can't remember when they were groomed last. Subsequent observations on 05/05/2026 and 05/06/2026 revealed that the resident's nails remained unchanged: excessively long with remnants of red nail polish.Review of R124's ADL CNA task sheets for April 04/22/2026 through 05/07/2026 revealed no documentation of resident refusal for personal hygiene. Further review of the record revealed documentation of daily finger pulse oximetry oxygen (O2) saturation assessments.During an observation and interview on 05/06/2026 at 9:40 AM, CNA AA stated that a negative outcome could be that the resident scratches himself or herself and could spread germs.During an observation and interview on 05/06/2026 at 9:45 AM, Licensed Practical Nurse (LPN) and Unit Manager (UM) BB stated that CNAs were responsible for cleaning and trimming the nails of non-diabetic residents during showers. Upon observing the nails of R44 and R77, she noted they were excessively long and soiled and stated she would ensure they were cleaned and trimmed immediately. She confirmed the same findings for R144 and R124. She indicated that potential negative outcomes included residents experiencing skin tears and harboring bacteria. Furthermore, she confirmed that because oxygen saturation levels are assessed using a finger pulse oximeter, the condition of the nails should have been observed by staff during those clinical assessments.During an interview on 05/06/2026 at 9:55 AM, the Administrator stated it was her expectation that staff kept residents' nails clean and trimmed. She further stated the potential negative outcomes of this deficient practice included potential skin injuries and infections.During an interview on 05/06/2026 at 10:13 AM, the Director of Nursing (DON) reviewed the nail photos for R44, R77, R124, and R144. She stated the nails should have been trimmed with routine morning ADL care and that the staff would provide the care immediately.

Based on observations, staff interviews, and review of facility's policy titled, Accidents and Supervision, the facility failed to ensure the resident's environment remained free of accident hazards for one of 59 sampled residents (R) (R9). The deficient practice had the potential for chemical hazards being accessible to residents. Findings include: Review of the facility policy titled Accidents and Supervision reviewed date 02/01/2024, documented under Policy: The resident environment will remain as free of accident hazards as is possible. Under Policy Explanation and Compliance Guidelines: 1. Identification of Hazards and Risk.b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident. Review of the electronic medical record (EMR) for R9 revealed admission to the facility on [DATE] with diagnoses that included, but were not limited to dysphagia, oropharyngeal phase, and chronic obstructive pulmonary disease (COPD). Review of R9's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was coded as 14, which indicated R9 was cognitively alert and oriented. Review of the care plan for R9, dated 12/08/2025, revealed no documentation for accident hazards. Observation during the initial screening of the facility on 05/04/2026 at 1:26 PM revealed in the room of R9, on top of a two-tier white plastic storage container, was one 16 fl oz (fluid ounce) bottle of 91% (percent) isopropyl alcohol and one 6.2 oz automatic room scent spray. Observation on 05/06/2026 at 10:52 AM revealed one 16 fl oz bottle of 91% isopropyl alcohol and one 6.2 oz automatic room scent spray by R9's bedside. The resident resided in a semi-private room. An interview on 05/06/2026 at 10:57 AM with Licensed Practical Nurse (LPN)/Unit Manager BB verified the presence of one 16 fl oz bottle of 91% isopropyl alcohol and one 6.2 oz automatic room scent spray. LPN BB retrieved the items from R9's bedside and indicated that she had explained the potential accident hazards associated with each item to R9. An interview on 05/06/2026 at 11:05 AM with the Administrator revealed the identified items located in R9's room should not be present in the residents' rooms.

Based on observations, staff and resident interviews, record review, and review of the facility policies titled Oxygen Administration, the facility failed to obtain a physician order for one of 11 residents (R) (R101) on oxygen. This deficient practice had the potential to cause respiratory distress.Findings include:Review of the policy titled Oxygen Administration, revised 2/1/2024, revealed Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Section titled Policy Explanation and Compliance Guidelines revealed the following:1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. 2. Personnel authorized to initiate oxygen therapy include physicians, RNs, LPNs, and respiratory therapists.Review of the electronic medical record (EMR) revealed resident (R) 101 was admitted to the facility on [DATE] and pertinent diagnoses, including but not limited to respiratory failure and generalized anxiety.Review of R 101 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 10, which indicates R101 has moderate cognitive impairment. Under Section I, active diagnosis revealed respiratory failure. Section J, health problems, revealed shortness of breath when lying flat. Section O, special treatments, procedures, and programs, did not include that the resident is receiving oxygen.Review of R 101 care plan initiated on 1/24/2026 and revised on 3/31/2026 did not indicate any respiratory issues.Review of the Physician's Orders for R 101 revealed no oxygen orders in the record. Observation and interview on 5/4/2026 at 1:42 pm revealed R 101 is sitting up in bed, eating lunch. She appears weak. She states she is here for rehab. She is receiving oxygen at 3L (liters). She states that she is on continuous oxygen. She also states she returned to the facility on oxygen following her last hospital discharge.5/5/2026 at 12:55 PM R 101 is resting quietly with closed. Oxygen at 2 L per nasal canula. An interview and observation on 5/6/2026 at 3:57 pm with Registered Nurse (RN) II while standing in room [ROOM NUMBER] confirmed that R 101 is receiving oxygen at 3L per min (minute). Surveyor opened the physician orders in R101 Emar (electronic medication administration record), and RN II confirmed that the resident did not have an order for oxygen. RN II states that the doctor's order specifies how much oxygen to give the residents. RN II confirmed that the R101 is continuously on oxygen. She says the tubing is changed once a week. She states that too much oxygen could cause lungs not to receive the maximum oxygen, and if the settings are too low, it could cause a hunger for oxygen, and the residents may begin to use accessory muscles to breathe. An interview on 5/6/2026 at 4:08 pm with the Director of Nursing (DON) revealed that I expect an order to be placed in the system when a resident is on oxygen. If a nurse receives a telephone order for oxygen, she should add the order to the resident's profile. Tubing should be changed weekly. An interview on 5/06/2026 at 4:10 pm with the Administrator revealed that her expectation is that if a resident is on oxygen, the resident should have an order for the oxygen rate. She revealed that hyperoxygenation or hypoxia could be a concern related to a resident receiving oxygen without an order.

Based on observation, record review, interviews, and policy review, the facility failed to determine if one of one resident (Resident (R) 33) was assessed as clinically appropriate to self-administer medications out of 41 sampled residents. The failure of the facility to leave medications at the bedside unattended prior to an assessment, created the potential that if R33 did not take the medication, the physician and nurses would not be aware. Findings include: Review of the facility's policy dated 02/01/24 and titled, Resident Self Administration of Medication revealed It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely .Each resident is offered the opportunity to self-administer medication during the routine assessment by the facility's interdisciplinary team. Review of R33's electronic medical record (EMR) Admission Record located under the Profile tab revealed the resident was admitted to the facility on [DATE]. R33 had a diagnosis that included major depressive disorder, schizoaffective disorder, and generalized anxiety disorder. Review of R33's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/01/25 indicated the resident had a Brief Interview for Mental Status (BIMS) score of four out of 15 which revealed the resident was severely cognitively impaired. The assessment did identify the resident had a depression, anxiety, psychotic, and schizophrenia diagnoses. Review of R33's EMR Administration Record revealed R33 received Lactulose Encephalopathy Oral Solution 10GM (gram)/15ML (milliliters) (Lactulose (Encephalopathy)) Give 30 ml by mouth every morning and at bedtime for Encephalopathy -Start Date- 09/01/2023 Review of R33's EMR revealed no assessments were conducted related to self-administration of medications. During an observation on 03/17/25 at 10:35 AM, R33 was sitting up on her bed. She was eating breakfast. To the left side of her plate she had a small medication cup, filled with a yellowish liquid. She stated she did not know what the liquid was but she stated she took it every morning and evening. The Director of Nursing (DON) entered the room and stated she did not know what the medication was and asked R33 if she could take it away. R33 started screaming at her and told her not to take it. During an interview on 03/17/25 at 11:16 AM, the DON stated she was not sure if the facility had completed a medication self-administration assessment. During an interview on 03/19/25 at 2:06 PM, Licensed Practical Nurse (LPN) 3 and Unit Manager (UM) both stated they had received education related to not leaving mediations at the bedside unless the resident has had a self-administration assessment. During an interview on 03/20/25 at 1:03 PM, the DON stated medications should not be left at any residents' bedside unless a self-administration assessment had been completed. She stated an assessment had been completed for R33 and she was not capable of self-administration.

Based on interview, record review, and policy review, the facility failed to ensure facility staff reported an allegation of potential sexual abuse for one out of seven residents (Resident (R) 103 against R113) immediately to the Administrator who was the abuse coordinator for the facility. This had the potential to delay the investigation conducted by the facility to determine whether abuse occurred or not. Findings include: Review of a facility policy titled Abuse, Neglect and Exploitation dated 11/01/24 indicated .It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident properly.Reporting of all alleged violations to the Administrator, state agency, adult protection services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes.Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Review of R103's electronic medical record titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R103's EMR titled quarterly Minimum Data Set with an Assessment Reference Date of 06/06/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of seven out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the resident had no previous behaviors directed towards others. Review of R103's EMR titled Health Status Note located under the Prog (Progress) Note tab dated 08/18/24 at 10:38 PM, indicated a nurse approached R103 and informed the resident that R113 had alleged R103 went to R113's bed and asked her for sex. The progress note indicated R103 denied the allegation. Review of R103's EMR titled Care Plan located under the Care Plan tab dated 08/20/24 indicated the resident was hypersexual at times and would pleasure herself. The goals of the care plan were to administer the resident's medications as physician ordered and to attempt to redirect her. There was no additional evidence of R103 acting out sexually after medical intervention. Review of R113's EMR titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R113's EMR titled admission MDS with an ARD of 08/05/24 indicated the resident had a BIMS score of eight out of 15 which revealed the resident was moderately cognitively impaired. Review of R113's EMR titled Health Status Note located under the Prog Note dated 08/18/24 which revealed R113 approached the charge nurse and informed the nurse that her roommate R103 asked her to have sex with her. R113 denied being scared and the nurse moved R103 to another room. Review of R113's EMR titled Care Plan located under the Care Plan tab dated 10/03/24 indicated the resident had a history of confabulation about things with staff and other residents. Review of a document provided by the facility titled Final Report with Investigation on Incident Report, dated 08/23/24, indicated the incident occurred on 08/19/24. The author of the document was the Administrator who was the facility's abuse coordinator and stated that she was notified on 08/19/24 at 10:00 AM that R113 alleged R103 wanted to have sex with her. There was evidence that the State Survey Agency (SSA) was notified at this time. During the investigation, R113 was interviewed and claimed R103 touched her breast and then, her buttocks. R113 stated she initially thought that this was an accident but then R103 came over to her side of the room, touched her breast and asked her for sex. The investigation indicated R113 voiced that she was upset and did not support those behaviors. The facility then interviewed R103 who denied the allegation. During an interview on 03/18/25 at 2:48 PM R113 stated she felt safe and has never been asked by another resident to have sex with her. During an interview on 03/20/25 at 9:21 AM, the Director of Nursing (DON) stated the allegation that R113 made against R103 should have been reported immediately. During an interview on 03/20/25 at 2:54 PM, the Administrator stated after the allegation was made a room change was made to make sure the residents felt comfortable. During an interview on 03/20/25 at 12:38 PM the Administrator, [NAME] President of Clinical Operations and the DON were present. The Administrator was asked why the delay in reporting to the SSA, and she stated that R113 claimed that she was asked by R103 to have sex and it was not until the next day that the allegation was reported to her then R113's story changed. The Administrator stated she would not report based on a statement made by R113 when R103 asked for sex. The Administrator stated the story changed from R113 and this was when she then alleged R103 had touched her and that was when the resident-to-resident was reported to the SSA.

Based on observation, interview, record review, and policy review, the facility did not ensure one of one resident (Resident (R)338) bed frame was not bigger than the air mattress. Failure to do so had the potential for R338's leg(s) and/or arm(s) to get caught in the bed frame and cause injury. Findings include: 1.Review of R338s EMR titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Further review of the medical record revealed their was no bed assessments completed for the resident. Observation on 03/18/25 at 10:05 AM revealed R338's air mattress was smaller than the bed frame. There was approximately 12 inches of the bed frame exposed making it a potential hazard. Licensed Practical Nurse/Wound Nurse (LPN/WN) and Certified Nursing Assistant (CNA)13 confirmed the above observation. LPN/WN said she would inform maintenance to switch out the bed frame. Observation on 03/19/25 at 11:00 AM revealed R338's air mattress was still smaller than the bed frame with approximately 12 inches of the bed frame exposed. Observation on 03/20/25 at 11:09 AM revealed R338's bed frame had still not been changed to ensure R338's legs or arms did not become trapped during care. Physical Therapist (PT) who was doing range-of-motion (ROM) exercises for R338 confirmed the mattress was too small for the bed frame. She said when he was repositioned from side-to-side one of his arms or legs could become trapped in the bed frame. Interview on 03/20/25 at 11:15 AM with the Director of Nursing (DON) revealed she had not been made aware R338's air mattress was too small for the bed frame. She agreed there was potential for injury to the resident while staff repositioned him if he had a leg/arm caught in the frame. Interview on 03/20/25 at 11:30 AM with LPN/WN said she had informed maintenance that the bed frame was too big for the air mattress on 03/18/25. She was not aware it had not changed. Review of the facility's policy titled Environmental Services Inspection implemented on 11/01/24 showed All opportunities will be corrected immediately by environmental services personnel. Review of the facility's policy titled, Resident Environmental Quality implemented on 02/01/24 showed Identify areas of possible entrapment by conducting regular inspections on all bed frames, mattresses, and bed rails. These inspections will be part of the facility's routine maintenance program. All facility personnel are responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately upon identification of the issue.

Based on interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure one of five residents (Resident (R) 1) for pneumococcal vaccines had accurate consents signed, including the risks and benefits explained to the resident and/or representative prior to the administration of the vaccine. The failure for not providing an accurate consent and providing education to the resident and/or representative prior to administering the pneumococcal vaccine did not give the resident and/or representative the ability to make an informed decision prior to the vaccine being administered. Findings include: Review of the CDC website titled Pneumococcal Disease, effective 10/26/24, indicated . Based on shared clinical decision-making, adults [AGE] years or older have the option to get PCV20 or PCV21, or to not get additional pneumococcal vaccines. Review of a facility policy titled Pneumococcal Vaccine dated 11/01/24 indicated .It is our policy to offer residents and staff immunizations against pneumococcal disease in accordance with current CDC guidelines and recommendation.Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization with the education documented in the clinical record. Review of R1's electronic medical records (EMR) titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. The resident was over the age of 65 at the time of his admission. Review of R1's EMR titled Immunizations located under the Immun (Immunizations) tab failed to include evidence that the resident received the PCV20 or PCV21 vaccination. Review of R1's document provided by the facility titled Initial Influenza & Pneumococcal Vaccine Administration Acceptance & Declination undated indicated the resident's representative (RR) consented to receive the Prevnar13 (pneumococcal conjugate vaccine) or the Pneurnovax23 (pneumococcal polysaccharide vaccine). The form asked the author to circle a vaccine. Neither of the vaccines were circled. There was no evidence the resident and/or her representative was provided the opportunity to be provided with education regarding the PCV20 or PCV21 vaccines. During an interview on 03/20/25 at 8:51 AM, the Director of Nursing (DON) who was also the facility's Infection Preventionist (IP) confirmed that the facility completed an audit for vaccinations and called and provided education to the RR but was unaware that the consents were inaccurate and did not follow current CDC recommendations.

Based on observation, interview and record review, the facility failed to provide equipment that was in good repair for five of the 35 wheelchairs. Specifically, the wheelchairs had cracked and/or peeling armrests. This failure placed the residents at risk for skin injury. Finding include: Observations conducted on 10/27/2023 at 9:15 am with the Maintenance Director (MD) revealed five of the 35 wheelchairs used by residents had cracked and/or peeling armrests. Interview with the MD on 10/27/2023 at 9:20 am confirmed the cracked and/or peeling armrests on the wheelchairs. MD revealed audits were conducted monthly to determine the need for replacement parts on wheelchairs. Interview with the Administrator on 10/27/2023 at 10:00 am acknowledged the cracked and/or peeling armrests on the wheelchairs and the monthly audit for maintenance needs of the wheelchairs. The facility failed to provide a policy, procedure or the maintenance audit log for wheelchair maintenance.

Based on observation, interviews, and policy review, the facility failed to maintain an effective pest control program was in place, so the facility was free of pests in two of 10 sampled resident rooms (Rooms 307, 508). Findings include: Review of the undated policy, Pest Control Program, revealed the policy of this facility is to maintain an effective pest control program that eradicates and contains common household pests and rodents . Policy Explanation and Compliance Guidelines: 1. Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis. 2. Facility will ensure that appropriate chemicals are used to control pests but can be used safely inside the building without compromising resident health. 3. Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as indicated. Observation on 9/15/22 at 9:16 a.m., a live cockroach was observed crawling around in the upper dresser drawer in Room 307. Observation and interview on 9/15/22 at 9:30 a.m. in Room 307, with the Administrator, upon opening the upper dresser drawer, a roach crawled up and over the side of the drawer. The Administrator acknowledged the roach and stated she would contact the Maintenance Director immediately, so Room 307 could be sprayed for pests. Observation on 9/15/22 at 7:57 p.m. revealed a live, small, brown cockroach in the dresser drawer next to the resident's bed in room 508. The resident was lying in bed at the time of observation and was not able to effectively communicate or state if he was aware of a roach in his dresser drawer. Interview on 9/14/22 at 5:47 a.m., the Maintenance Director stated pest control within the facility has improved since they switched pest control companies approximately one year ago. He stated once the change in companies was made, it took three to four months before an improvement was noticeable. During further interview, he stated when the pest control company came, they sprayed one hall or area at a time. He stated he was talking with the pest control company at the present time for them to come and spray during the night which would allow them to spray the kitchen thoroughly. Interview on 9/15/22 at 9:31 a.m., Resident R#12 stated there are always bugs in my room. Interview on 9/15/22 at 10:10 a.m. with the Social Services Director (SSD), stated that during a recent resident council meeting, the facility encouraged the residents to avoid storing food in their dresser drawers due to it attracting pests. The facility policy is for the administrative staff to notify the maintenance department who then notifies the contracted pest extermination company. The pest control company comes to spray the facility twice weekly. SSD noted to continue to see roaches/pests at least twice weekly in resident rooms, usually crawling on the walls or on the floors. Interview on 9/15/22 at 7:54 p.m. with Licensed Practical Nurse (LPN) A confirmed there had been an issue with roaches throughout the building. LPN A stated the roaches were usually found in the dark areas of the room, especially in the dresser drawers, when the resident's store food in their drawers the roaches multiply. Interview on 9/15/22 at 10:00 p.m., with the Administrator, when questioned about the problem with cockroaches, stated they added pest control to their Quality Assessment Process Improvement (QAPI) Program as a project. The Administrator said this QAPI project included the facility managers completing environment rounds on Thursdays. The Administrator stated the facility staff have provided education to the residents about not keeping open containers of food in their rooms. The Administrator stated the pest control company has changed the pest control solution they were using in an attempt to rid the facility of the pests.

Based on observations, record review, and interviews, the facility failed to provide quality of care related to a staff member sleeping while on duty. This failure had the potential to affect 138 residents who resided in the facility. Findings included: Review of the facility policy titled, Conduct and Behavior revised October 2022, stated 1. Conduct that interferes with the safe operation of .brings discredit to the company, residents or staff, or that is offensive to a resident, family member, visitor, or employee, will not be tolerated and can be grounds for disciplinary action. 2. Examples of conduct and behavior that are considered inappropriate and are prohibited by this company include, but are not limited to, the following . sleeping on the job. Review of the document provided by the facility dated 9/14/22, revealed CNA B was involuntarily terminated as of 9/14/22 and was not eligible for rehire. Additionally, CNA B was hired on 6/19/18, and terminated on 9/14/22 due to sleeping on the job, during work hours. Observation on 9/14/22 at 4:44 a.m., revealed CNA B was observed with her eyes closed, sitting in a chair with her head leaned back on the chair between rooms [ROOM NUMBERS], with a fan blowing on her. Interview on 9/14/22 at 4:44 a.m. with CNA B, after surveyor woke her up, stated, I just dozed off a while ago because I just got done changing five people. CNA B stated she usually worked on that hall, but sometimes staff assignments are rotated to include other halls. Interview on 9/14/22 at 4:50 a.m., Licensed Practical Nurse (LPN) C stated he was not aware of any staff sleeping while on the job. This surveyor notified LPN C that CNA B was found resting with her eyes closed on 9/14/22 at 4:44 a.m. LPN C then spoke with CNA B who denied sleeping with her eyes closed while on duty. LPN C verbalized to CNA B that was against company policy to sleep on the job and that she would need to leave immediately. Interview on 9/14/22 at 8:36 a.m., the Administrator revealed LPN C had informed her when she arrived that CNA B was found sleeping on the job and that she was sent home immediately. The Administrator further stated that the facility was performing in-services to remind staff to not sleep while on the clock. Interview on 9/14/22 at 5:38 p.m., Emergency Medical Technician (EMT) D revealed that on 7/22/22 the nurse on duty was sleeping in the chair at the nurse's station, along with a female staff member in a chair next to him that was sleeping. The complainant was not aware of the names of the staff members that were sleeping. Interview on 9/14/22 at 6:10 p.m., with EMT E stated on 7/22/22 he came to pick up a resident for transport and an unspecified male nurse and an unspecified female staff member were both sleeping at the nurses' station. Interview on 9/15/22 at 10:10 a.m., the Social Services Director (SSD) stated that R#32 recently had come to her and let her know that staff were sleeping out in the hallway outside her door. She stated she gave the information to the Director of Nursing (DON), who provided in-services for the staff. Interview on 9/15/22 at 5:20 p.m., R#32 stated staff frequently sleep outside her room, every night. R#32 stated that at times, she has waited several hours during the night shift, and on one occasion she fell asleep with her call light on and woke up with it still on the next morning. R#32 was not able to recall when this occurred. Interview on 9/15/22 at 9:48 p.m., the Administrator stated that the certified nursing assistants had a 30-minute break during their eight-hour shift. The charge nurse was to designate when each CNA was to take their break. Additionally, the Administrator stated that it was against company policy to sleep while on the clock.

Based on observations, interviews, and policy titled Maintaining a Sanitary Tray Line, the facility failed to ensure a dietary staff member's hair was covered during tray line food preparation and handling to prevent hair contaminations with food. This deficient practice had the potential to affect 138 of 141 residents receiving meals. Findings include: Review of the facility policy titled Maintaining a Sanitary Tray Line dated December 1, 2021, revealed during tray assembly, staff shall: Wear hair restraints (bonnets, caps, nets) to cover hair when preparing or handling food. During a kitchen tour on 3/6/22 between 5:00 p.m. and 5:30 p.m. Cook AA was observed with his hair uncovered while serving meals on the tray line. Interview on 3/9/22 at 12:30 p.m. with Cook AA regarding facility procedure before entering the kitchen. AA confirmed kitchen staff are required to cover their hair before entering the kitchen to serve meals to the residents. Interview on 3/9/22 at 12:37 p.m. with Regional Dietary Director CC regarding kitchen procedure for staff members and he confirmed that staff are expected to cover their hair before entering the kitchen, then wash their hands, and wear gloves depending on task at hand. Interview on 3/9/22 at 12:56 p.m. with Dietary Manager BB who confirmed that staff are expected to cover their hair before entering the kitchen or touch anything. They then should sanitize their hands and put on appropriate person protective equipment (PPE) before prepping or serving food. Interview with the Administrator on 3/9/22 at 12:50 p.m. who confirmed that staff are required to cover their hair before entering the kitchen.

Based on observation, record review, staff interview, and facility policies titled General Guidelines for Administering Medications via Enteral Tube and Nasal Administration the facility failed to ensure the medication error rate was less than 5%. There were 8 errors with 35 opportunities for three of four residents (R) R#35, R#47, and R#135) by two of three nurses observed. For a medication error rate of 22.86%. Facility census was 143. Findings: Review of facility policy titled Nasal Administration effective dated 9/2018 revealed under Procedure 5. Have resident gently blow their nose to remove excess mucous. 8. Use finger of your other hand to close the nostril that is not receiving medication by gently pressing the side of the nostril. Review of facility policy titled General Guidelines for Administering Medications via Enteral Tube dated 9/2018 revised date 8/2020 revealed Procedures 6. Each medication is administered separately to avoid interaction and clumping. The enteral tubing is flushed with at least 15 ml (milliliters) of water between each medication to avoid physical interaction of the medications. 1. Record review of the Order Summary Report revealed Refresh Tears Solution (instill 1 drop in both eyes two times a day for dry eye syndrome) with a start date of 2/21/22. On 3/7/22 at 7:45 a.m. Licensed Practical Nurse (LPN) DD nurse was observed giving R#35 her scheduled morning medications. Eye drops were not in medication cart and were not available in facility for administration to R#35. Interview with LPN DD on 3/7/2022 at 8:05 a.m. revealed that when a medication runs out it is documented in the resident's chart that medication was not available. Further interview revealed that the eye drops for R#35 was not available and was only a floor stock medication and should come in from the pharmacy soon. When asked if the physician would be notified of omitted medication response was I guess I could call him and let him know. 2. Record review of the Order Summary Report revealed [MEDICATION(S)] suspension 50 micrograms (mcg) (spray in both nostrils one time a day for allergy) with a start date of 8/24/21. Observation of nasal spray administration to R#47 on 3/7/22 at 8 a.m. revealed LPN DD did not instruct resident to blow nose before administration of nasal spray. LPN DD also was observed spraying one spray in each nostril without occluded nostril on the opposite side. Interview with LPN DD on 3/7/22 at 8:05 a.m. revealed that when a medication runs out it is documented in the resident's chart that the medication was not available. Further interview revealed that the eye drops for R#35 was not available and was only a floor stock medication and should come in from the pharmacy soon. When asked if the physician would be notified of omitted medication response was I guess I could call him and let him know. LPN DD reported that she did not know that R#35 was supposed to blow nose before administration of the nasal spray. She also denied knowledge of administration of the nasal spray by holding one nostril while administering in the opposite nostril. 3. Record review of the Order Summary Report revealed order to flush peg tube with 30 cc (cubic centimeter) of water before and after medication administration every shift. There also was an order that indicated that medications may be crushed if necessary and appropriate. Observation of G-tube medication administration for R#135 on 3/7/22 at 9:00 a.m. revealed LPN EE washed hands before preparing medications for administration, which consisted of [MEDICATION(S)] 75 milligram (mg) (give one tablet via peg-tube one time a day related to [CONDITION(S)] following cerebral infarction), [MEDICATION(S)] 10 mg (give 1 tablet via peg-tube one time a day related to essential primary hypertension), Losartan 25 mg (give 1 tablet via PEG-Tube one time a day related to essential primary hypertension hold if bp less than 120/65), [MEDICATION(S)] 5mg (give 1 tablet via peg-tube two times a day for muscle spasm), multivitamin tablet (give 1 tablet via peg-tube one time a day for supplementation), [MEDICATION(S)] 100 mg (give 10 ml via peg-tube two times a day related to constipation), [MEDICATION(S)] suspension 100 mg/5ml (milliliters) (give 10 ml via peg-tube two times a day related to conversion disorders with seizures or convulsions), and aspirin tablet 81 mg (give 81 mg via PEG -tube one time a day for pain). After each medication was selected all medications were placed in one silent night crush pouch and crushed together and put in 30 ml of tap water and dissolved. After medications were prepared nurse proceeded to residents' room knocked on the door and asked for permission to enter room. After permission was granted, nurse sanitized her hands with ABH sanitizer and donned clean gloves and proceeded to draw up medication with a sixty-cc syringe to administer to resident. Once medication was drawn up nurse proceeded to push medication into reside g-tube. After medication was administered nurse then proceeded to push 30 ml of tap water through residents g-tube as well. Interview with LPN EE on 3/7/22 at 9:15 a.m. revealed that all medications can be crushed together and administered at the same time. Further interview also revealed that the reasoning for pushing the medication instead of letting medication go in by gravity was because sometimes the medication gets clogged in the tube causing the tube to be clogged up. LPN EE also revealed that some residents have a lot of gas in their stomach which causes the medication not to flow freely and that is why the medication is pushed instead of given by flow of gravity. She confirmed that that there is 30 ml of water that is to be given before and after each medication administration. Interview with DON on 3/7/22 at 11:56 a.m. revealed that during medication administration for g-tube patients that residual should be checked as well as placement of the g-tube. There are parameters that determine that if a resident has a certain amount of residual. Further interview also revealed each medication should be crushed separately and given by flow of gravity. There should also be five ml of water given between each medication administered.

Based on observation, record review, staff interview, and review of the facility policy titled Comprehensive Care Plans the facility failed to implement a care plan for one resident (R) R#32) who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility policy titled Comprehensive Care Plans date implemented 12/1/21 revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative will be documented, as needed. Review of R#32's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R#32's Annual Minimum Data Set (MDS) dated [DATE] revealed: Section C-Cognition: Brief Interview of Mental Status (BIMS) score of 1 indicating very poor cognition; Section G-Functional Status: resident required extensive assistance with bed mobility, total dependence for transfers, eating, toileting, personal hygiene, and bathing; Section I-Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#32's care plans revealed the facility did not complete a care plan for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R#32's Physician's Orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the MDS Coordinator on 3/9/22 at 8:50 a.m. who verified R#32 did not have a care plan in place for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She indicated the Social Worker does the cognitive care plans. An interview held on 3/9/22 at 9:00 a.m. with the Social Worker revealed care plans are updated during clinical meetings when changes occur, resident/family care plan meetings, and daily meetings and as needed. She first indicated the resident R#32 did have a dementia care plan but realized the MDS Coordinator had just put it in. She also indicated it was triggered on section V CAA of the recent MDS. An interview held on 3/9/22 at 9:47 a.m. with the Director of Nursing (DON), who indicated that she expected the residents care plans and assessments to be accurate and reflect the resident's current needs and problems. An interview held on 3/9/22 at 11:32 a.m. with the Administrator revealed she expected the residents' assessments and care plans to be completed according to the schedule. She indicated not all residents who have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It all depends on the BIMs score and the severity of their cognition.

Based on observations, staff interviews, and review of facility policy titled Catheter Care the facility failed to maintain dignity by ensuring a privacy bag was provided for one of six residents (R) R#28 who had an indwelling foley catheter. Findings include: Review of facility policy titled Catheter Care with an implemented date of 12/1/21 revealed the following: Policy Explanation 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. Observation on 3/6/22 at 2:56 p.m. revealed R#28 noted to have catheter urine bag attached to the bedside with tea colored urine drainage in the urine bag. The urine bag was not in a privacy bag. Observation on 3/7/22 at 8:00 a.m. of R#28 revealed catheter urine bag was facing door and there was no privacy bag. Review of R#28 medical record revealed resident was admitted to facility on 2/5/15 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 12/16/21 revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimum Data Set (MDS) Quarterly assessment dated [DATE] section C0500 revealed Brief Interview of Mental Status (BIMS) score of 2 which indicated severe cognitive impairment. During interview on 3/7/22 at 8:00 a.m. with Licensed Practical Nurse (LPN) FF it was reported that R#28's catheter was changed on 3/6/22 at 6 p.m. LPN FF also confirmed that R#28 did not have a privacy bag when the catheter was changed on 3/6/22 or at the time of this interview. Lastly, LPN FF revealed that residents, with catheters, should always have a privacy bag as well as a leg strap. Interview with Director of Nursing (DON) on 3/7/2022 at 9:00 a.m. revealed that all residents that have an indwelling catheter urine bag should be placed in a privacy bag at all times.

Based on observations, resident and staff interviews, and review of the facility policy titled, Maintenance Inspection the facility failed to ensure a clean, comfortable and homelike environment. This was evidenced by spots on walls, missing caulk around the base of toilet, dust build up on air conditioner (AC) filters and vents, and dirt/grime with black spots on AC vents. This was observed on two (300 and 400) of six halls. Findings include: Review of the facility policy titled Maintenance Inspection implemented 12/1/21 revealed: It is the policy of this facility to utilize a maintenance inspection checklist in order to ensure a safe, functional, sanitary, and comfortable environment for resident's, staff and the public. The policy for housekeeping was requested was not received by the time of exit of the survey. Environmental concerns made during resident observations after entrance to facility on 3/6/22 at 1:30 p.m. and 3/7/22 at 10:00 a.m. revealed: 1. Room 314 had red spots on the wall behind bed A, dust buildup on the air conditioner (AC) filters, dirt/grime and dark black spots on the AC vents, dust buildup on air vent in the bathroom, white colored buildup around toilet in the bathroom, and missing caulk around base of toilet. 2. Room 316 had dust buildup on AC filters, dirt/grime and dark black spots on the AC vents, and dust buildup on the air vent in the bathroom. 3. Room 401 had dust buildup on AC filters, dirt/grime and dark black spots on the AC vents, dust buildup on the air vent in the bathroom, and a dried milk type spill on the floor on the far side of bed B. 4. Room 402 had dust buildup on the AC filters, dirt/grime and dark black spots on the AC vents, and dust buildup on the air vent in the bathroom. 5. Room 403 had dust buildup on the AC filters, dirt/grime and dark black spots on the AC vents, and dust buildup on the air vent in the bathroom. 6. Room 404 had dust buildup on the AC filters, dirt/grime and dark black spots on the AC vents, and dust buildup on the air vent in the bathroom. 7. Room 405 had dust buildup on the AC filters, dirt/grime and dark black spots on the AC vents, and dust buildup on the air vent in bathroom. 8. Room 406 had dust buildup on the AC filters, dirt/grime and dark black spots on the AC vents, and dust buildup on the air vent in bathroom. 9. Room 407 had dust buildup on the AC filters, dirt/grime and dark black spots on the AC vents, and dust buildup on the air vent in bathroom. 10. Room 408 had dust buildup on the AC filters, dirt/grime and dark black spots on the AC vents, and dust buildup on the air vent in bathroom. 11. Room 409 had dust buildup on the AC filters, dirt/grime and dark black spots on the AC vents, and dust buildup on the air vent in bathroom. 12. Room 410 had dust buildup on the AC filters, dirt/grime and dark black spots on the AC vents, and dust buildup on the air vent in bathroom. 13. Room 411 had dust buildup on the AC filters, dirt/grime and dark black spots on the AC vents, and dust buildup on the air vent in bathroom. 14. Room 412 had dust buildup on the AC filters, dirt/grime and dark black spots on the AC vents, and dust buildup on the air vent in bathroom. 15. Room 413 had dust buildup on the AC filters, dirt/grime and dark black spots on the AC vents, and dust buildup on the air vent in bathroom. 16. Room 414 had dust buildup on the AC filters, dirt/grime and dark black spots on the AC vents, and dust buildup on the air vent in bathroom. 17. Room 415 had dust buildup on the AC filters, dirt/grime and dark black spots on the AC vents, and dust buildup on the air vent in bathroom. 18. Room 416 had dust buildup on the AC filters, dirt/grime and dark black spots on the AC vents, and dust buildup on the air vent in bathroom. An environmental round was conducted on 3/8/22 at 9:46 a.m. with the Maintenance Supervisor and Housekeeping Supervisor who confirmed the following: 1. In Room 314 there was dust buildup on the air conditioner (AC) filters, dirt/grime and dark black spots on the AC vents, dust buildup on air vent in the bathroom, white colored buildup around toilet in the bathroom, and missing caulk around base of toilet. 2. In Room 401 there was dust buildup on AC filters, dirt/grime and dark black spots on the AC vents, dust buildup on the air vent in the bathroom, and a dried milk type spill on the floor on the far side of bed B. 3. There was dust buildup on the AC filters, dirt/grime and dark black spots on the AC vents, and dust buildup on the air vent in the bathroom for rooms 316, 402, 403, 404, 405, 406, 407, 408, 409, 410, 411, 412, 413, 414, 415, and 416. An interview held on 3/8/22 at 9:46 a.m. with the Maintenance Supervisor revealed maintenance is responsible for cleaning the AC unit filters at least quarterly. He did not have a log indicating when he last cleaned the filters. He further indicated housekeeping is responsible for cleaning the AC vents and the air vents in the bathrooms. An interview held on 3/8/22 at 9:46 a.m. with the Housekeeping Supervisor indicated she expected the house keepers to clean the AC vents and air vents in the bathrooms at least weekly. She verified they were dirty and dusty. She did not have a schedule or documentation of cleaning the AC vents or bathroom vents. An interview held on 3/9/22 at 11:32 a.m. with the Administrator revealed she expected the facility to always be clean.

Based on record review, staff interviews, and review of the facility policy titled, Bed Hold Notice Upon Transfer, the facility failed to provide two residents (R#13 and R#144) reviewed for hospitalization with a written copy of the bed-hold policy upon transfer to the hospital. The sample size was 51 residents. Findings include: A review of the policy titled Bed Hold Notice Upon Transfer dated 12/1/21, revealed at the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and /or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. Policy Explanation and Compliance Guidelines: 2. In the event of an emergency transfers of a resident, the facility will provide withing 24 hours written notice of the facility's bed-hold policies, as stipulated in the State's plan. 1. Review of the medical record for R#13 revealed the resident was transferred from the facility to an acute care hospital on 11/4/21 and 11/19/21. Review of document which indicated verbal notification of the bed hold policy for the hospitalization on [DATE] was dated 11/19/22. Further review of the medical record did not reveal any evidence of written bed-hold information being provided to R#13 or the responsible party for discharges to the hospital on 11/4/21 or 11/19/21. 2. Review of the medical record for R#144 revealed the resident was transferred from the facility to an acute care hospital on 1/6/22. Verbal notification of the bed hold policy was provided on 1/6/22 to the responsible party. Further review of the medical record did not reveal any evidence that written bed-hold information had been provided to R#144 or the responsible party within 24 hours of the emergency discharge to the hospital on 1/6/22. During an interview with the Minimum Data Set (MDS) Coordinator on 3/9/22 at 9:40 a.m. revealed she is informed of the discharges during the morning clinical meetings by the Social Services Director (SSD), but the Business Office Manager (BOM) is responsible for giving residents the bed hold policy. During an interview with the Director of Nursing (DON) on 3/9/22 at 9:50 a.m. it was revealed a bed hold policy is given if a resident is sent to the hospital or out to [CONDITION(S)]. DON stated she is not sure of the bed-hold policy for this facility as she is new to the facility. DON stated she would provide the surveyor with a copy of the facility's bed-hold policy. DON also stated a discharge summary is normally given when a resident is not returning. DON stated there should be some type of communication documented. The DON confirmed that she could not provide evidence that a copy of the bed hold policy was provided to (R#13 or R#144) or their responsible party at the time of transfer. During an interview with the BOM on 3/9/22 at 10:05 a.m. it was revealed the bed-hold policy is given to residents on admission in the admission packet. She stated if someone goes out to the hospital the SSD calls the family to see if they want a bed hold. She stated they do not give a written copy of the bed hold policy upon transfer to the hospital. BOM stated she or the SSD is responsible for making calls to the family via phone and verbally ask if they want a bed hold. BOM further stated R#144 did not have Medicaid. BOM confirmed that a bed-hold policy was not given to (R#13 or R#144) or their responsible party at the time of transfer to the hospital. She stated R#144 only had Medicare. She stated because R#144 had Medicare only he was discharged from the facility the day he was transferred to the hospital. During an interview on 3/9/22 at 11:00 a.m. with the Administrator it was revealed that a bed-hold policy is given upon admission in the admission packet. She stated a bed-hold is not given every time a resident is sent to the hospital. Administrator stated she is responsible for calling families to see if they want a bed hold when resident's transfer to the hospital. She stated bed-hold is automatic for Medicaid. Administrator also stated that they normally don't document on discharges. Administrator confirmed that a bed-hold policy was not given to (R#13 and R#144) or their responsible party at the time of transfer to the hospital. During an interview on 3/9/22 at 11:00 a.m. with the SSD revealed she and/or the BOM is responsible for providing the bed-hold policy to residents and or their responsible party at the time of transfer. SSD stated a written copy of the bed-hold policy is in the admission packet and it is provided to residents and/or their responsible party on admission. SSD confirmed a bed-hold policy is not given to residents or their responsible party at the time of transfer to the hospital.

Based on observation, interview and record review, the facility failed to complete Quarterly Minimum Data Set (MDS) as required by the guidelines in the Resident Assessment Instrument (RAI) for one resident (R) R#1) out of 51 sampled residents. Findings include: Review of the RAI revealed a Quarterly assessment is considered timely if the Assessment Reference Date (ARD) of the Quarterly MDS is within 92 days after the ARD of the previous OBRA assessment (Quarterly, Admission, Annual, Significant Change in Status, Significant Correction to Prior Comprehensive or Quarterly assessment) and the MDS completion date must be no later than 14 days after the ARD. Review of R#1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#1's MDS list revealed the last comprehensive assessment was completed and accepted on 10/5/21. According to the RAI manual a quarterly assessment should been completed 92 days after the last comprehensive assessment. An interview held on 3/8/22 at 10:00 a.m. with the MDS Coordinator revealed she was not working as the MDS Coordinator when R#1's quarterly assessment was due in January 2022 but confirmed that the assessment was not completed. She reported that she has a calendar that she follows that included the assessments that are due. For new residents she opens the program and schedules the assessments that are needed. She reported that she does not print a missing MDS report herself but Corporate will send her a report when an assessment is missing. MDS Coordinator reported that she has not received a missing assessment report since she has returned as the MDS Coordinator. She expressed that she follows the RAI Manual for instruction and policies. An interview held on 3/8/22 at 10:10 a.m. with the Administrator and the Registered Nurse (RN) Nurse Consultant revealed it is the expectation that the MDS assessments are done in a timely manner and the RAI manual is followed.

Based on observation, staff interview, and record review, the facility failed to provide services, related to incontinence care to address pressure sore prevention, as specified by the care plan for one (1) resident (#1), of three (3) residents having pressure sores, on the survey sample of eleven (11) sampled residents. Resident #1 subsequently developed two (2) dime-sized Stage 2 pressure sores. Findings include: Cross refer to F314 for more information regarding Resident #1. Record review for Resident #1 revealed an Annual Minimum Data Set assessment with an Assessment Reference Date of 09/03/2013 which documented, in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. The Care Plan for Resident #1 dated 9/11/2013 identified that the resident was at risk for pressure-sore development, and identified as Approaches to keep the resident as clean and dry as possible, to keep the linens clean and dry, and to provide incontinence care after each incontinent episode. During observation in the day room on 09/21/2013 at 12:00 noon, Resident #1 was noted to have a strong urine odor. A later interview, conducted on 09/21/2013 at 2:35 p.m., with Certified Nursing Assistant (CNA) "EE" revealed that this CNA had changed Resident #1's brief around 1:00 p.m., at the request of a nurse. Interview with Charge Nurse "FF" on 09/21/2013 at 2:40 p.m. revealed that Resident #1 been in the day room the entire morning, and that the nurse had to ask CNA "EE" to change Resident #1 at 1:00 p.m., when she smelled a urine odor. During a 09/21/13, 2:42 p.m. observation with Nurse "FF" and Nurse "GG" in attendance, even though Resident #1's diaper was dry after having been changed around 1:00 p.m., the draw sheets under the resident were still saturated with urine, and two Stage 2 pressure sores were observed on the resident's buttocks. During a 09/21/2013, 3:10 p.m. observation with the Wound Manager/Assistant Director of Nursing in attendance, this nurse acknowledged that the two dime-sized pressure ulcers on the resident's buttocks were new. Based on the above, Resident #1, the facility failed to provide pressure sore prevention in conformance with the Care Plan, which specified the provision of incontinence care as necessary for the prevention of pressure sores. The resident was subsequently noted to have two newly-developed dime-sized Stage 2 pressure sores on the buttocks.

Based on observation, staff interview, and record review, the facility failed to ensure that one (1) resident (#1), of three (3) sampled residents having pressure sores, on the survey sample of eleven (11) residents, received the necessary care to prevent pressure sore reoccurrence. This failure resulted in harm for Resident #1, who developed two dime-sized Stage 2 pressure sores after the failure to provide timely incontinence care. The findings include: Record review for Resident #1 revealed an Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date of 09/03/2013 which documented, in Section C - Cognitive Patterns, that the resident had a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. Section I - Active [DIAGNOSES REDACTED]. Section H - Bladder and Bowel documented that the resident was always incontinent of both bowel and bladder, and Section G - Functional Status documented that the resident was totally dependent on staff for toilet use. Section M - Skin Conditions of this MDS documented that at the time of the assessment, the resident had no unhealed pressure sores, but that the resident did have a history of Stage 2 pressure sores. Further record review for Resident #1 revealed no documented evidence of any current pressure sores. During an observation conducted in the day room on 09/21/2013 at 12:00 noon, Resident #1 was observed to be seated in a geri-chair, and a strong urine odor was noted at that time. During a later observation of Resident #1 conducted in the resident's room on 09/21/2013 at 2:24 p.m., the resident was observed in bed. A strong urine odor was noted upon entering the room, which was even stronger at the resident's bedside. During an interview with Certified Nursing Assistant (CNA) "EE" conducted on 09/21/2013 at 2:35 p.m., this CNA stated that he had changed Resident #1's brief just before the resident's lunch tray arrived around 1:00 p.m., at the request of a nurse who had indicated that the resident smelled. The CNA stated that when the nurse asked him to change Resident #1, that was when he had changed the resident. During an interview with Charge Nurse "FF" conducted on 09/21/2013 at 2:40 p.m., Charge Nurse "FF" stated that Resident #1 had eaten breakfast in the dining room that morning at around 7:30 a.m., and that the resident had then been taken back directly to the day room after breakfast, then had remained there for the entire morning. Charge Nurse "FF" acknowledged that she had asked CNA "EE" to change Resident #1 at 1:00 p.m., when she had smelled an overpowering urine odor in the day room. During an observation of Resident #1 with Nurse "FF" and Nurse "GG" conducted on 09/21/13 at 2:42 p.m. in the resident's room, Resident #1's diaper was dry, however, the draw sheets under the resident were observed to be saturated with urine. These nurses said it appeared that CNA "EE" had changed the resident's brief during the earlier incontinence care, but did not change the wet draw sheets. Additionally, it was noted, and acknowledged by both nurses during the observation, that two open pressure sores were located on Resident #1's buttocks. During a 09/21/2013, 3:10 p.m. observation of Resident #1 with the Wound Manager/Assistant Director of Nursing in attendance, two dime-sized Stage 2 pressure ulcers were observed on the resident's buttocks. During an interview with this nurse conducted at the time of this observation, she stated that these two pressure ulcers were new. She further stated that CNAs were supposed to report new open skin areas to the charge nurse. Based on the above, Resident #1, who was incontinent of both bowel and bladder, had been placed in the day room for the entirety of the morning of 09/21/2013 without receiving incontinence care until approximately 1:00 p.m., by which time the resident was noted by nursing staff to have an overpowering urine smell. Upon observation at 2:42 p.m. on that date, the resident was noted to have two newly-developed dime-sized Stage 2 pressure sores on the buttocks.