Every finding on record at Stonecrest Healthcare

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 54.Review of the facility's policy titled, Dietary - Receiving and Storing Food and Supplies, revised June 2023, showed: Do not accept and return to the supplier, any item that is: Not what was ordered, dented, rusty, damaged cans;Dented or bulging cans shall be placed on Damaged Goods Shelf and returned for credit;All products shall be dated upon receipt or when they are prepared, use date shall be marked on all food containers according to the timetable in the Dry, Refrigerated and Freezer Storage Chart found in this section;Storage area shall be easily accessible for receiving new items, the walls, ceiling, and floor shall be maintained in good repair and regularly cleaned, the area should be well lit and ventilated, the temperature shall be in the range of 50 degrees Fahrenheit ( F) to 70 F;Shelving shall be sturdy and provided with a surface which is smooth and easily cleaned. Shelving shall be mounted at least 6 inches (in.) from the floor and 18 in. from the ceiling;All foods shall be stored away from the walls and off the floor;Any opened products shall be placed in seamless plastic or glass containers with tight-fitting lids or Ziploc bags. Open products may also be sealed utilizing plastic film or tape;Label and date all storage containers as follows, the received date should already be on it, date opened, date the item expires;Check for pest infestation regularly. There shall be a monthly pest control program in place. Review of the facility's policy titled, Dietary - Equipment Operations, Infection Control, and Sanitation Policy, revised February 2024, showed: The dietary staff shall maintain the sanitation of the Dietary Department through compliance with written, comprehensive cleaning schedules developed for the facility by the Dietary Manager;All surfaces and equipment shall be washed with a sanitizing solution;After each meal remove debris and rinse interior of machine, wipe exertion of machine, dry and polish with cloth;Weekly clean dish machine interior and exterior with de-liming solution;The concentration of the sanitary solution during the rinse cycle is 200 parts per million (ppm) on low temperature dish machines;Cleanup dishwasher and sanitize counter areas, walls and all dish room work areas sink exterior, legs, make certain all equipment is turned off, water drained, dish room is clean and sanitized before leaving outside of dish machine, spray all areas of dish machine's exterior and all pipe areas with de-liming solution let stand for 10 minutes, scrub stainless steel, scrub pipes with green scouring pad, rinse exterior and pipe areas thoroughly with clear water, dry surface with clean cloth and apply stainless steel polish;Garbage and trashcans, all food waste must be placed in covered garbage and trash cans;Ice machine sanitation of equipment, wash exterior of machine daily, use sanitizing solution and clean cloth, allow to air dry, remove ice and wash inside machine monthly, use sanitizing solution and clean cloth allow to air dry;Wipe down microwave oven daily inside with special attention to inside of oven door to provide adequate seal to prevent microwave leakage;Wipe up spills on shelves, sides, and floor of refrigerator daily;Walls and ceilings must be free of chipped and/or peeling paint;Walls and ceilings must be washed thoroughly at least twice a year, heavily soiled surfaces must be cleaned more frequently and as required, it is important to repair peeling paint areas as soon as they appear, the type of surface will determine the type of detergent and cleaning method, painted walls and ceilings shall be washed with a mild detergent solution, rinsed using a clean cloth, and dried to eliminate streaking; ceramic tile, stainless steel, and other surfaces must be cleaned according to product. 1. Observation on 07/28/25 at 10:00 A.M., and 07/29/25 at 2:00 P.M., of the kitchen showed:Water temperature checked at 100 F and not within the accepted range of no less 110 F at the three compartment manual dishwashing sinks; Room temperature of 84 F;Sewer gas odor near the reach-in refrigerators and staff bathroom;Commercial dishwasher liquid did not register on the chemical test strip; A window air-conditioner unit with approximately 1 in. by 2 foot (ft.) unsealed gaps around three edges;The floor below the reach-in freezer, reach-in refrigerator, range, and ice machine with scattered debris, oily film, and brown grime;The ice machine with a white build up on the exterior surfaces and black grime on the interior plastic surface;The commercial style can opener with an oily film on the blade;The reach-in refrigerator with scattered food debris on the food shelves;The microwave oven interior with food debris build-up and a 1 in. diameter chipped surface along the top surface;The dishwasher with white build up on the exterior surfaces;The floor and plumbing pipes below the dishwashing area counters and three compartment sinks with scattered debris, oily film, and brown grime build-up;One rolling cart with four uncovered trays of individual dessert gelatin bake cups;Three trays contained 28 uncovered individual milk and lemonade cups;Four approximately 12 in. x 12 in. ceiling diffuser (one of the few visible parts of an air conditioning system) with dust buildup and a brown substance on the front exterior surfaces near the food shelves;A f4 ft. cracked plastic light fixture cover above the steam table;A 4 in. non-intact wall section without a baseboard. 2. Observation on 07/28/25 at 10:10 A.M., and 07/29/25 at 2:10 P.M., of the dry food storage area showed:A 3 quart (qt.) fruit pie filling can with a 3 in. dent near the bottom edge, dated 10/20/24 and received 07/09/25; An opened 25 pound (lb.) cardboard box of instant food and beverage thickening powder, dated 07/16/25, with an unsealed plastic liner lay on the food shelf approximately 4 in. off the floor;A partially full 5 gallon (gal.) clear plastic storage bin with oatmeal, undated or labeled, lay on the metal shelving;Scattered food debris lay on the floor and along the walls below the food shelves;An opened and loosely folded 50 lb. brown paper sack with oatmeal, dated 07/06/25, lay less than 4 in. from the floor on the bottom food shelf;Painted wooden shelves with scuffed and peeled surfaces, scattered food debris, and a bottom shelf approximately 4 in. above the floor. During an interview on 07/29/25 at 2:40 P.M., the Maintenance Director said he/she was aware of the sewer gas odor in the kitchen and used drain cleaner on the floor drain in the staff restroom. The dishwasher currently was not working properly, and the service company had been called to make repairs. The air conditioner thermostat was not showing an accurate room temperature, and it was closer to 84 degrees in the kitchen. The air conditioner repair service would replace the thermostat, but the vents were blowing cold air and would need to be cleaned. The wall section near the can opener would need to be repaired, and there was grime build up on the floor that would need to be cleaned. During an interview on 07/29/25 at 3:00 P.M., the Dietary Manager said he/she was aware of the sewer gas odor near the back of the kitchen it has been a problem since pipes were backed up in the winter. The air conditioner has not been cooling the kitchen down very well and the floors will need to be cleaned. The individual foods should not be left uncovered and there should not have been a dented food can or unlabeled foods in the dry storage, but it may have been overlooked. The refrigerator and ice machine should have been kept clean. During an interview on 07/29/25 at 3:15 P.M., the Administrator said the dishwasher should be serviced, there should not be an odor in the kitchen, and it was possibly coming from the drain pipes. The dry storage should have better storage containers that were labeled, and the walls should be intact and in good repair with baseboards. The lighting cover should be repaired, and vents needed to be cleaned. The appliances and the floor areas below the appliances should be clean and the refrigerator should not have food debris on the lower shelves. There needed to be more deep cleaning scheduled. The kitchen area air conditioner should have been working properly.

Based on interview and record review, the facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program to include and infection surveillance program and antibiotic use protocols. This deficient practice had the potential to affect all residents in the facility. The facility census was 54Review of the facility's policy titled, Antibiotic Stewardship Program, last reviewed 06/29/23, showed:-To optimize antibiotic use in our nursing home and reduce unnecessary use of laboratory tests and antibiotics using a systematic approach;-This Facility Antibiotic Stewardship Program (ASP) will comply with all State and federal laws and regulations;-The Facility will track and monitor antibiotic prescribing practices and resistance patterns among its residents;-The Facility Antibiotic Steward will review and generate the Infection Log in the Point Click Care (PCC - an electronic medical record and charting program);-The Facility Antibiotic Steward will review and audit the Infection Log weekly in PCC and ensure that each field of the Infection Entry including orders pertaining to the infection, and treatments pertaining to the infection are completed accurately;-The Antibiotic Utilization Report will be used to collect and track antibiotic usage. Each antibiotic start date for a resident will be listed in the database. Some residents may have more than one entry if they have had more than one course of antibiotics during the month. The information included in the Antibiotic Utilization Report is: resident name, antibiotic name, indication for antibiotic, route of administration, dose of antibiotic, prescribed length of antibiotic course (days), prescriber, and prescribing facility;-Additionally, the Facility Antibiotic Steward will track the following: antibiotic time-outs, recommended actions for evaluation of ongoing treatment needs, interventions for syndrome-specific antibiotic use and antibiotic prophylaxis, and multi-drug-resistant infections.Review of the facility's Infection Control binder showed:-No documentation of infection surveillance for 2024 or 2025.Review of facility's Matrix (a listing of all facility residents), dated 07/28/25, showed:-Two residents currently received antibiotics.Review of the facility's PCC Infection Surveillance log, dated 07/01/24 - 07/31/25, showed:-No infection type documented for 169 out of 184 entries;-No infection site documented for 166 out of 184 entries;-No signs and symptoms documented for 167 out of 184 entries;-No precautions documented for 173 out of 184 entries;-No organisms documented for 183 out of 184 entries;-No lab documentation.During an interview on 07/31/25 at 7:45 A.M., the Director of Nursing (DON)/Infection Preventionist said all of the required documentation should be included in the antibiotic stewardship and the tracking of infections. During an interview on 07/31/25 at 4:00 P.M., the Administrator said it was expected that all of the required parts of the antibiotic stewardship be documented.

Based on interview and record review, the facility failed to maintain the surety bond (a purchased bond for security of residents' personal funds) for at least one and one half times the average monthly balance of the residents' personal funds for the last twelve consecutive months from July 2024 to June 2025. The facility census was 54.Review of the facility's policy titled Resident Trust, revised 06/12/25, showed:-The facility shall provide assurance of financial security by means of a surety bond;-The bond shall be in an amount equal to at least one and one half times the average total of the reconciled monthly balances;-A copy of the current bond shall be kept in a file in the facility by the Resident Trust Clerk.Review on 07/30/25 of the Residents' Personal Funds Account for the last twelve consecutive months from July 2024 to June 2025 showed:-The facility's current approved bond amount equaled $52,000.00;-The average monthly balance for the residents' personal funds equaled $127,499.59;-An average monthly balance of $127,499.59 required a bond of at least $190,500.During an interview on 07/31/25 at 2:07 P.M., the Business Office Manager (BOM) said the surety bond should be one and one half times the amount of the average resident trust balance. The bond amount should have already been raised. During an interview on 07/31/25 at 2:25 P.M., the Administrator said the surety bond amount should be one and one half times the amount of the average resident trust balance to meet the regulatory requirement. It was currently too low.

Based on observation, interview, and record review, the facility failed to use proper infection control techniques during incontinent care for three residents (Residents #2, #3, and #39) out of three sampled residents, and during catheter (a flexible tube inserted into the bladder to drain urine) care for two residents (Residents # 4 and #5) out of two sampled residents. The facility failed to provide appropriate documentation of tuberculosis (TB - an infectious bacterial disease that affects the lungs) testing for five residents (Residents #1, #2, #7, #10, and #45) out of five sampled residents. The facility census was 54. Review of the facility's policy titled, Infection Prevention and Control Program, dated 06/26/24, showed: The purpose is to have established and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections; Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures; All staff shall use personal protective equipment (PPE) according to established facility policy. Review of the facility's policy titled, Glove Utilization, dated 05/18/24: The purpose of this procedure is to provide guidelines for the use of gloves to prevent the spread of infection and disease to residents and employees; Wash hands after removing gloves; Use gloves when touching excretions, secretions, blood, body fluids, mucous membranes, or non-intact skin. Review of the facility's policy titled, Hand Hygiene, dated 06/24/24, showed: The purpose is to perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors; Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of antiseptic hand rub; Staff will perform hand hygiene when indicated, using proper technique consistent with acceptable standards of practice; If your task requires gloves, perform hand hygiene prior to putting on gloves, and immediately after removing gloves; Hand hygiene should be done between resident contacts, after handling contaminated objects, before applying and after removing PPE, before and after handling clean or soiled dressings and/or linens, before performing resident care procedures, when during resident care moving from a contaminated body site to a clean body site, and after assistance with personal body functions. Review of the facility's policy titled, Catheter Care, revised 06/26/24, showed: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use; Care for females: Gently separate the labia (the outer folds that surround the opening of the vagina) to expose the urinary meatus (the opening of the female urethra (the tube that lets urine leave your bladder and your body). Wipe from front to back with a clean cloth moistened with water and perineal cleaner. Use a new part of the cloth or different cloth for each side. With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter. Dry area with a towel; Care for males: Gently grasp the penis, draw the foreskin back if applicable. Using a circular motion, cleanse the meatus with a clean cloth moistened with water and perinea! cleaner. With a new moistened cloth, starting at the urinary meatus moving down, cleanse the shaft of the penis. With a new moistened cloth, starting at the urinary meatus moving outward, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter. Dry area with a towel; Completing care: Bag and gather all supplies used, discarding disposable items in the trash can. Assist the resident to a comfortable, appropriate position. Ensure call light is within reach. Return room back to the original order. Perform hand hygiene. Review of the facility's policy titled, Tuberculosis Testing, revised 06/29/23, showed: To ensure each resident of the facility is tested for TB after entering the facility to prevent the spread of infection; Upon admission and readmission, each resident will receive a two step purified protein derivative (PPD - type of skin test for TB) skin test as ordered by the physician. Each resident will also have an annual one step TB test as ordered by the physician to ensure that any possible infections can be triggered proactively to prevent further spread. If the resident has not been hospitalized for the year, they will receive a signs and symptoms checklist to monitor for communicable diseases; All TB tests and chest x-ray records will be kept on file in the residents records. Review of 19 CSR 20-20.100 Tuberculosis Testing for Residents and Workers in Long-Term Care Facilities and State Correctional Centers, revised 01/29/23, showed: For Long-Term Care Residents: Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a Mantoux (type of PPD test) PPD two-step tuberculin test. If the initial test is negative, zero to nine millimeters (mm), the second test, which can be given after admission, should be given one to three weeks later. Documentation of a chest x-ray evidence ruling out tuberculosis disease within one month prior to admission, along with an evaluation to rule out signs and symptoms compatible with infectious tuberculosis, may be accepted by the facility on an interim basis until the Mantoux PPD two-step test is completed; All residents of long-term care facilities who are exposed to a case of infectious tuberculosis or who develop signs and symptoms which are compatible with tuberculosis disease shall be medically evaluated. All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. Review of the Division of Community and Public Health, Section 2.0 Testing for Latent Tuberculosis Infection, revised May 2020, showed: Interpretation of Tuberculin Skin Test (TST) reactions should be conducted within 48 to 72 hours after administration by a trained health care professional. If the test is not read within the 48 to 72 hour window, it must be repeated; Patients or family members should not interpret or read TST results. 1. Review of Resident #1's medical record showed: admitted on [DATE]; Annual TB Screening, dated 03/16/25, TST administered with a result of negative 0.0 mm and no read date. 2. Review of Resident #2's medical record showed: admitted on [DATE]; Annual TB Screening, dated 03/31/25, administered with a result of negative 0.0 mm and no read date; Annual TB Screening, dated 04/11/25, administered with a result of negative 0.0 mm and no read date. 3. Observation on 07/29/25 at 11:05 A.M., of Resident #2's incontinent care and Hoyer lift (a mechanical lift) showed: Certified Nursing Assistant (CNA) C and CNA A did not perform hand hygiene and put on gloves; CNA C cleaned the resident's right groin fold twice with the same area of the wash cloth; CNA C cleaned the left groin fold twice with same area of the wash cloth; CNA C did not change gloves, did not perform hand hygiene, and rolled the resident to his/her side; CNA A cleaned the resident's buttocks; CNA C and CNA A changed gloves and did not perform hand hygiene; Registered Nurse (RN) F entered the room, did not perform hand hygiene, put on gloves, and applied Calmoseptine (a moisture barrier) to the resident's open area on the buttocks and coccyx (the small triangular bone at the base of the spinal column), removed gloves, did not perform hand hygiene, and exited the room; CNA A and CNA C transferred the resident from the bed to the geri chair (a large padded chair with wheeled bases) via a Hoyer lift; CNA A and CNA C removed gloves and performed hand hygiene. 4. Observation on 07/30/25 at 1:31 P.M., of Resident #3's incontinent care and Hoyer transfer showed: CNA D and CNA E performed hand hygiene, put on gloves, and transferred the resident from the wheelchair to the bed via a Hoyer lift (a mechanical device used to move or transfer a person). A pillow lay in the seat of the wheelchair saturated with urine and a large area of yellow discoloration on the pillowcase. The front and rear of the resident's pants saturated with urine from the waistband to the lower thigh area with a strong urine odor; CNA D pulled the resident's urine saturated pants down both of his/her legs, changed gloves, and performed hand hygiene; CNA E unfasted the urine saturated brief, changed gloves, and performed hand hygiene; CNA D gave the resident a wet washcloth in his/her right hand, the resident wiped the top of his/her peri area with a back-and-forth motion with the same area of the wash cloth, the resident gave the soiled wash cloth to CNA D. CNA D gave the resident a second washcloth, the resident wiped the same area of his/her peri area with a back-and-forth motion with the same area of the wash cloth, the resident gave the soiled wash cloth to CNA D. CNA D and CNA E did not assist/perform hand hygiene for the resident. CNA D did not change gloves and did not perform hand hygiene; CNA D and CNA E assisted the resident to turn to the left side and the resident touched CNA D's shirt on the shoulder and side with his/her right hand; CNA E cleaned the resident's right buttock, didn't change gloves, didn't perform hand hygiene, touched the resident to roll him/her to his/her other side, cleaned the resident's left buttock, removed the urine saturated brief and urine soiled incontinent pad, did not change gloves, did not perform hand hygiene, touched the resident's sheet and blanket to cover him/her; CNA D and CNA E did not clean the resident's pelvic, groin, and peri areas, the lower extremities and the lower back where the urine and/or urine saturated items touched skin; CNA E removed gloves, did not perform hand hygiene, touched the doorknob of the room to exit, took the trash to the barrel in the hall, did not perform hand hygiene, entered the staff break room, perform hand hygiene, retrieved clean linen from the cart in the hall; CNA D removed gloves, did not perform hand hygiene, tied bags containing soiled linens and trash, exited the room, took the soiled linen to the barrel in the hall, did not perform hand hygiene, retrieved a clean brief from the hall cart; CNA D and CNA E entered the resident's room, performed hand hygiene, and put on gloves; CNA E turned the urine saturated pillow in the wheelchair over to the dry side of the pillow with a large area of yellow discoloration on the pillowcase, did not change the urine saturated pillowcase, did not clean and dry or change the pillow in the seat of the wheelchair, did not change gloves, and did not perform hand hygiene; CNA E put on a clean brief and pants on the resident, did not change gloves, and did not perform hand hygiene; CNA D and CNA E transferred the resident from the bed to the wheelchair via a Hoyer lift; CNA E did not change gloves, did not perform hand hygiene, touched the resident's blanket to cover him/her up, retrieved the resident's hat and placed it on his/her head, touched the wheelchair handles, and propelled the resident in the wheelchair to the dining room for activities, removed gloves and performed hand hygiene; CNA D removed gloves and performed hand hygiene. 5. Observation on 07/28/2025 at 11:06 A.M., of Resident #4's of catheter care showed: CNA A and CNA C put on gloves and gowns, did not perform hand hygiene, entered the room, and lowered the resident's pants and the brief; CNA A did not perform hand hygiene, did not change gloves, used a wipe to clean the resident's suprapubic (a type of indwelling catheter) catheter tubing with a twisting motion from the insertion point down the catheter, cleaned the skin at the catheter insertion site with a clean wipe, changed gloves, and did not perform hand hygiene; CNA C did not change gloves, did not perform hand hygiene, removed multiple wipes from the package, used a wipe to clean the resident's buttock, used another wipe to clean the buttock again, did not clean the peri area, removed gloves, did not perform hand hygiene, touched the bathroom door knob, did not perform hand hygiene, put on gloves, moved the catheter drainage bag from the bed frame to the top of the mattress; CNA A used a wipe to clean the left groin area; did not clean the pubic area, the right groin, or the peri area; did not change gloves; and did not perform hand hygiene; CNA A and CNA C pulled the resident's brief and pants back up into place, did not change gloves, and did not perform hand hygiene; CNA C moved the catheter drainage bag from the mattress to the side pocket of CNA A's scrub pants; CNA C and CNA A removed gloves and did not perform hand hygiene; CNA A transferred the catheter drainage bag from his/her scrub pant pocket to the bar under the wheelchair seat with his/her bare hands, did not perform hand hygiene, removed trash and soiled linen from the room, placed in the appropriate barrels in the hall, went to the linen cart on a different hall, retrieved a clean incontinent pad, did not perform hand hygiene, entered the resident's room, placed the clean incontinent pad on the bed, and made the bed; CNA C touched the wheelchair handles, propelled the resident in the wheelchair to the dining room, knocked on the kitchen door with his/her bare hand, touched the doorknob to the kitchen, did not perform hand hygiene, entered the resident's room, did not perform hand hygiene, walked to the clean linen cart in the hall, and touched the netting that covered the linen cart, 6. Observation on 07/29/25 at 9:27 A.M., of Resident #5's catheter care and transfer showed: CNA A and CNA B put on gowns and gloves and did not perform hand hygiene; CNA B placed the resident's catheter drainage bag on the floor without a privacy bag; CNA B picked up the catheter drainage bag and hooked it onto CNA A's scrub pants; CNA A and CNA B transferred the resident from the wheelchair to the bed; CNA A and CNA B unfastened the resident's brief and removed his/her pants; CNA B removed gloves, did not perform hand hygiene, wet wash clothes, and put on gloves; CNA B wiped the resident's right groin fold, left groin fold, and perineal area, did not change gloves, and did not perform hand hygiene; CNA B then cleaned the resident's catheter from the insertion point down twice with the same area of the wash cloth; CNA B removed gloves and gown, did not perform hand hygiene, left the room, got a brief, entered the room, did not perform hand hygiene, did not put on a gown, and put on gloves; CNA B removed the urine soiled brief and put it in the trash; CNA A and CNA B removed gloves, did not perform hand hygiene, and exited the room. 7. Review of Resident #7's medical records showed: admitted on [DATE]; Annual TB Screening, dated 02/23/25, administered with a result of negative 0.0 mm and no read date; Annual TB Screening, dated 03/31/25, administered with a result of negative 0.0 mm and no read date. 8. Review of Resident #10's medical record showed: admitted on [DATE]; Annual TB Screening, dated 03/16/25, administered with a result of negative 0.0 mm and no read date. 9. Observation on 07/29/25 at 11:34 A.M., of Resident #39's incontinent care showed: CNA A and CNA C put on gloves and did not perform hand hygiene; CNA C unfastened the resident's brief; CNA A unfastened the brief soiled with fecal material, did not change gloves, and did not perform hand hygiene; CNA C cleaned fecal material from the resident's buttocks with the same area of the wipe soiled with fecal material multiple times, retrieved another wipe and cleaned fecal material from the buttocks with same area of the wipe soiled with fecal material two times, retrieved another wipe and wiped the buttocks two times with same area of the wipe, changed gloves, did not perform hand hygiene, and placed a clean brief under resident; CNA C pulled the brief soiled with fecal material through the front of the resident's legs and placed it in a trash bag, did not change gloves, and did not perform hand hygiene; CNA A used a clean wipe to clean the left groin area, changed gloves, and did not perform hand hygiene; CNA C used a clean wipe to clean the left groin soiled with fecal material multiple times with same area of the wipe, retrieved another wipe to clean the left groin area soiled with fecal material again with multiple times with the same area of the wipe, gloves soiled with fecal material, cleaned the peri area, changed gloves, did not perform hand hygiene, and touched the wipe package; CNA A used a clean wipe to clean the right side of the groin and the peri area with the same wipe, changed gloves, did not perform hand hygiene, and did not clean the pubic area; CNA C put on a clean brief and shorts on the resident, changed gloves, and did not perform hand hygiene; CNA C wiped the wheelchair cushion off with a clean wipe, did not change gloves, and did not perform hand hygiene; CNA A removed gloves, did not perform hand hygiene, touched the doorknob to exit the room, retrieved an incontinent pad for the wheelchair seat, did not perform hand hygiene, entered the room, and put on gloves; CNA A and CNA C transferred the resident from the bed to the wheelchair; CNA C removed gloves and did not perform hand hygiene; CNA A removed the trash bag from the trash can, removed gloves, did not perform hand hygiene, exited the room with bags of trash and soiled linens to the barrels in the hall, entered the shower room, and performed hand hygiene; CNA C propelled the resident in the wheelchair to the dining room, entered the shower room, and performed hand hygiene. 10. Review of Resident #45's medical records showed: admitted on [DATE]; No documentation the two step TST was administered. During an interview on 07/30/25 at 2:18 P.M., CNA D said hand hygiene should be performed before and after resident care, and in between residents. Sanitize hands and change gloves anytime gloves were soiled during incontinent care. When performing incontinent care, the brief was removed, clean the front, front to back, clean the groin, and the inner thighs. Clean anywhere there was incontinence. Perform hand hygiene and change gloves when moving to a new area. If the resident's seat cushion was soiled, it should be sanitized and dried before the resident was put back into the seat. If the seat cushion was wet, remove and replace the cushion with a clean, dry cushion. If a resident assisted with their own incontinent care, make sure the resident cleaned their self properly, and/or ask to make sure they were clean. If the resident refused, report to the nurse. Always offer the resident to perform hand hygiene with care, wash hands at the sink, a wet washcloth, or sanitizer. During an interview on 07/30/25 at 2:30 P.M., Registered Nurse (RN) N said he/she would expect hand hygiene to be completed before and after resident care and in between residents, and for gloves to be changed and hand hygiene to be performed when hands were soiled. Residents should not be sat on soiled or wet cushions or pillows, and residents should be offered hand hygiene after care. During an interview on 07/31/25 at 7:45 A.M., the Director of Nursing (DON) said hand hygiene should be done when entering a resident room, going from dirty to clean care, with glove changes, and upon completion of care. Gloves should be put on when entering a room for care, when soiled or going from one area to another or dirty to clean, and removed at the end of care. TST should be completed as a two step for residents on admission. The TST should be read 72 hours after admission and documented with the read date and result. Then another TST was administered 10 days afterwards. Residents receive an annual TST and signs and symptoms completed. A catheter should be cleaned from insertion point down and a new section of a cloth or a new cloth should be used with each wipe. During an interview on 07/31/25 at 4:00 P.M., the Administrator said she expects hand hygiene and glove changes to be done correctly. It was expected that TST be documented with read dates and completed per policy.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the insect population in the facility. The facility census was 54.Review of the facility's policy titled, Pest Control Program Policy, revised 05/14/24, showed:It is the policy of this facility to maintain an effective pest control program (measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitoes, flies, mice and rats) that eradicates and contains common household pests and rodents;Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis;Facility will ensure that appropriate chemicals are used to control pests but can be used safely inside the building without compromising resident health;Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as indicated;Facility will utilize a variety of methods in controlling certain seasonal pests, i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations;Facility will ensure that the outside pest service also treats the exterior perimeter of the facility and any outlying buildings or structures Review of the facility's Pest Control Invoices, dated 2025, showed:No service invoices for January, May, and June;February, March, and April services targeted roaches;July with an initial service with a new service provider;No documentation services targeted flies.Review of the facility's Pest Control documentation showed:No documentation of a system or log for staff to report pest activity. Observations on 07/28/25 at 10:00 A.M., and 1:27 P.M., and on 07/29/24 at 2:46 P.M., of the kitchen showed 12 roaches crawled and six flies flew around in the kitchen food preparation area, under the three-compartment sink, near the dishwashing liquid containers, and near a non-intact wall section beside the can opener and plastic utensil drawers. During an interview on 07/28/25 at 10:40 A.M., Dietary Aide (DA) G said the kitchen had several issues that should be addressed, including roaches that had been a problem near the dishwasher.During an interview on 07/28/25 at 11:32 A.M., DA H said he/she saw roaches in the kitchen for the last three days and the Dietary Manager (DM) was made aware of the problem.During an interview on 07/28/25 at 11:38 A.M., DA I said he/she saw roaches in the kitchen for the last couple of weeks and the DM was made aware of the problem. The kitchen was sprayed but the bugs came back. Observations on 07/28/25 at 11:55 A.M., 07/29/25 at 1:27 P.M., and 07/30/25 at 9:16 P.M., of the 300 Hall and the unit dining area showed:One dead fly stuck to the ice dispenser and 12 flies flew around the room and landed on tables, residents, and resident food trays. During an interview on 07/30/25 at 9:15 P.M., Certified Nursing Assistant, (CNA) J said nursing was verbally advised about the flies or bugs in the facility and there was no monthly reporting system or pest log to report the bugs. Flies were common on the unit hall and rooms. During an interview on 07/30/25 at 9:20 P.M., CNA K said there was no monthly reporting system or pest log to report bugs, but nursing was informed about the flies. It was not uncommon to see flies in the 300 Hall and the unit dining area, hallway, and the resident rooms. The residents went outside to smoke, and the open door let the bugs in the building.During an interview on 07/30/25 at 1:45 P.M., Nursing Assistant (NA) L said there were always flies in the 300 Hall and the unit dining area during meals and they used a fly swatter once per shift. The let maintenance know about the flies but there was no log to report pests. During an interview on 07/30/25 at 1:49 P.M., CNA B said usually a fly swatter was used once per shift because the flies were always in the 300 Hall and the unit dining area, but they did seem worse today. During an interview on 07/30/25 at 2:10 P.M., the resident in room [ROOM NUMBER] said the flies were frustrating during meals and other activities in the dining area. During an interview on 07/30/25 at 2:15 P.M., the resident in room [ROOM NUMBER] said the flies were frustrating during meals and they were always in the dining area and in the hall. Observation of rooms [ROOM NUMBERS] on 07/29/25 at 11:59 A.M., and 07/30/25 at 1:37 P.M., showed:Six flies flew around the rooms and landed on the privacy curtains and the floor. During an interview on 07/30/25 at 1:37 P.M., the resident in room [ROOM NUMBER] said flies were a problem in the room and made it hard to sleep. The flies were also frustrating during meals, and it felt like nothing helped.During an interview on 07/30/25 at 1:50 P.M., the resident in room [ROOM NUMBER] said that the flies were always in the room and they were frustrating. The flies landed on the bed and on the privacy curtain and flew around the room and dining area during meals. During an interview on 07/29/25 at 2:40 P.M., the Maintenance Director said he/she was told by kitchen staff there were roaches and flies so it was sprayed about two weeks ago. There hadn't been any other complaints about the roaches or other bugs since then. During an interview on 07/29/25 at 3:00 P.M., the DM said he/she was aware of roaches and flies in the kitchen but had not noticed them crawling in and out of the non-intact wall in the kitchen. He/She told maintenance about the problem of the roaches in the kitchen and the kitchen had been sprayed a couple weeks ago.During an interview on 07/29/25 at 3:15 P.M., the Administrator said there should not be flies on the halls or in the dining areas. The facility had been sprayed and there should not be roaches in the kitchen and dishwashing areas. It was apparent the bugs were still a problem.

Based on observation, interview, and record review, the facility failed to ensure a urinary indwelling catheter (a tube inserted into the bladder to drain urine) drainage bag was maintained in the proper position of above the bladder for two residents (Residents #4 and #5) and the facility failed to ensure a catheter drainage bag had a privacy cover for one resident (Resident #5) out of two sampled residents. The facility also failed to ensure one resident (Resident #3) received appropriate treatment and services after an incontinent episode which left the resident in a urine saturated brief with a strong urine odor out of three sampled residents who were incontinent of bladder. The facility census was 54. Review of the facility's policy titled, Catheter Care, revised 06/26/27, showed:It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use;Catheter care will be performed every shift and as needed by nursing personnel;Privacy bags will be available and catheter drainage bags will be covered at all times while in use;Ensure the drainage bag is located below the level of the bladder to discourage backflow of urine. 1. Review of Resident #3's medical record showed:admitted on [DATE];Diagnoses of intracranial injury with loss of consciousness (a brain injury that caused by an outside force with loss of consciousness), quadriplegia (paralysis caused by illness or injury that results in the loss of the use of all limbs and the torso), cerebral infarction (stroke), lack of coordination, muscle weakness, UTI, hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness). Review of the resident's Physician Order Sheet (POS), dated July 2025, showed:An order for Macrobid (an antibiotic medication) 100 milligram (mg) by mouth two times a day related to urinary tract infection for seven days, dated 07/26/25. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated process for clinical assessment of all residents in certified nursing homes), dated 07/18/25, showed:Dependent for toileting hygiene and personal hygiene;Always incontinent of bowel and bladder. Review of the resident's Care Plan, dated 07/13/25, showed:History of UTI's and recurring UTI's with interventions of check the resident at least every two hours for incontinence and PRN; Wash, rinse, and dry soiled areas; Monitor/document/report to the physician PRN for signs/symptoms of UTI;Potential impairment to skin integrity due to incontinent of bowel and bladder and immobility with interventions of identify/document potential causative factors and eliminate/resolve where possible;Bladder incontinence with interventions of clean the peri area with each incontinent episode. Observation on 07/30/25 at 1:31 P.M., of the resident's incontinent care showed:CNA D and CNA E performed hand hygiene, put on gloves, transferred the resident from the wheelchair to the bed via a Hoyer lift (a mechanical device used to move or transfer a person), a pillow saturated with urine with a large area of yellow discoloration on the pillow case sat in the seat of the wheelchair, and the front and rear of the resident's pants saturated with urine from the waist band to the lower thigh area with a strong urine odor;CNA D and CNA E performed incontinent care for the resident;CNA D turned the pillow in the wheelchair seat over to the dry side and with a large area of yellow discoloration on the pillow case;CNA D and CNA E did not change the urine saturated pillow case and did not clean and dry or change the pillow in the wheelchair seat;CNA D and CNA E transferred the resident from the bed to the wheelchair via the Hoyer lift and covered the resident with a blanket. During an interview on 07/30/25 at 2:10 P.M., Resident #3 said he/she was not checked or changed since staff got him/her up this morning before breakfast. Staff changed him/her but did not know how often. 2.Review of Resident #4's medical record showed:admitted on [DATE];Diagnoses of inflammatory disease of the prostate (a frequently painful condition that involves inflammation of the prostate and sometimes the areas around the prostate), gross hematuria (blood in the urine), and urinary tract infection (UTI - a condition in which bacteria invade and grow in the urinary tract). Review of the resident's POS, dated July 2025, showed:An order to change the supra pubic catheter (a hollow flexible tube inserted into the bladder through an incision in the abdomen to drain urine) and urinary drainage bag with a 24 French (size) catheter with 30 milliliter (ml) balloon every evening shift starting on the 19th and ending on the 19th every month related to inflammatory disease of the prostate, dated 06/05/25; An order for a supra pubic catheter change as needed (PRN) for leaking or blockage, dated 04/16/24. Review of the resident's quarterly MDS, dated [DATE], showed:Indwelling catheter; Always incontinent of bowel;Dependent for toileting hygiene. Review of the resident's Care Plan, dated 05/12/25, showed:Has inflammatory disease of the prostate and gross hematuria and utilizes a supra pubic catheter;Interventions of monitor/document for pain/discomfort due to the catheter and monitor/record/report to the physician for signs/symptoms of UTI. Observation of the resident showed: On 07/28/2025 at 11:10 A.M., the resident sat in a wheelchair in the dining room and eight inches (in.) of catheter drainage tubing lay on the floor under the wheelchair with a privacy cover in place;On 07/30/2025 at 8:50 A.M., the resident lay in bed and four in. of catheter tubing lay on the floor with a privacy cover in place. Observation on 07/29/25 at 11:06 A.M., of the resident's transfer showed: Certified Nurse Assistant (CNA) C unhooked the catheter drainage bag from the bed frame and put it on top of the mattress near resident's feet; CNA C picked up the catheter drainage bag from the bed, held the catheter drainage bag above resident's bladder, and hooked the catheter draining bag onto CNA A's pant pocket to assist the resident to sit on the side of the bed;CNA A removed the catheter drainage bag from his/her pant pocket and hooked the drainage bag under the resident's wheelchair seat with a privacy cover in place and six in. of catheter tubing lay on the floor and the catheter tubing also touched the right front wheel of the wheelchair;CNA C propelled the resident in the wheelchair from his/her room, though the hallway, and to the dining room while the catheter tubing drug the floor under the wheelchair. 3. Review of Resident #5's medical record showed:admitted on [DATE];Diagnosis of urine retention. Review of the resident's POS, dated July 2025, showed:An order to change the Foley catheter (a type of indwelling catheter) and urinary drainage bag monthly on the 24th of every month and PRN with an 18 French 30 ml balloon, dated 06/24/25.Review of the resident's admission MDS, dated [DATE], showed: Indwelling catheter;Required assistance for toileting and transfers. Review of the resident's Care Plan, dated 07/21/25, showed:Urinary catheter due to bladder retention. Position the catheter bag and tubing below the level of the bladder;Activities of daily living (ADLs) deficit and dependent for toileting. Observation of the resident's catheter drainage bag and tubing placement showed:On 07/28/25 at 11:08 A.M., the resident sat in a wheelchair in the dining room and 18 in. of catheter tubing lay on the floor with no privacy bag;On 07/29/25 at 8:12 A.M., the resident sat in a wheelchair in the hall outside of the dining room and six in. of catheter tubing lay on the floor with the drainage bag covered with a privacy cover; On 07/29/25 at 9:25 A.M., the resident sat in a wheelchair in the dining room and six in. of catheter tubing lay on the floor and the catheter bag with the spout rested on the floor. The privacy drape did not cover the bottom of the catheter drainage bag which allowed the bottom and the spout of the drainage bag to rest on the floor. Observation on 07/29/25 at 9:27 A.M., of the resident's transfer showed:CNA A unhooked the catheter drainage bag, put it on the floor where the bottom of the catheter bag touched the floor, and the drainage bag was not covered by a privacy bag;CNA A picked up the catheter drainage bag and hooked it onto CNA B's pant pocket;CNA A and CNA B transferred the resident from the wheelchair to the bed;CNA B unhooked the catheter drainage bag from his/her pocket, held the drainage bag above his/her waist height which was also above the resident's bladder, and hung the catheter drainage bag on the bed frame. During an interview on 07/29/25 at 5:33 P.M., CNA C said catheter care should be completed from insertion point down the catheter, and the drainage bag should not be above the resident's bladder. During an interview on 07/29/25 at 5:42 P.M., CNA B said the catheter drainage bag should not be above the resident's bladder or on the bed. The catheter drainage bag and tubing should not be on the floor. During an interview on 07/30/25 at 2:18 P.M., CNA D said when performing incontinent care, if the wheelchair cushion was soiled, it should be cleaned, sanitized, and dry before the resident was placed back in the chair. If the seat cushion was wet, remove it, and replace it with a dry one. If the resident assisted with cleaning him/herself, make sure the resident cleaned their self properly, or ask to make sure everything was clean. If the resident refused, report it to the nurse. During an interview on 07/31/25 at 7:45 A.M., the Director of Nursing (DON) said catheter drainage bags and tubing should never touch the floor. Catheter drainage bags should always stay below the resident's bladder and be covered. Incontinent residents should be checked at least every two hours and more if needed. During an interview on 07/31/25 at 4:15 P.M., the Administrator said catheter drainage bags and tubing should never touch the floor and the catheter bag should never be above the resident's bladder level and the drainage bag should have a privacy cover. Incontinent residents should be checked at least every two hours or per their care plan.

Based on interview and record review, the facility failed to provide the correct Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms and failed to complete and notify in the proper time frame, at least two calendar days before services ended, for the SNF ABN and the Notice of Medicare Non-Coverage (NOMNC) forms for two residents (Residents #9 and #11) out of three sampled residents whose Medicare services ended and remained in the facility. The facility census was 54. The facility did not provide a policy regarding SNFABN. 1. Review of Resident #9's medical record showed:- The resident discharged from Medicare skilled services on 02/28/25, and remained in the facility;- The facility provided the resident with the ABN and the NOMNC forms on 02/28/25;- The facility failed to issue the correct SNFABN form to the resident;- The facility failed to provide the SNFABN and the NOMNC to the resident at least two calendar days before the skilled Medicare services ended. 2. Review of Resident #11's medical record showed:- The resident discharged from Medicare skilled services on 05/09/25, and remained in the facility;- The facility provided the resident with the ABN and the NOMNC forms on 05/09/25;- The facility failed to issue the correct SNFABN form to the resident;- The facility failed to provide the SNFABN and the NOMNC to the resident at least two calendar days before the skilled Medicare services ended. During an interview on 07/31/25 at 1:00 P.M., the Business Office Manager (BOM) said the previous Social Service Designee (SSD) did not do doing things correctly. There was a new SSD in training now. During an interview on 07/31/25 at 1:10 P.M., the SSD said he/she was new and still in training. During an interview on 07/31/25 at 4:00 P.M., the Administrator said she would expect the correct form to be used and the forms to be provided in the correct time frame.

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) when medications were administered. There were 32 opportunities with two errors made, for an error rate of 6.25%. This practice affected two residents (Residents #7 and #15) of five sampled residents. The facility census was 54.Review of the facility's policy titled, Medication Administration, last revised 06/26/24, showed: Medications are administered by licensed nurses, or staff who are legally authorized to do so in this state, as ordered by the physician, and in accordance with professional standards of practice;Compare medication source with medication administration record (MAR) to verify resident name, medication name, form, dose, route, and time;Report and document any adverse side effects or refusals;Correct any discrepancies and report to nurse manager. 1. Review of Resident #7's medical record showed:- Diagnoses of chronic obstructive pulmonary disease (COPD - condition caused by damage to the airways or other parts of the lung), nontraumatic subdural hemorrhage (collection of blood between the brain and its outer covering that occurs without a significant head injury), generalized anxiety disorder (mental health condition characterized by excessive and persistent worry), lack of coordination, and vascular dementia (decline in thinking skills caused by conditions that reduce or block blood flow to the brain, leading to brain damage). Review of the resident's August 2025 Physician Order Sheet (POS), showed: An order for oxybutynin chloride (medication used to treat an overactive bladder) extended release (ER) 10 milligram (mg) by mouth one time a day, dated 07/29/25. Observation on 7/30/25 at 9:50 A.M., of the resident's medication administration showed:Certified Medical Technician (CMT) D failed to administer oxybutynin chloride ER 10 mg to the resident. 2. Review of Resident 15's medical record showed:Diagnoses of COPD, major depressive disorder (a mental health condition characterized by persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in activities), generalized anxiety disorder, fibromyalgia (chronic condition characterized by widespread musculoskeletal pain, fatigue, and other symptoms), and osteoarthritis (a common degenerative joint disease that affects the cartilage and surrounding tissues in the joints). Review of the resident's August 2025 POS showed: An order for fluticasone furoate-vilanterol (a COPD medication) inhaler 200/25 microgram (mcg) one puff inhaled orally one time a day and to rinse mouth after use, dated 10/14/24.Observation on 7/30/25 at 8:55 A.M., of the resident's medication administration showed:CMT D failed to administer fluticasone furoate-vilanterol 200-25 mcg inhaler one puff to the resident. During an interview on 07/30/25 at 11:00 A.M., CMT D said for Resident #7, the oxybutynin chloride ER 10 mg medication order was and the new dosage hadn't been delivered from the pharmacy. Resident #15's fluticasone furoate-vilanterol inhaler 200/25 microgram (mcg) one puff medication order hadn't been delivered from the pharmacy. Resident #15's medication hadn't been given as ordered for two weeks and had not been reported to the Director of Nursing (DON). During an interview on 07/30/25 at 11:15 A.M., the DON said she was unaware of any medications not being available for the residents as per the physician orders and would expect this to be done. During an interview on 07/31/25 at 4:20 P.M., the Administrator said she would expect all medications to be at the facility and to be administered as per physician orders.

Based on interview and record review, the facility failed to provide written information to the resident and/or the resident's representative for the ombudsman (resolves complaints for residents of long term care facilities) contact information, the contact information for the agency responsible for protective and advocacy of individuals with mental disorders, contact information for the protection and advocacy of individuals with development disabilities, and appeal information for two residents (Residents #20 and #45) out of two sampled residents. The facility's census was 54.Review of the facility’s policy titled, “Resident Transfer/Discharge, Immediate Discharge, and Therapeutic Leave, dated 04/25/25, showed: Purpose is to establish a policy and procedure regarding the transfer/discharge of residents. To ensure no inappropriate discharges are made and that no discharges are made in an unsafe manner; Residents who are sent emergently to the hospital are considered transfers because the resident’s return is generally expected; Notification of resident and resident representative with the reason for the transfer or discharge in writing should occur; The notice should include: reason for transfer/discharge; effective date; location to which resident is going; resident’s right to appeal, name, address, email and number of the long-term care ombudsman office; for residents with development disabilities the mailing address, email, and the telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities; and for residents with mental disorders related to a disability the mailing address, email, and the telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder. 1. Review of Resident #20’s medical record showed: admitted on [DATE]; The resident transferred to the hospital on [DATE], with a return anticipated; No documentation the facility provided the written information to the resident and/or the resident's representative of the ombudsman's contact information, the contact information for the agency responsible for the protective and advocacy of individuals with mental disorders, the contact information for the protection and advocacy of individuals with development disabilities, and the appeal information. During an interview on 07/31/25 at 11:45 A.M., the Business Office Manager (BOM) and the Social Services Designee (SSD) said the discharge paperwork should include all the required information. The nurses had been using the form in the electronic medical record but it did not have the appeal, ombudsman, or other required information. During an interview on 07/31/25 at 4:00 P.M., the Administrator said the discharge paperwork did not include all of the required information, but it should. 2. Review of Resident #45’s medical record showed: admitted on [DATE]; The resident transferred to the hospital on [DATE], with a return anticipated; No documentation the facility provided the written information to the resident and/or the resident's representative of the ombudsman's contact information, the contact information for the agency responsible for the protective and advocacy of individuals with mental disorders, the contact information for the protection and advocacy of individuals with development disabilities, and the appeal information. During an interview on 07/31/25 at 10:45 A.M., the Administrator said there was not a transfer/discharge notification form for Resident #45.

Based on interview and record review, the facility failed to limit the use of an as needed (PRN) psychotropic (medications that affect mental processes and behaviors) medication orders for 14 days unless specific duration and clinical rationale were provided for two residents (Residents #2 and #6) out of two sampled residents. The facility census was 54. Review of the facility's policy titled, Use of Psychotropic Medication Policy, dated 06/26/24, showed:- Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s);- PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days)- If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order.1. Review of Resident #2's July 2025 Physician Order Sheet (POS) showed:- Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), anxiety (persistent worry and fear about everyday situations), vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain) with behavioral disturbance, and schizoaffective disorder (a condition characterized by abnormal thought processes and deregulated emotions) bipolar type (a mental disorder that causes unusual shifts in mood). - An order for lorazepam (an antianxiety medication) 2 milligram (mg)/milliliter (ml) one mg by mouth every four hours PRN for anxiety, shortness of breath, dated 07/18/25, and with no stop date;- An order for lorazepam 0.5 mg by mouth every six hours PRN for agitation/anxiety, dated 06/07/25, and with no stop date.Review of the resident's medical record showed:- No documentation for a greater than 14 day time frame rationale for the lorazepam PRN orders;- The facility failed to provide a 14 day stop date for the lorazepam PRN orders. 2. Review of Resident #6's July 2025 POS showed:- Diagnoses of Alzheimer's disease (progressive mental deterioration), nontraumatic subdural hemorrhage (bleeding in the area between the brain and the skull), insomnia (difficulty sleeping), major depressive disorder (long-term loss of pleasure or interest in life), suicide attempt, panic disorder (a sudden episode of intense fear that triggers severe physical reactions when there is no real danger or apparent cause), and bipolar disorder; - An order for lorazepam 2 mg/ml 0.125 ml by mouth every four hours PRN for anxiety/ agitation, dated 03/13/25, and with no stop date;- An order for diazepam (an antianxiety medication) 5 mg by mouth every six hours PRN for anxiety, dated 04/14/25, and with no stop date. Review of the resident's medical record showed:- No documentation for a greater than 14 day time frame rationale for the lorazepam and the diazepam PRN orders;- The facility failed to provide a 14 day stop date for the lorazepam and diazepam PRN orders.During an interview on 07/31/25 at 7:30 A.M., the Director of Nursing (DON) said all PRN psychotropic medications should have a 14 day stop date or a clinical rationale for a longer prescription period. During an interview on 07/31/25 at 4:00 P.M., the Administrator said all PRN psychotropic medications should have a 14 day stop date. The physician should provide a clinical rationale for an extended order time frame.

Based on observation, interview and record review, the facility failed to ensure staff utilized safe transfer techniques for two residents (Residents #4 and #39) when staff failed to use a Hoyer lift (a mechanical device used to move or transfer a person) out of three sampled residents and to use a gait belt (a canvas belt placed around the resident's waist to assist with ambulation and transfers) appropriately when transferring one resident (Resident #39) out of one sampled resident. The facility failed to ensure quarterly smoking assessments were completed per facility policy for one resident (Resident #39) out of two sampled residents. The facility census was 54. Review of the facility's policy titled Precautionary Measures for Gait Belt Application and Usage, Revised 06/29/23, showed: The purpose of this policy is to ensure precautionary and safe measures are taken during the application and use of gait belts; Safe usage of a gait belt can prevent potential risk of injury to residents that could be caused by pulling on their arms, shoulders and wrists during ambulation, transfers or repositioning; Safety Measure: Never transfer any resident by lifting them under their arms. Avoid the axillary area on the resident as this has the potential to cause nerve damage, shoulder dislocation, bruising, pain and fractures; Never attempt to transfer a resident independently that cannot bear weight. A mechanical device/lift must be used in the plan of care for the resident that cannot bear weight; Application of gait belt: The gait belt will be applied over the resident's clothing to avoid skin discomfort or irritation by excessive pressure or pinching of skin; The gait belt is to be applied around the resident's waist below the ribs securely so that staff may grasp the belt which will prevent the belt form sliding above the resident's waist. The gait belt buckle should be fastened securely in the front, away from the mid line. Review of the facility's policy titled Fall Risk Assessment Policy, revised 04/30/24, showed: It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents; The risk assessment will be completed by the nurse or designee upon admission, quarterly, or when a significant change is identified; The risk assessment will contain the following components: Identify environmental hazards and individual risks, including the need for supervision; Evaluate and analyze hazards and risks; An At Risk for Falls care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly; The At Risk for Falls care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident; Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice. Review of the facility's policy titled Smoking Safety Regulations, revised 06/29/23, showed: The purpose of this policy is to ensure that all staff and residents are following the safety regulations for smoking as outlined by the Life Safety Code of the National Fire Protection Association and State and Federal Regulations; The facility will follow all smoking regulations. 1.Review of Resident #4's medical record showed: An admission date of 12/16/23; Diagnoses of heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs), muscle weakness, lack of coordination, and weakness. Review of the resident's quarterly Minimum Data Set (MDS - part of a federally mandated process for clinical assessment of all residents in certified nursing homes), dated 05/09/25, showed: Severely impaired cognition; Lower extremity functional impairment on both sides for range of motion (ROM); Dependent for oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, chair/Bed to chair transfer; Substantial/Maximal assistance for roll left and right, sit to lying, lying to sitting on side of bed. Review of the resident's Care Plan, dated 05/12/25, showed: High risk for falls related to confusion, gait/balance problems, and incontinence. Interventions of: anticipate and meet the resident's needs, assess the resident for appropriate clothing to ensure clothing worn fits appropriately and will not aide in possible fall; Fall on 02/11/25, with laceration to the head due to falling asleep in the wheelchair, was sent to the emergency room for evaluation and diagnosed with a urinary tract infection (UTI). Interventions: When resident is showing signs/symptoms weakness and fatigue immediately monitor for a UTI; Usually present when resident is showing those signs/symptoms; Educate when feeling tired or fatigue to inform staff and staff to assist him/her to bed to rest; First aide and treatment/order for laceration to the head; Review information on past falls and attempt to determine cause of the falls; Record possible root causes; Remove any potential causes if possible; Educate resident/family/caregivers/interdisciplinary team (IDT) as to causes; Did not address how staff was to transfer the resident. Review of the resident's quarterly Assistive Devices and Care List, dated 02/25/25, showed: Manual wheelchair; Limited/Non-weight bearing to left and right; Contractures; Resident on the Total Dependent list. Review of resident's Progress Note dated 07/28/25, showed: Contractures noted to bilateral legs, arms, and fingers. Observation on 07/29/25 at 11:06 A.M., of the resident's transfer from the side of bed to the wheelchair showed: Certified Nursing Assistant (CAN) A and CNA C did not put a gait belt around the resident's waist; CNA A and CNA C placed their forearms under the resident's axillary areas; CNA A and CNA C held onto the back waistband of the resident's pants with their other hands, and lifted the resident from the bedside, pivoted the resident while holding the resident upright by the axillary areas and waistband, drug his/her feet on the floor due to the resident did not bear weight, and placed the resident into the wheelchair seat. 2. Review of Resident #39's medical record showed: admission date of 04/28/25; Diagnoses of hemiplegia (paralysis of one side of the body) affecting right dominant side, scoliosis (an irregular curvature of the spine), traumatic brain injury (TBI - a brain injury that is caused by an outside force, that affects the way the brain works), unsteadiness on feet, abnormal posture, muscle weakness, contracture (shortening and hardening of muscle, tendon, or tissue) of right shoulder, contracture of right elbow, contracture of right wrist, contracture of right hand, and tobacco use. Review of the resident's admission MDS, dated [DATE], showed: No current tobacco use. Review of the resident's quarterly MDS assessment, dated 07/05/25, showed: Moderate cognitive impairment Functional limitation impairment for ROM of one side for the upper extremities and both sides for the lower extremities; Used a wheelchair; Partial/Moderate assistance for eating, oral hygiene, roll left and right, Substantial/Maximal assistance for toileting hygiene, Dependent for personal hygiene; sit to lying, lying to sit on side of bed, chair/bed-to-chair transfers. Review of the resident's Care Plan, dated 05/21/25, showed: Activity of Daily Living (ADL) self-care performance deficit related to fatigue, hemiplegia, impaired balance, scoliosis, wheelchair use, and assistance with transfers and ADLs; Interventions of bed mobility: The resident is totally dependent on one to two staff for repositioning and turning in bed and as necessary; Interventions for contractures: The resident has contractures of the right wrist, right hand, and right ankle. Provide skin care when needed to keep clean and prevent skin breakdown; Interventions for toilet use: The resident is totally dependent on one to two staff for toilet use. Incontinent of bowel and bladder; Interventions for transfer: The resident is totally dependent on two staff for transferring; Did not address how to transfer the resident; Did not address the resident smoked with interventions. Review of the resident's Fall Risk Evaluation, dated 07/15/25, showed: Intermittent confusion; Chairbound and continent; Balance problem while standing and walking; High risk for falls. Observation on 07/29/25 at 11:34 A.M., of the resident's transfer from the wheelchair to bed and from the bed to the wheelchair showed: Resident sat in a wheelchair at the side of the bed; CNA C wrapped the gait belt around the resident's lower chest loosely and did not tighten; CNA C and CNA A each looped one arm underneath the resident's axillary areas, CNA A held the gait belt at the resident's back with his/her other hand, CNA C grabbed the waistband of the resident's pants and the gait belt and pivoted the resident to sit on the side of the bed, the resident's right foot did not turn, CNA C reached down with his/her hand and turned the resident's right foot, and CNA C and CNA a assisted the resident to lay back in bed with the gait belt around the resident's waist; CNA A and CNA C performed incontinent care; CNA C assisted the resident to sit on the side of the bed; With gait belt loosely wrapped around the resident's upper abdomen, CNA C and CNA A looped one arm each underneath resident's axillary areas, CNA C and CNA A grabbed the waistband of the resident's pants with their other hands, raised the resident from the side of the bed, and placed the resident into the wheelchair at the bedside; CNA C removed the gait belt from the resident. Observations of the resident smoking showed: On 07/29/25 at 8:32 A.M., the resident sat in a wheelchair in the smoking area and an ashtray sat on his/her arm table attached to the right arm of the wheelchair. CNA C walked up to the resident's right side, picked up the ashtray from the arm table, held the ashtray up to the resident's chest, and the resident tapped the cigarette in his/her left hand on the side of the ashtray. CNA C returned the ashtray to the attached arm table, the resident smoked the cigarette to the filter. CNA C readjusted the small pillow at the resident's right side to position the resident upright when he/she leaned to the right side while smoking. When the resident was finished smoking, CNA C lifted the ashtray to the resident from the arm table, the resident placed the cigarette butt into the ashtray, and CNA C placed the ashtray on a table. The resident did not wear a smoking apron or utilize any smoking interventions; On 07/30/25 at 1:30 P.M., the resident sat in a wheelchair in the smoking area. Staff lit the resident's cigarette lit by staff and an ashtray was given to the resident by staff. The resident smoked the cigarette with 1 1/2 inches of ash on it. The resident tried to tap the ash into the ashtray but it missed and landed on the plastic arm rest of the arm table that sat between the ashtray and the resident's right arm. The Resident blew the 1 1/2 inch of ash away from his/her arm and asked staff for help. Staff flicked the ash off of the plastic arm rest and onto the ground. The Resident smoked the cigarette to the filter and and put it in the ashtray that sat on the plastic covered arm rest of the table. Staff removed the ashtray from the resident's arm table. The resident did not wear a smoking apron or utilize any smoking interventions. During an interview on 07/29/25 at 8:45 A.M., Resident #39 said he/she did not use a smoking apron during smoke breaks. Staff just sat with him/her. Sometimes the ashes fell off the end his/her cigarette and the staff moved them away. During an interview on 07/29/25 at 8:50 A.M., CNA C said Resident #39 never used a smoking apron. He/She just stood near the resident and held the ashtray up when needed, and made sure the resident was sat up good, because he/she leaned to that right side. During an interview on 07/29/25 at 5:33 P.M., CNA C said he/she thought Resident #39 needed a smoking apron but the resident pulled it off when he/she tried to put one on before. Residents were care planned for smoking aprons if needed. The gait belt should be positioned above/at the resident's hip when applied. During an interview on 07/29/25 at 5:42 P.M., CNA B said gait belts were to be positioned around the resident below the breast, above the belly button, with just enough room to put fingers under it to raise them up. If a resident couldn't bear weight, don't use the gait belt. He/She would sit them back down. During an interview on 07/31/25 at 2:02 P.M., Certified Occupational Therapist Assistant (COTA) O said Resident #39 should be transferred via a Hoyer lift (a mechanical lift) at this time. The resident resided at the facility in the past and was a two-person transfer, but the resident had put on weight, weaker, and leaned more than he/she did last time they were at the facility. COTA O educated staff to use the small pillow to prop the resident up on his/her right side. The therapy staff always used a gait belt if a resident was to be assisted, even if they were ambulatory. When a new resident admitted to the facility, the physical therapist would evaluate them for a method of transfer. If a resident was non-weight bearing, they should be a Hoyer lift transfer. If a resident declined, the nurse would usually let the physical therapist know they needed re-evaluated. During an interview on 07/31/25 at 7:45 A.M., the DON said a gait belt should be used on any resident that required assistance to stand or ambulate. The gait belt should be under the breast line and tight enough you could get your hand under it. Ambulation and transfer ability was assessed upon admission and put in the report and admission notes. There should be a quarterly evaluation that addressed ambulation and transfers. Part of the floor training was how a resident transferred and that was done by the floor leader. Care plans should be individualized and include transfer method, falls, smoking and everything a resident needed. Nurses did the smoking assessments on admission and quarterly. During an interview on 07/31/25 at 3:45 P.M., the Administrator said that it was expected that staff know how residents transfer. Gait belts should be used anytime a resident required assistance and should be used correctly. Smoking assessments should be done quarterly and reflect the resident's needs for safety.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This deficient practice had the potential to affect all residents. The facility census was 60. Review of the facility's policy titled, Resident Food Storage, revised 07/05/23, showed: - The purpose of this policy is to ensure that resident's food storage is safe with sanitary, handling and consumption; - Food items will be dated after opening. Observations made on 03/26/24 at 9:44 A.M. and 03/26/24 at 11:47 A.M. of the kitchen standup freezers, showed: - A large opened bag of frozen rolls/biscuits undated and not labeled; - Three bags of miscellaneous frozen breaded patties undated and not labeled; - A large opened bag of frozen egg omelets undated; - A large bag of frozen meatballs undated; - A large opened bag of frozen cinnamon rolls undated; - A large bag of pepperoni slices undated. During an interview on 03/26/24 at 11:02 A.M., the Dietary Manager (DM) said he/she would expect all foods to be labeled and dated prior to consumption. He/She was not aware there were food items without a date or a descriptive label in the stand up freezers. During an interview on 03/27/24 at 10:17 A.M., Dietary Cook A said he/she would expect all foods to be labeled and dated prior to consumption. During an interview on 03/27/24 at 11:32 A.M., the Administrator said he would expect the DM and kitchen staff to have all foods labeled and dated prior to consumption.

Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year, failed to provide the required annual competencies of Dementia Care (care of a resident with an impaired ability to remember, think, or make decisions) or Abuse Prevention for one out of two nurse aides sampled. The facility census was 60. 1. Review of the facility's 2023 in-service records showed: - Certified Nurse Aide (CNA) F with a hire date of 01/09/2022; - CNA F attended a total of one hour and 15 minutes of in-services; - CNA F did not attend an annual competency in-service on Dementia Care or Abuse and Neglect. During an interview on 03/28/2024 at 10:26 A.M., the Director of Nursing (DON) said he would be responsible for monitoring the in-services for all staff. The facility did not provide a policy.

Based on interview and record review, the facility failed to provide and document that residents received or declined appropriate immunizations and failed to provide and document pertinent education to residents or resident's representative regarding benefits, side effects or warnings of those immunizations for four residents (Residents #3, #18, #28, and #163) out of the five sampled residents. The facility's census was 60. Review of the facility's policy titled, Influenza and Pneumococcal Immunizations, revised on 6/30/23, showed: - The purpose of this policy is to ensure that all residents residing in the facility are offered influenza and pneumococcal immunizations to prevention infection and the spread of communicable diseases; - The resident or resident representative will be provided education on benefits and potential side effects of both the Influenza and Pneumococcal Immunization; - The resident or representative will be told the Influenza Immunizations are provided yearly (between October 1 and March 31) unless the immunization is medially contraindicated; - The resident or representative will be told the Pneumococcal Immunization will be offered upon admission and a second Pneumococcal Immunization may be recommended after five years from the first immunization; - The resident or representative will be asked to sign the revolving consent form attached to this policy; - The consent/refusal form will include documentation to support that the resident or their legal representative is fully informed and educated on the benefits and potential side effects of the immunizations; - Physicians orders will be obtained for the immunizations unless medically contraindicated or the resident or their legal representative has refused the immunizations; - The resident's clinical record will document: a. The resident or their legal representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations; b. The resident either received the influenza and pneumococcal immunizations or did not receive them due to medical contraindication or refusal. 1. Review of Resident #3's medical record showed: - admitted [DATE]; - Resident signed revolving consent for refusal of Influenza and Pneumococcal signed and dated 12/14/23; - Physicians' Order for annual influenza and pneumococcal vaccination dated 1/16/24; - No documentation of refusal or education for the influenza or pneumococcal vaccination. 2. Review of Resident #18's medical record showed: - admitted [DATE]; - No record of legal representative consent for Influenza and Pneumococcal vaccination; - Physicians' Order for annual pneumococcal and influenza vaccination dated 2/19/24; - No record of annual flu vaccination; - No documentation of refusal or education for the influenza vaccination; - No record of pneumococcal vaccination; - No documentation of refusal or education for the pneumococcal vaccination. 3. Review of Resident #28's medical record showed: - admitted [DATE]; - Legal representative signed consent for Influenza and Pneumococcal signed and dated 3/1/19; - Documentation of refusal of influenza and pneumococcal vaccinations undated; - No documentation of education for the influenza or pneumococcal vaccinations. 4. Review of Resident #163's medical record showed: - admitted [DATE]; - Physicians' Order for annual influenza vaccination dated 3/14/24; - No record of annual flu vaccination; - No documentation of refusal or education for the influenza vaccination. During an interview on 03/27/24 at 02:01 P.M., the Facility Corporate Nurse said he/she would expect administration or refusals for Influenza and Pneumococcal Vaccinations to be completed for each resident yearly and documented under the immunizations tab of the Electronic Medical Record (EMR). During an interview on 03/28/24 at 09:53 A.M., the Director of Nursing (DON) said he/she would expect residents to be offered a flu shot annually and refusals to be documented in the medical record. During an interview on 03/29/24 at 12:12 P.M., the Administrator said he/she would expect Influenza and Pneumococcal Vaccinations to be offered yearly.

Based on observation, interview, and record review, the facility failed to limit the use of an as needed (PRN) order for antipsychotic medication (a medication to treat a mental disorder characterized by a disconnection from reality) to 14 days for one resident (Resident #10) out of 15 sampled residents. The facility census was 60. Review of the facility's policy titled, PRN Antipsychotic and Psychotropic Medications, dated 06/29/2023, showed: - The purpose of the policy and guidelines regarding the use of prn medications orders for psychotropic and antipsychotic drug classifications; - PRN orders for Anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication; - Antipsychotic drugs must receive a new order by attending physician or prescribing practitioner every 14 days if they wish to continue the order; - IF they wish to write a new order for an antipsychotic they must evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate. 1. Review of Resident #10's March 2024 Physician Order Sheet (POS) showed: - Diagnoses included schizoaffective disorder (a combination of symptoms of schizophrenia, a disorder that affects a person's ability to think, feel, and behave clearly) and mood disorder (affective disorders are described by marked disruptions or emotions); - An order dated 02/29/24, for Zyprexa (an antipsychotic medication) 5 milligram (mg) one tablet by mouth every 12 hours as needed PRN for agitation. Review of the resident's Medication Administration Record (MAR), dated March 2024, showed: - An order, dated 02/29/24, for Zyprexa; - Zyprexa administered to Resident #10 on 03/25/24, 12 days past the 14 day PRN maximum. Observations showed: - On 03/26/24 at 12:15 P.M., the resident reclined in his/her tilt and space wheelchair in the dining room; - On 03/27/24 at 11:33 A.M., the resident lay in his/her bed with eyes closed; - On 03/28/24 at 11:45 A.M., the resident sat in his/her wheelchair in the hall near the dining room window; - On 03/29/24 at 9:00 A.M., the resident lay in his/her bed with eyes closed. Review of the Pharmacy review note to the physician, dated 03/10/24, showed: - Please review Zyprexa PRN order for addition of a stop date (14 days) or have a physician or psych progress note for continued use. During an interview on 3/28/24 at 3:10 P.M., the Director of Nursing (DON) said a PRN 14 day medications should be stopped at the 14th day, or a new order obtained from the physician on the 14th day.

Based on interview and record review, the facility failed to implement a baseline care plan upon admission with specific interventions for two residents (Residents #34 and #163 ) out of 15 sampled residents and three residents (Resident #50, #52, and #213) outside the sample. The facility census was 60. Review of the facility's policy titled, Comprehensive Care Plan and Baseline Care Plans, revised 01/19/22, showed: - A licensed nurse will coordinate each assessment with the appropriate participation of health professionals, the Interdisciplinary Team (Social Services, Dietary, Physical Therapy, Occupational Therapy, Speech Therapy, Activities and various staff of Nursing); - The Baseline Care plan must be started upon admission and completed within 48 hours of admission; - The Baseline Care plan must include: Resident Information, Allergies, Alarms, Bowel and Bladder needs, Cognition, Communication, Diet and Dining Needs, Discharge Planning, Hearing needs, Mood and Behavior, Resident Risks, Medications, Safety, Weight Monitoring needs, Code Status, Physician Orders, Equipment needs, Restorative Needs, Functional Goals, Skin Condition, Social Service Needs, Therapy Needs, and Vision information and needs. 1. Review of Resident #34's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 03/04/24, showed an admitted [DATE]. Review of the resident's medical chart showed no documentation of a baseline care plan with specific interventions completed. 2. Review of Resident #50's MDS, dated [DATE], showed an admitted [DATE]. Review of the resident's medical chart, showed no documentation of a baseline care plan with specific interventions completed. 3. Review of Resident #52's MDS, dated [DATE], showed an admitted [DATE]. Review of the resident's medical chart showed no documentation of a baseline care plan with specific interventions completed. 4. Review of Resident #163's entry tracking record MDS, dated [DATE], showed an admitted [DATE]. Review of the resident's medical chart showed no documentation of a baseline care plan with specific interventions completed. 5. Review of Resident #213's MDS, dated [DATE], showed an admitted [DATE]. Review of the resident's medical chart showed no documentation of a baseline care plan with specific interventions completed. During an interview on 03/29/24 at 1:26 P.M., the MDS Coordinator said he/she was not aware a baseline care plan needed to be done on new admissions. He/she spoke with the corporate office and was informed that a baseline care plan should be done on all new admissions with specific interventions within 48 hours. During an interview on 03/29/24 at 1:27 P.M., the Director of Nursing said she had just started employment and was not aware baseline care plans were not being completed on new admissions within 48 hours. During an interview on 03/29/24 at 1:28 P.M., the Administrator said he would expect a baseline care plan with specific interventions to be completed within 48 hours for each new admission to the facility. 45872

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS, a federally mandated assessment to be completed by the facility staff) for two residents (Resident #28 and #46) out of the 15 sampled residents. The facility census was 60. Review of the facility's policy titled, MDS 3.0 Care Assessment Summary and Individualized Care Plans, dated 11/06/23, showed: - The purpose is to understand the changes presented by CMS for the MDS 3.0, to define the intent of each section of the MDS 3.0, and to ensure the MDS 3.0 sections are completed accurately and in a timely manner by the assigned responsible parties; - Section N is to be completed by nursing staff. This section focuses on the medications the resident has received in the last 7 days or since admission or re-entry if less than 7 days; - It is used to record the number of days that the resident receives any type of injection insulin and/or specific oral medications. 1. Review of Resident #28's medical record showed: - An admitted [DATE]; - Diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (one sided muscle weakness), cerebrovascular disease (a condition that affects blood flow and blood vessels in the brain) and atrial fibrillation (irregular and very rapid heart rhythm that can lead to blood clots); Review of the resident's Physician Order Sheet (POS), dated March 2024, showed: - No order for an anticoagulant (a group of medications that decrease the blood to clot); - An order for clopidogrel (an antiplatelet medicine that keeps platelets in the blood from attaching to each other) and aspirin (an antiplatelet medicine that keeps platelets in the blood from attaching to each other.) Review of the resident's quarterly MDS, dated [DATE], showed: - The resident received an anticoagulant on a routine daily basis. 2. Review of Resident #46's medical record showed: - An admitted [DATE]; - Diagnoses of Alzheimer's (a progressive disease that destroys memory and other important mental functions) disease and unspecified dementia (dementia without a specific diagnosis, mild cognitive impairment). Review of Resident #46's POS, dated March 2024, showed: - No order for an antipsychotic (a medication that treats psychosis); - An order for Namenda (a medication that can treat dementia associated with Alzheimer's disease) and Aricept (a medication that can treat Alzheimer's disease). Review of the resident's quarterly MDS, dated [DATE], showed: - The resident received an antipsychotic on a routine daily basis. During an interview on 03/27/24 the MDS coordinator said: - At 2:00 P.M., she thought Namenda and Aricept were antipsychotics. He/She was told to use the tabs in the computer that showed the medication was an antipsychotic medication. - At 3:10 P.M., the MDS coordinator said she was instructed to go by the paper she had with all of the drug classifications on it, not the computer. 48532

Based on observation, interview, and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS, a federally mandated assessment completed by the facility) assessments for two residents (Resident #17 and #39) out of 15 sampled residents. The facility's census was 58. Record review of the facility's policy titled MDS 3.0, Care Assessment Summary and Individualized Care Plans Policy, revised 2/26/21, showed: - MDS 3.0 sections are to be completed accurately and in a timely manner by the assigned responsible parties. 1. Record review of Resident #17's medical record showed: - An admitted [DATE]; - diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - an order for [MEDICAL RECORD OR PHYSICIAN ORDER] - No order for an anticoagulant (medication that delays or prevents blood clotting). Record review of the resident's quarterly MDS, dated [DATE], showed: - Resident received anticoagulant medication; - The MDS did not reflect an accurate assessment of the resident's medications. 2. Record review of Resident #39's medical record showed: - An admitted [DATE]; - diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Order Summary Report, dated 10/19/22, showed: - an order for [MEDICAL RECORD OR PHYSICIAN ORDER] - No current or discontinued order for an anticoagulant. Record review of the resident's quarterly MDS, dated [DATE], showed: - Resident received anticoagulant medication for 7 days of the look-back period; - The MDS did not reflect an accurate assessment of the resident's medications. During an interview on 10/19/22 at 1:47 P.M., the MDS Coordinator said he/she would not expect a resident with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 10/19/22 at 1:50 P.M., the Director of Nursing said [MEDICATION(S)] should not be coded as an anticoagulant on a resident's MDS.

Based on interview and record review, the facility failed to electronically transmit significant change and quarterly Minimum Data Set assessments (MDS - a federally mandated assessment instrument completed by the facility) in a timely manner and in accordance with guidelines for four residents (Resident #15, #27, #43, and #58) of 15 sampled residents. The facility's census was 58. Record review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual for assessment transmission showed the following: - Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date (V0200C2+14 days); - All other MDS assessments must be submitted within 14 days of the MDS completion date (Z0500B+14 days). Record review of the facility's policy titled MDS 3.0, Care Assessment Summary and Individualized Care Plans, revised 2/26/21, showed: - MDS's must be kept current and up to date; - MDS's must be transmitted weekly with validation reports printed out and kept within the MDS office for easy access and viewing if needed; - If MDS's are not transmitted within the correct time frame, payment can be denied for the facility. 1. Record review of Resident #15's medical record showed: - A comprehensive Significant Change in Status MDS assessment, dated 10/2/21, and completed 11/24/21; - Care plan decisions for the comprehensive Significant Change in Status MDS assessment completed 11/24/21; - The comprehensive Significant Change in Status MDS assessment transmitted and accepted 12/9/21 (Validation Report ID # 829); - The facility failed to ensure the MDS assessment was transmitted electronically within 14 days of the care plan completion date. 2. Record review of Resident #27's medical record showed: - A quarterly MDS assessment, dated 8/5/21 and completed 9/9/21; - The quarterly MDS assessment transmitted and accepted 10/6/21 (Validation Report ID # 741); - The facility failed to ensure the quarterly MDS assessment was submitted within 14 days of the MDS completion date. 3. Record review of Resident #43's medical record showed: - An entry MDS, dated [DATE] and completed 10/14/21; - The entry MDS transmitted and accepted 10/28/21 (Validation Report ID # 264); - The facility failed to ensure the quarterly MDS assessment was submitted within 14 days of the MDS completion date. 4. Record review of Resident #58's medical record showed: - A comprehensive annual MDS assessment, dated 10/2/21 and completed 11/16/21; - Care plan decisions for the comprehensive annual MDS assessment completed 11/16/21; - The comprehensive annual MDS assessment transmitted and accepted 12/9/21 (Validation Report ID # 829); - The facility failed to ensure the MDS assessment was transmitted electronically within 14 days of the care plan completion date. During an interview on 10/19/22 at 1:47 P.M., the Director of Nursing (DON) and MDS Coordinator said they would expect the RAI manual and facility policy to be followed for completion and submission of every MDS. They would also expect every MDS to be completed and submitted timely.

Based on record review and interview, the facility failed to complete comprehensive Minimum Data Set assessments (MDS-a federally mandated assessment tool) within the required time frames for five residents (Resident #15, #18, #43, #48, and #58) out of 15 sampled residents and one resident (Resident #50) outside of the sample. The facility census was 58. 1. Record review of Resident #15's medical record showed: - An admitted [DATE]; - A comprehensive Significant Change in Status MDS assessment, dated 10/2/21, with a completion date of 11/24/21; - No comprehensive Significant Change in Status MDS assessment by the 14th calendar day after the determination that a significant change had occurred. 2. Record review of Resident #18's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with a completion date of 5/6/22; - No comprehensive admission MDS assessment within 14 calendar days of admission. 3. Record review of Resident #43's medical record showed: - An admitted [DATE]; - An annual comprehensive MDS assessment, dated 7/27/20; - An annual comprehensive MDS assessment, dated 7/28/21 with a completion date of 10/23/21; - No comprehensive MDS assessment within 366 calendar days of the last comprehensive MDS assessment. 4. Record review of Resident #48's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with a completion date of 4/18/22; - No comprehensive admission MDS assessment within 14 calendar days of admission. 5. Record review of Resident #50's medical record showed: - An admitted [DATE]; - A comprehensive admission MDS assessment with a completion date of 3/17/22; - No comprehensive admission MDS assessment within 14 calendar days of admission. 6. Record review of Resident #58's medical record showed: - An admitted [DATE]; - A comprehensive annual MDS assessment, dated 10/1/20; - A comprehensive annual MDS assessment, dated 10/2/21 with a completion date of 11/16/21; - No comprehensive MDS assessment within 366 calendar days of the last comprehensive MDS assessment. Record review of the facility's policy titled MDS 3.0, Care Assessment Summary and Individualized Care Plans, revised 2/26/21, showed: - Purpose: To ensure that MDS 3.0 sections are completed accurately and in a timely manner by the assigned responsible parties; - MDS's must be kept current and up to date; - The MDS will be completed within twenty-four (24) hours of the ARD being due. During an interview on 10/19/22 at 1:47 P.M., the Director of Nursing (DON) and MDS Coordinator said they would expect the RAI manual and facility policy to be followed for completion and submission of every MDS. They would also expect every MDS to be completed and submitted timely.

Based on observation, interview and record review, the facility failed to protect one cognitively impaired resident (Resident #2) from mental abuse and humiliation when staff recorded and posted an unauthorized degrading video of the resident on social media. The facility also failed to protect one resident's (Resident #4) safety and well-being when staff willfully provided the resident with an illegal substance. The sample size was seven. The facility census was 52. On 03/24/21 at 11:24 A.M., the administrator was notified of the immediate jeopardy (IJ) past noncompliance which occurred on 02/24/21. On 02/25/21 the facility administrator became aware that a Certified Nurse Aide (CNA) recorded and posted an unauthorized degrading video of a resident on social media. The facility took corrective action by immediately initiating an investigation. The Administrator completed a facility wide mandatory inservice on personal phone use and zero tolerance on using any such device for videoing residents. They contacted the local law enforcement and the resident's guardian. The CNA was terminated from employment on 02/25/21. The IJ was removed and corrected on 02/25/21. Record review of the facility's Abuse and Neglect Policy, dated 11/2016, showed: - It is the policy of the facility that every resident has the right to be free from verbal, sexual, physical or mental abuse, corporal punishment and involuntary seclusion. - Neglect is defined as failure of an employee to provide reasonable or necessary services to a consumer (resident) according to the individualized treatment/rehabilitation plan, if feasible, or according to acceptable standards of care. This includes actions or behaviors, which may cause psychological harm to a consumer due to intimidation, causing fear or otherwise causing undue anxiety. - Each resident has a right to personal privacy of not only his/her own physical body, but also his/her personal space, including accommodations and personal care. Taking photographs or recordings of a resident and/or his/her private space without the resident's (or legal representative's) written consent is a violation of the resident's right to privacy and confidentiality. Record review of the facility's Social Media Policy, provided by the facility and dated 1/2014, showed: - Any and all information about our residents is covered by Health Insurance Portability and Accountability Act (HIPPA) and staff should ensure that no postings violate HIPPA's privacy protections. - Staff shall not post anything about residents or their care. Even if you do not post the resident's name or other information, that posting can still violate HIPPA. - Staff shall not post any photos or videos of residents (even in the background of photos) on social media or any website unless authorization is received in advance from corporate management. - Additionally, postings could be considered abuse of a resident including both psychological and financial abuse. - Anything that makes fun of a resident or puts them in an unfavorable light can be considered abuse. 1. Record review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 12/1/2020 showed: - Cognition impaired; - Inattention with disorganized thinking, continuously; - Ambulates independently; - Requires one person physical assist for hygiene, bathing, and dressing; - Requires meal set up for meal consumption; - Frequently incontinent of bowel and bladder; - No rejection of care. Record review of Resident #2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 2/25/21 at 9:45 A.M., Significant Other (SO) A said CNA C made an inappropriate video of a resident and posted it to Snapchat (social media platform). SO A said the video showed a resident walking with no brief or pants on. The video had been titled as Code Naked Guys. SO A said he/she had a copy of the video and was not sure if the facility administration was aware of the video. During telephone interviews on 2/25/21 at 11:30 A.M., the Administrator said he/she received a report that CNA C posted a video of a naked resident on a social media site. At 12:30 P.M., the Administrator said he/she interviewed CNA C and he/she denied taking any videos and had none on his/her phone. However, the more he/she was questioned the more agitated the CNA became, finally saying he/she was mad at someone. The Administrator told the CNA to clock out for the day since he/she was upset. At 1:45 P.M., the Administrator said CNA C was no longer employed at the facility, and would not be allowed to come back on the premises. The Administrator verified the resident in the video as Resident #2 who resides on the secure unit of the facility. The facility security footage verified the CNA video taping the resident on 2/24/21 at 7:08 P.M. (The computer time was 1 hour ahead). The Administrator said he/she immediately completed a facility wide mandatory inservice on personal phone use and zero tolerance on using any such device for videoing residents. As per their policy, they have contacted the local law enforcement and have a call in to the resident's guardian. Observation on 2/25/2021 at 11:45 A.M., of a cell phone video showed a resident dressed only in shoes, socks and a shirt. The resident walked into a dining area and sat at a table, exposing his/her genitals. The resident gets back up and walks out of the room. The caption across the photo frame read Code Naked Man. The name on the video showed CNA C as the owner of the video. Observation on 3/2/21 of the facility surveillance video for 2/24/2021 showed: - At 7:08 P.M., CNA C stood in a dining area with his/her phone in hand. This dining area was later verified as the secure unit's dining area. - Resident #2 walked into the dining room wearing an orange shirt with no pants or underpants, and sat in a chair at a table partially exposing his/her genital area. - CNA C remained standing in the dining room now holding his/her cell phone at his/her upper abdominal area pointing towards the resident. - CNA D walks into the dining room, assists the resident to a standing position and leads Resident #2 out of the dining room while CNA C continues to point the phone at the resident leaving the dining room. CNA D did not see CNA C with the phone pointing towards Resident #2. During an interview on 3/3/2021 at 11:20 A.M., CNA D said on 2/24/2021 CNA C had asked for assistance with dressing Resident #2. CNA D said he/she went to the dining room, focused on Resident #2 and never noticed CNA C with his/her phone out. CNA D said the facility policy prohibits the use of cell phones during work hours including videoing any resident or staff. CNA D said if he/she had realized what CNA C was doing, he/she would have stopped CNA C and reported the incident to the charge nurse. During a telephone interview on 3/3/2021 at 2:10 P.M., the Public Administrator (PA) said he/she was made aware of the video that was made of Resident #2. He/She made no comment on how the incident would have made the resident feel. During an interview on 3/3/2021 at 2:15 P.M., CNA C said he/she used his/her cell phone on 2/24/2021 to video record Resident #2 walking in and out of the dining room partially dressed. CNA C said he/she did not know why he/she did it, he/she just did. CNA C said he/she accidentally posted the video on an Internet social media site. CNA C said he/she had received facility training regarding no cell phone use and no resident videos upon hire, however, he/she did not read the actual policy, but signed it anyway. CNA C refused to write a statement and or answer any further questions. 2. On 03/24/21, the administrator was notified of the past noncompliance which occurred on 02/15/21. On 02/15/21 the facility administrator became aware that a CNA had provided a resident with an illegal substance in exchange for the resident's pain medication. The facility took corrective action by immediately initiating an investigation and notified local law enforcement. The Administrator completed a facility wide mandatory inservice regarding illegal drugs and criminal activity in the facility. CNA A was terminated on 02/15/21. The noncompliance was corrected on 02/15/21. Record review of Resident #4's quarterly MDS, dated [DATE] showed the resident was cognitively intact. Record review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Admission Record dated 3/2/21 showed: - The resident admitted to the facility on [DATE]; - Hip Fracture; - The resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - Resident is his/her own responsible party. Record review of the Police Report dated 2/15/21, showed: - On 2/15/21 the facility contacted the police based on a text between Resident #4 and CNA A, showing a picture of a substance appearing to be Marijuana; - The text was provided to the Administrator by a staff member who had seen the post on the resident's phone; - CNA A was called into the facility office at the facility, read his/her rights, and questioned by the police; - CNA A freely admitted to bringing 5 or 6 Marijuana joints (cigarettes) into the facility for Resident #4; - CNA A said he/she exchanged the Marijuana for the resident's pain pills; - CNA A said there were no other types of illegal drugs brought in the building; - CNA A will be charged with possession and distribution based on his/her voluntary statement. During an interview on 3/3/21 at 10:05 A.M., CNA B said he/she had viewed a picture on social media that appeared to be a conversation between CNA A and Resident #4. The conversation included a photo of what appeared to be Marijuana. CNA B said he/she then provided the picture to the Administrator. During an interview on 3/2/21 at 2:20 P.M., the Administrator said on 2/15/21 CNA B showed him a cell phone picture of a substance believed to be Marijuana that had been sent to Resident #4 from CNA A. The Administrator said he contacted the police on 2/15/21. The police came to the facility and questioned CNA A, regarding the photo he/she had sent to Resident #4. CNA A then freely confessed to the police the resident had wanted Marijuana. CNA A told the police he/she traded the resident's prescription pain pills for Marijuana. CNA A was terminated this date (2/15/21). He started an investigation and in-serviced the staff regarding illegal drugs and criminal activity in the facility. During an interview on 3/3/21 at 9:50 A.M., Resident #4, said CNA A was only trying to help the resident with his/her pain and there was no exchange of any pain medications. The resident said the substance CNA A brought in was an over the counter [MEDICATION(S)] (CBD - an over the counter cannabis (Marijuana) derivative used to help with pain). The resident said he/she did not know why CNA A confessed to bringing in Marijuana and that he/she should have kept quiet. Resident #4 said he/she will never tell on the CNA and will admit to nothing. During an interview on 3/3/21 at 10:20 A.M., the Director of Nurses (DON) said CNA A had been having some pain issues and a history of drug abuse. The DON said she was not aware CNA A brought Marijuana to the resident. During an interview on 3/3/21 at 12:20 P.M., CNA A said approximately one year ago Resident #4 asked him/her to bring Marijuana into the building due to his/her liking the drug. CNA A said Resident #4 would trade the prescription pain medications being provided to the resident by the facility in exchange for the Marijuana. CNA A said he/she had been experiencing pain and wanted the resident's pain medications. CNA A said this had happened three or four times since October 2020. CNA A said the facility had provided in-servicing on abuse/neglect and he/she knew better than to take illegal drugs into the facility. Complaint #MO 0, MO 4

Based on interview and record review, the facility failed to ensure one resident (Resident #1) of three sampled residents at risk for falls received personal attention and care, when the facility failed to adequately assess, effectively communicate the resident's condition with the physician and implement interventions after experiencing two falls. A third fall resulted in hospitalization for significant head injury and facial fractures. The facility census was 56. Record review of the facility's Policy and Procedure for Focus Risk Assessment Plan Scope/Severity (FRAPSS); related to falls, dated (MONTH) 5, (YEAR) showed: -Residents will be assessed using the FRAPSS assessment form upon admission, quarterly and in an acute situation where resident has fallen. Every resident who has a fall, including those without injury will be screened by the therapy department and nursing interventions will be put into place to reduce the risk of further falls. -The policy did not include follow up monitoring after a resident fall. The facility did not provide policies or procedures specific to a resident's post fall protocol. Record review of the facility's Policy and Procedure Guidelines on when to Notify the Physician, dated (MONTH) 17, (YEAR), showed staff should notify the physician of the following: -Falls (must be notified on falls, others, lowered to the floor); -Changes in condition; -Changes in baseline behaviors. Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 11/13/18 showed: -Cognition impaired; -Independent with ambulation, transfers, dressing, toileting; -Requires supervision for meal consumption, hygiene and bathing; -Continent of bowel and bladder; -No falls since the previous assessment completed 8/14/18. Record review showed no admission or quarterly fall FRAPSS assessments documented for the resident as directed by the facility policy. Record review of the resident's care plan, dated 11/29/18, showed the resident at risk for falls related to [MEDICAL CONDITION] drug use and staff stating frequent falls due to dizziness and lightheaded when going from sitting to standing position, especially after smoking. There were no fall interventions care planned. Record review of the Resident's nurse's notes, dated 12/17/18 through 12/26/18, showed staff documented: -On 12/17/18 at 5:57 P.M., staff heard a loud crash in the dining room, observed the resident on the floor leaning against a bookshelf. The resident alert with face reddened, and stated to the staff he/she was fine. Assessment showed purplish reddened area to mid-back, and lower right side of the back with purple, reddish areas. Ambulated back to unit with stand by assist of staff. No documentation of physician and or guardian notified. No documentation of post-fall monitoring; -On 12/20/18 at 3:14 P.M., Certified Nurse Aide (CNA) A alerted Licensed Practical Nurse (LPN) A the resident was in need of emergency assist. The CNA reported the resident crashed into the laundry cart in the hallway. The CNA turned and saw the resident laying in the floor. LPN A and the Director of Nurses (DON) noted the resident exhibited [MEDICAL CONDITION] activity for 1.5 minutes. The resident stayed in the nurse's supervision until he/she regained consciousness and was able to be assisted from floor to room and then to bed. Staff notified the resident's physician's group and informed them of incident. The physician's group instructed staff to continue monitoring the resident and send out for an evaluation if further [MEDICAL CONDITION] activity occurred; -On 12/21/18 at 12:32 P.M., staff found a large red and purple area on the resident's parietal bone (back of head), 3 millimeters (mm) in size. Bruises on the resident's back were red-yellow, healing. Neuro check (to assess an individual's neurological function and level of consciousness) and range of motion (ROM) within normal limits (WNL). No documentation staff notified the physician of the bruising to the resident's head; -On 12/21/18 at 3:07 P.M., staff documented the resident has had difficulty with standing and walking since fall and [MEDICAL CONDITION] on 12/20/18, has been using a wheelchair for mobility. The resident attempted to self-transfer from chair in dining room to wheelchair and slid onto the floor at noon today. Resident assessed with [REDACTED]. Physician notified of decline of mobility in legs, with a new order for x-rays of bilateral hips, no complaints of pain or discomfort. No documentation staff notified the physician of the bruising to the resident's head; -On 12/22/18, the DON documented the resident's gait had returned to normal and the resident refused to use a wheelchair, no acute distress noted; -On 12/23/18 at 11:53 A.M., facility staff documented the resident alert and somewhat verbal, not as verbal as normal. Bruises on parietal lobe still present. Resident's gait unsteady, but refused to use wheelchair; -On 12/24/18 at 11:10 A.M., the resident had been up to shower with standby assist of staff due to unsteady gait. No [MEDICAL CONDITION] activity, no signs or symptoms of pain or discomfort. Encourage standby assist when ambulating; -On 12/24/18 at 3:02 P.M., the resident seen by Advanced Practice Registered Nurse (APRN), new orders received for chest x-ray and [MEDICATION NAME] sprinkles at hour of sleep. Blood work of complete blood count and complete metabolic panel ordered, check [MEDICATION NAME] level in one month; -On 12/26/18, a late entry for 12/25/18 at approximately 9:45 A.M. was called to the unit. Upon staff arrival, the resident was lying face down on the floor with blood noted on the floor under the face, he/she also began urinating. The resident began to try and get up and was encouraged to remain still. The resident was turned slowly over to find blood coming from left side of the nose, with laceration, left brow laceration jagged with bleeding. Pressure applied to both areas, staff called 911, and left messages for doctor and guardian. The resident sat upright and was transferred to a stretcher per ambulance personnel and transferred to emergency room . Record review of the resident's Physician order [REDACTED]. -Facility admitted [DATE]; -Diagnoses of [MEDICAL CONDITIONS]; -an order written [REDACTED]. -an order written [REDACTED]. -an order written [REDACTED]. -No [DIAGNOSES REDACTED]. Record review showed no fall related FRAPSS evaluations completed 12/17/18 through 12/25/18 as directed by the facility policy. Record review of the resident's care plan, dated 11/29/18, showed no additional interventions added after the fall on 12/17/18 or the fall and [MEDICAL CONDITION] activity on 12/20/18. Record review of the resident's hospital emergency department records dated 12/25/18, showed the resident had a 2 centimeter (cm) laceration to mid left eyebrow and 2-3 cm laceration to the left side of nose with bleeding controlled to both. Resident was oriented to self and dysphasic (impairment of speech). The lacerations were repaired with two sutures each. The computerized tomography (CT) scan findings showed multicompartment [MEDICAL CONDITION], with a thin right subdural hematoma (brain bleed), small bilateral temporal lobe hemorrhagic contusions (brain bleed) and a left frontal lobe hemorrhagic contusion (brain bleed). Nothing causing any significant mass effect at this time. The overall appearance indicates significant head trauma. Additional findings showed a nondisplaced right temporal bone fracture (cracked skull) and mildly displaced right zygomatic arch fracture (cheek bone near eye fracture). During an interview on 1/3/19 at 10:45 A.M., LPN A said: -The resident had no [DIAGNOSES REDACTED]. -On 12/20/18, he/she was called to the unit by a CNA and informed the resident had fallen. LPN A found the resident laying on his/her back with a blank stare, very rigid in posture and incontinent of urine. The resident then went into a deep sleep. The DON was also on the unit and assisted with the assessment of the resident; - LPN A conducted an assessment of the resident, checked vitals and looked the resident over on 12/20/18. The LPN could not be sure if he/she noticed any injuries to the resident's head as LPN A did not document it; -LPN A could not recall if he/she informed the doctor's office of the resident's head injury, nor could LPN A recall if anyone contacted the resident's guardian; -LPN A said prior to the fall on 12/20/18, the resident ambulated independently, although at a fast pace, but required no assistance from staff. After the fall on 12/20/18, the resident required standby assistance from staff due to an unsteady gate and leaning; -On 12/21/18, LPN A noted the resident had a decreased ROM; -LPN A notified the physician's office of the resident's decline in mobility and asked for orders to X-ray and check for injuries. He/She received an order for [REDACTED].>-LPN A could not recall if he/she notified the physician of any head trauma the resident may have experienced; -On 12/24/18, the APRN was in the facility. LPN A said he/she was unsure of what details were given to the APRN regarding the condition of the resident. LPN A could not recall if he/she told the APRN on 12/24/18 of any changes in the resident's baseline condition or what the conversation was about and only documented new orders received; -LPN A did not know what the facility's policy was for following up on a resident after a fall; -LPN A was aware he/she was supposed to document when a physician or guardian was notified. During an interview on 1/3/18 at 11:00 A.M., the DON said the following: - The facility has no policy and procedure for post-fall monitoring; - After a fall, licensed staff should complete a FRAPSS; - The facility did not have a definition of what is considered a fall; - She was aware the resident fell on [DATE] into the bookshelf in the dining room and received injuries and was not aware if the staff called the physician due to it was not noted in the nurses notes and she did not ask the staff; - She did not follow up on Resident #1 after the fall on 12/17/18; - On 12/20/18 she was called on the unit and found the resident laying on the floor in the hall and exhibiting [MEDICAL CONDITION] activity. The DON assisted LPN A in his/her assessment of the resident and knew the LPN contacted the resident's physician's office, but did not know the resident had been injured or what exactly was reported by the LPN to the physician; - She expected staff to notify the physician of all injuries with a fall; - She stated she did not consider the [MEDICAL CONDITION] activity as a fall and would not expect the staff to implement fall procedures although would have expected the nursing staff to implement neuro checks due to the resident being unable to state what had happened; - She did not do any further follow up after the incident with suspected [MEDICAL CONDITION] activity. During an interview on 1/3/18 at 11:30 A.M., CNA C said on 12/17/18 at 5:30 P.M., he/she saw the resident stand up and fall backwards into the bookshelf. CNA C went over to assist the resident as other staff and the charge nurse came in to see what made the noise. During an interview on 1/3/19 at 2:00 P.M., the APRN said: -Upon his/her visit to the facility on [DATE], LPN A led APRN to believe the resident had been sent out for hospital evaluation after having a [MEDICAL CONDITION] a few days earlier and questioned why there had been no orders for [MEDICAL CONDITION] medications; -He/She was aware of the resident's history of a [MEDICAL CONDITION]; -During his/her assessment, the APRN heard crackles and wheezing while listening to the resident 's lung sounds and decided to order a chest x-ray to see if the [MEDICAL CONDITION] activity was related to possible pneumonia, which is not uncommon; -The facility staff did not inform the APRN of any head injuries or changes in condition since the [MEDICAL CONDITION]. The APRN said if he/she had that information, he/she would have changed the treatment plan to include a computerized tomography (CT) scan especially since the resident was not sent to the emergency room for evaluation previously. A CT scan would have shown any head trauma. During an interview on 1/3/19 at 4:00 P.M., the APRN said he/she checked the physician group call log from the facility and there were no calls regarding the resident having suffered a fall with a head injury, a head injury with the [MEDICAL CONDITION] activity or any calls related to the resident after the [MEDICAL CONDITION] activity call on 12/20/18. During an interview on 1/3/18 at 3:30 P.M., CNA B said: -On 12/20/18, while he/she was on the unit, he/she heard a loud noise and turned to see the resident fall forward into the laundry cart and then fall backwards onto the floor and appeared unconscious. CNA B called for emergency help while the resident lay on his/her back completely still and incontinent of bowel and bladder; -The resident remained in that state for two to three minutes while licensed staff watched; -Three staff members (including CNA B) had to assist the resident to a standing position and to ambulate to his/her bed. The resident was very wobbly and unable to ambulate like normal; -The resident slept for the remainder of the shift; -When CNA B returned to work the next day, the resident was unable to walk right, very wobbly, leaning to one side, sliding out of the chairs and had to be assisted to ambulate when he/she normally could walk independently; -He/She noticed a red area on the back of the resident's head on 12/21/18, but did not report it to the charge nurse as he/she figured the charge nurse was already aware; -The resident remained unsteady and almost fell a couple of times in the following days, never returning to normal and then fell again on 12/25/18 and was sent to the hospital. During an interview on 1/3/19 at 3:00 P.M., the guardian stated he/she was not aware the resident was not at the facility or the resident had experienced head /injuries. On 12/20/18, the facility contacted him/her regarding a fall with pain in the hips and x-rays were normal. There was no mention of [MEDICAL CONDITION] activity or head trauma. On 12/25/18 the hospital informed the guardian that the resident was at the hospital. The guardian did not know the resident had been admitted to the hospital and currently resided in the hospital due to head trauma. NOTE: At the time of the investigation, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed by SLCR staff, it was determined the facility had implemented corrective action to address and lower the violation at the time of exit. During the onsite visit, the facility administration completed inservices with staff that included review of the new policy and procedure on post fall monitoring and intervention implementation. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation. Complaint MO 000

Based on observation, interview and record review the facility failed to provide a safe environment free of accident hazards, by allowing open access to razor blades for a resident with a history of self mutilating behaviors, for one (Resident #1) of five sampled residents. The facility census was 53. Record review of Resident #1's February 2012 physician's orders [REDACTED]. Upon admission to the facility the resident resided on the locked behavior unit. Record review of a hospital history and physical (H&P), dated 10/17/11, showed the resident entered the facility after a psychiatric hospitalization . The H&P showed the resident had a longstanding history of schizoaffective disorder with a borderline personality, poor impulse control, multiple psychiatric hospitalization s and a history of self mutilation. Record review of Resident #1's Minimum Data Set (MDS) (a federally mandated assessment instrument completed by facility staff) dated 10/25/11, did not address the resident's history of self harm. The resident was independent with all Activities of Daily Living (ADLs) and no problems identified with mood or behavior. Record review of the resident's initial care plan dated 10/24/11 did not address the resident's history of self mutilation. The care plan did not include direction for assistance with ADLs or residents behaviors. Record review of nurses' notes showed the following: -On 10/29/11 Resident #1 upset and wanted to move off the unit. -On 11/2/11 Resident #1 folded a soda can until it broke and used the sharp edges to cut her left wrist. Resident more agitated stated she wanted to leave. Assisted resident back to her room. Once in room resident pushed bed at staff and refused to allow staff to put bed back in place. Resident transferred to hospital for psychiatric evaluation. Record review of the care plan dated 10/24/11, showed the plan of care was not updated with new interventions after the resident cut her wrist with a soda can on 11/2/11. Record review of nurses' notes showed the following: -On 11/9/11 resident returned to facility from hospital. -On 12/9/11 the resident moved off the locked unit to the skilled section of the facility. Resident had not displayed any behaviors and compliant with facility rules. -On 12/29/11 the resident said she wanted to move from the facility and agreed to give it two more months at the facility. -On 2/26/12 the resident informed the nurse that she had done something very "stupid." Resident said she placed a broken razor blade inside her vaginal area and was now unable to get it back out. Two female staff tried to visually check the vaginal area but could not see it. Blood noted in the area. Call placed to doctor and order obtained to send resident to hospital. Record review of the facility RN (Registered Nurse)Investigation Report dated 2/26/12 showed facility staff searched Resident #1's room and found a broken handle of a razor in resident's trash can. Record review of Resident #1's hospital records showed she entered the hospital on [DATE]. An x-ray of her pelvis confirmed that she had a metallic linear foreign body present in her lower pelvis area. The resident proceeded to the operating room and a twin blade razor head was removed from her vagina. There were no severe lacerations in the vaginal vault. Observation on 2/27/12 at 10:30 A.M., showed the facility had two shower/bath rooms. The shower/bath room referred to as the independent shower room had an unlocked wooden cabinet mounted on the wall for storage of toiletries and bath supplies. The cabinet had a wooden door with a hasp (hinged metal fastening) in place. The unlocked cabinet contained five razors, deodorants, shampoos, cologne, medicated shampoo and a gallon of body wash. The shower/bath room referred to as the dependent shower/bath room had a large, black metal cabinet. The cabinet had two silver handles with a key lock on one handle. A hasp had been mounted two feet above the door handles. The hasp had a padlock in place to prevent the doors from opening. During an interview on 2/27/12 at 10:45 A.M., certified nurse aide (CNA) A said the black cabinet had been in the dependent shower room for about 3 months. He/she said at first the lock worked on the cabinet but at some point the lock got sprung and would not lock. CNA A said he/she had seen razors in the black cabinet when it was not locked. During an interview on 2/27/12 at 11:20 A.M., CNA B said the black cabinet had been in the dependent shower room for 2-3 months and he/she had seen razors in the unlocked cabinet. During an interview on 2/27/12 at 11:30 A.M., CNA C said he/she had worked at the facility for 30 days and the locks on both cabinets had been broken ever since he/she had been there. He/she said razors had been kept in both cabinets and the cabinets were not locked. During an interview on 2/28/12 at 1:25 P.M., CNA E said on 2/26/12 Resident #1 told her she had put a razor blade in her vagina in the past but it had come out on its own. CNA E said the resident had been saying for a long time she wanted to leave the facility. The resident told CNA E that she took the razor from the black cabinet in the shower room. CNA E said the lock on the black cabinet had been broken for at least 3 months. He/she said the wooden cabinet is not supposed to have razors in it and it has never had a lock on it. During an interview on 2/28/12 at 1:40 P.M., CNA D said on 2/26/12 at 5:00 A.M. Resident #1 took a shower independently. CNA D did not know the resident took the razor but said the lock on the black cabinet was broken that morning. During an interview on 2/27/12 at 11:40 A.M., Licensed Practical Nurse (LPN) A said the independent shower room cabinet had not had a lock on it for a long time. He/She said the black cabinet lock did get messed up but did not know how long it had not worked. LPN A said he/she did not report the broken lock because he/she thought someone else reported it. During an interview on 2/28/12 at 2:00 P.M., LPN B said the black cabinet in the dependent shower room had been broken for a long time. During an interview on 2/28/12 at 12:30 P.M., the Maintenance Man said prior to the incident with Resident #1 on 2/26/12 none of the staff had ever told him that the lock was broken on the black cabinet or that the lock was missing from the wooden cabinet. He said they are fixed for now and he had ordered two new cabinets with stronger locks. Record review on 2/28/12 of the maintenance requisition sheet showed no requests to fix the locks on the storage cabinets in the shower rooms. Record review on 2/28/12 of the facility maintenance work order policy and procedure directs staff finding needed repairs to fill out work orders as problems are found. Record review on 2/28/12 of the facility safety and supervision policy and procedure directed staff to use the systems approach to safety. This approach directed staff to consider hazards in the environment, provide supervision and assess resident needs. During a telephone interview on 2/29/12 at 9:00 A.M., the resident's guardian said he/she informed the Director of Nursing (DON) prior to the resident's admission that Resident #1 had a long standing history of self mutilation and inserting things in her vagina. The guardian said it did not surprise him/her that the resident did something like this. During interviews on 2/27 and 2/28/12 the DON said upon admission Resident #1 resided on the locked unit due to her history of self mutilation but later moved off the unit at the request of the resident's guardian. The DON said after the resident cut her wrist with the soda can they no longer allowed resident's to have soda cans in their rooms. The DON said upon admission the resident's MDS was not completed correctly and the care plan should have addressed self mutilation but it did not. During interviews on 2/27 and 2/28/12 the Administrator said on 2/26/12 Resident #1 took a razor from the black cabinet in the shower room. The Administrator did not know how long the lock had been broken on the cabinet and no one had reported it to the maintenance man before now. After the incident the maintenance man installed a hasp and lock he brought from home the morning of 2/26/12. The Administrator said the maintenance man still needed to purchase a pad lock for the other cabinet when the store opened. The Administrator said she was not aware the cabinet in the independent shower room had razors in it and that there should not be razors in that cabinet. The Administrator said any of the staff who sees something that needs fixed can and should enter the problem on the maintenance requisition sheet that is hanging by the nurse's station. COMPLAINT #MO and MO *The higher classification merited due to the extent of the violation and the impact on the resident. *NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review, completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, all facility staff was in-serviced on environmental safety and the new policy and procedures for securing grooming supplies. The in-service also included educating staff to complete the maintenance sheets that are kept at the nurses' station when any type of repair is needed. The maintenance staff put a lock on both shower room cabinets. The keys to the cabinets will be kept at the nurses' station. There will be daily monitoring to ensure the cabinets are locked. All MDS's and care plans will be reassessed to ensure all potential problems are identified. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the "D" level. The facility needs to ensure all staff receives the in-service training regarding environmental safety and the new policy and procedures for securing grooming supplies and that all MDS's and care plans are reassessed to ensure all potential problems are identified. This statement does not denote that the facility has complied with state law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address Class I violations.

Based on observation, interview and record review, the facility failed to provide treatment and services to promote healing for one resident (Resident #1) of six sampled residents at risk for skin breakdown. Since admission to the facility, Resident #1 developed skin breakdown. The facility census was 53. 1. Record review showed: - The physician's orders [REDACTED]. - The admission transfer sheet, dated 4/14/11, showed the resident had redness on his/her coccyx with no open areas. - The plan of care (POC), dated 7/28/11, directed nurse aide staff to observe for skin breakdown and report to the nurse. The POC directed the charge nurses to provide weekly skin assessments. - The weekly skin assessments, kept in the treatment administration record (TAR), showed 7/11/11 as the last skin assessment completed for Resident #1. - Nurse's notes for August, 2011 did not show any skin issues for Resident #1. - Shower sheets reviewed on 8/30/11 provided areas to document skin issues and had not been completed by the direct care staff for the last two weeks. - On 8/30/11 the POS showed the facility notified the physician of the pressure ulcer (A localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear.) for the first time and directed staff to use stoma adhesive powder followed by [MEDICATION NAME] to the area every shift and as needed. - On 8/31/11 at 3:30 P.M., documentation of the pressure ulcer had not been completed in the nurse's notes or the TAR. - The facility policy and procedure (P&P) showed the direct care staff should notify the Charge Nurse immediately of any skin problems. The Charge Nurse should assess the wound and notify the physician, guardian and Director of Nursing (DON). The Charge Nurse should complete a wound assessment sheet and document a description of the wound in the Nurse's Notes. Observation on 8/30/11 showed: - At 1:10 P.M., during incontinent care, Resident #1 had an open sore, with a deep, red center, the size of a dime on the inner aspect of his/her left thigh. Certified Nurse Aide (CNA) A cleaned the area during incontinent care and the resident yelled out that the sore hurt and burned. During an interview on 8/30/11 at 1:10 P.M.: - CNA A said he/she told LPN A a month ago about the resident having a pressure sore on his/her thigh. CNA A said LPN A gave him/her a tube of [MEDICATION NAME] ointment to put on the resident. CNA A said he/she did not know what the LPN did after that about getting any other kind of treatment for [REDACTED]. - CNA A said the resident had been refusing to get up for showers, so he/she had been giving the resident a bed bath. The CNA said he/she had not thought to fill out a shower/bath skin assessment sheet after the bed baths. CNA A said he/she had signed that he/she had given a bed bath on the nurse aide activity of daily living sheets. During an interview on 8/30/11 at 1:20 P.M.: - CNA B said that he/she had told LPN A about two weeks ago that the resident had a pressure sore on his/her left thigh. During an interview on 8/31/11 at 10:50 A.M.: - LPN A said he/she did not recall anyone ever telling him/her that Resident #1 had a pressure sore on his/her thigh. - LPN A said he/she thought the night shift had the responsibility to complete the skin assessments. During an interview on 8/31/11 at 11:15 A.M.: - The DON said the Charge Nurses on each shift had the responsibility of completing the skin assessments and she did not know why they had not been doing them. - The DON could not find any bath/shower skin assessments completed for Resident #1. The DON said if there had been no documentation of any skin problems, she would have thrown the sheets away. The DON said she had to assume the CNA staff had not documented any skin problems during the shower/baths given. -The DON had LPN A call the resident's physician regarding the pressure ulcer and received a treatment order for stoma adhesive powder followed by [MEDICATION NAME] to the area every shift and as needed. Complaint #MO