Every finding on record at Summers Healthcare Center

Based on observations, record reviews, and staff interviews, the facility failed to ensure residents received physician-ordered therapeutic diets by not providing honey-thickened liquids at the correct consistency. This deficient practice was identified for 1 of 1 residents reviewed for therapeutic diets (Resident #98). The State Agency determined this to be an Immediate Jeopardy situation as the failure created a likelihood for serious harm, aspiration pneumonia, and/or death. Resident identifier: #98. Facility census: 102. Findings Include:a) Resident #98An observation on 08/19/25 at 11:00 AM revealed the following:Resident #98's bedside cup of water dated 8/19/25 thickened was observed. The liquid did not appear to meet the required honey-like (moderately thick) consistency.The record review on 08/19/25 revealed the following:Physician orders for Resident #98 directed: Regular diet, Dysphagia Mechanical texture, Honey Thickened Liquids consistency.Policy Review:The facility's Diet and Nutrition Care Manual stated honey-thickened liquids are a Level 3 (moderately thick) and provided instructions:Two (2) pumps of thickener per 4 oz liquid.Stir briskly for 30 seconds.Allow additional time for some beverages.These same instructions were printed on the SimplyThick bottle.An observation on 08/18/25 revealed No honey-like pre-thickened liquids were available in the nourishment pantry refrigerator. LPN #76 confirmed this finding.During an interview with LPN #78 on 08/18/25 at 11:15 AM the LPN stated, It takes three pumps. I need a measuring cup. She then asked Unit Manager LPN #26, It does say three pumps for eight ounces? Three pumps were added to 8 oz water, resulting in a consistency inconsistent with honey-thick.During an interview with Unit Manager LPN #26 on 08/18/25 the UM stated, She's on the thickest.green directions, referring incorrectly to spoon-thick liquid directions. The UM also explained that aides or kitchen staff typically thicken beverages, and nurses thicken only for medication administration.Interview with Director of Nursing (08/18/25 at 11:25 AM):The DON confirmed the thickener instructions and stated, I will type up an education for that.Clinical Risk:Resident #98 was hospitalized on [DATE] for septic shock, acute chronic hypoxic respiratory failure, and aspiration pneumonia. Resident returned on 08/18/25 and was again provided liquids not mixed to the correct honey-thick consistency. Incorrectly prepared liquids placed the resident at immediate risk for aspiration, aspiration pneumonia, and death.Immediate Jeopardy Determination:The deficient practice constituted Immediate Jeopardy (IJ) as the failure to provide physician-ordered honey-thickened liquids in the proper consistency was likely to result in serious harm or death. This practice was a random opportunity of discovery but posed a risk to all residents in the facility requiring thickened liquids.IJ Declared: 08/19/25 at 2:19 PMPlan of Correction Accepted: 08/19/25 at 4:19 PMAbatement Confirmed: 08/20/25 at 9:00 AMImmediate Jeopardy Removal (Abatement):The facility submitted and implemented the following actions:All residents ordered thickened liquids were assessed immediately to ensure correct consistency.All identified residents received liquids at the ordered consistency.Nurses were immediately re-educated on thickener instructions and demonstrated competency in preparing liquids to the correct honey-thick consistency per manufacturer guidelines.DON/designee conducted direct observation of staff mixing thickened liquids to verify correct procedure.Staff education was initiated on 08/19/25 regarding physician orders for therapeutic diets, proper thickening techniques, and monitoring for aspiration risk.Ongoing audits were implemented to ensure thickened liquids were prepared and served correctly, with noncompliance reported to the DON and corrected immediately.The State Agency confirmed the facility removed the Immediate Jeopardy on 08/20/25 at 9:00 AM.

Based on record review, staff interview and resident interview the facility failed to assess, monitor and treat pain in accordance with professional standards of treatment. For Resident #85 this resulted in actual harm because the nurse assessed him as having pain but failed to treat the residents pain with non pharmacological or pharmacological interventions both of which he had physician orders for. The nurse further failed to assess the pain for location or duration and never notified the physician or the residents increased pain. For Resident #104 the resident an increase in pain upon movement and transfers. Though the facility treated her pain and increased her pain medications they failed to assess the cause of the pain which was later identified at two (2) fractures. For Resident #73 the resident reported to the nurse he was experiencing numbness and tingling in his toe amputation site the physician was notified and indicated he would address the next day but failed to do so and the resident continued to suffer tingling and pain in the site. These failures affected three (3) of eight (8) sampled residents reviewed for the care area of pain during the long term care survey process. Resident Identifiers: #85, #104 and #73. Facility census: 102. Findings Include: a) Resident #85 A review of Resident #85's medical record found the following physician orders related to pain: -- Non Pharmacological Interventions: 1. Attempt Repositioning. 2. Encourage Rest Periods. 3. Dim lighting in the room. 4. Check for well fitting clothing and shoes as needed. Order effective date 04/20/25 and current at the time of this review. -- Pain level q (every shift) (1-3 mild) (4-7 moderate) (8-10 severe) pain 1-3 with no PRN (As needed): contact practitioner, greater than or equal to 4 with no PRN or PRN not effective or new onset pain contact practitioner. Document non-pharmacological pain intervention prior to PRN pain medication administration. Order effective date 04/21/25 and current at the time of this review. -- Tylenol Oral Tablet 325 MG give 650 MG by mouth every 6 hours as needed for pain. This order had an effective date of 01/30/25 and was discontinues on 05/16/25 when an new Tylenol order was entered. -- Acetaminophen Extra strength oral tablet 500 mg Give 2 tablets by mouth every eight (8) hours as needed for pain. Order effective date 05/16/25 and current at the time of this review. A review of the medication administration records for the months of 05/2025, 06/2025, 07/2025 and 08/2025 found the following occasions when Registered Nurse (RN) #44 documented the resident was experiencing pain but provided no interventions to treat the pain nor did she contact the practitioner about the resident experiencing pain. Day Shift: --05/05/25 pain score of 5. -- 05/06/25 pain score of 5. -- 05/11/25 pain score of 10. -- 05/14/25 pain score of 8. -- 05/23/25 pain score of 2. -- 05/29/25 pain score of 2. -- 06/07/25 pain score of 2. -- 06/16/24 pain score of 3. -- 06/17/24 pain score of 3. --06/23/25 pain score of 2. -- 07/04/25 pain score of 1. -- 07/05/25 pain score of 8. -- 07/10/25 pain score of 2. -- 07/20/25 pain score of 3. -- 07/21/25 pain score of 2. -- 07/28/25 pain score of 8. -- 07/29/25 pain score of 3. -- 08/01/25 pain score of 3. -- 08/06/25 pain score of 3. -- 08/07/25 pain score of 3. Nigh Shift: -- 07/29/25 pain score of 3. Further review of the MAR's for this time period found the non- pharmacological interventions nor the PRN pain medications was never provided by RN #44. A review of the progress notes found no indication the physician was notified of the residents reports of pain. During an interview with the Director of Nursing (DON) in the afternoon of 08/20/25 she confirmed there was no further information she could provide related to Resident #85's complaints of pain. b) Resident #104 On 08/18/25 at 9:00 AM, a review of Resident #104’s medical record revealed: 07/25/25 1:32 PM: Resident received Oxycodone-acetaminophen 5-325 mg tablet PRN for pain. Documentation reflected the medication was effective. 07/25/25 5:18 PM: Physician ordered Oxycodone HCL oral solution 5 mg/5ml, 7.5 mL four times daily for pain. Documentation noted the medication was awaiting arrival from the pharmacy. 07/25/25 8:00 PM: Nursing note documented resident was nonresponsive to verbal/tactile stimuli and unable to take medications. 07/25/25 10:00 PM: CNA found resident without respirations or pulse. Resident pronounced deceased at 10:00 PM. The last documented effective pain medication was at 1:32 PM on 07/25/25, approximately 8.5 hours before the resident’s death. Interview with LPN #78 (08/18/25 at 3:00 PM):LPN stated “we don’t have liquid Oxycodone in the e-box for pain, we do have liquid morphine available.” Interview with Director of Nursing (08/19/25 at 11:20 AM): The DON confirmed the physician should have been notified that the ordered Oxycodone solution was not available in the emergency box. The DON stated the physician could have given an order for morphine, which was available in the emergency box. The facility failed to notify the physician when the ordered Oxycodone solution was unavailable and failed to obtain an alternative pain management order despite the availability of liquid morphine. c) Resident #73 During an interview on 08/11/2025 at 2:38 PM, Resident #73 stated that he received pain medications every six (6) hours for pain at the site of a left great toe amputation. He stated the pain medication was effective but sometimes he had pain in between pain medication administration. He stated he believed he was having phantom pain at the amputation site. A nursing note written on 8/17/2025 at 2:13 PM stated, Resident approached this nurse and stated he is having some numbness and tingling in his left foot. He also states he has been getting strangled on food and drink during meals. He states that it does not happen during every meal, but it is becoming more of an issue for him. [Physician] notified of these new issues. Orders obtained: ST [speech therapy] eval [evaluation] and treat. He stated he will address the numbness and tingling tomorrow when he comes in. Orders noted. Resident has capacity and is aware. On 08/18/25 at 4:36 PM, Resident #73 confirmed he was having numbness and tingling at his amputation site. He stated he had not been seen by the physician today. On 08/20/2025 at 10:55 AM, the Director of Nursing (DON) stated there was no documentation the physician had evaluated or prescribed treatment for the resident's numbness and tingling after the resident had reported it on 08/17/25.

Based on record review, interview, and observation, the facility failed to provide the necessary care and services to recognize and treat changes in condition, follow physician's orders for medication parameters, document medication administration, and provide food in the correct form.Resident #93 suffered actual harm after the facility failed to identify and timely treat a change in condition resulting in the resident being hospitalized with Respiratory Failure, Urinary Tract Infection , and Aspiration Pneumonia. Resident #110 suffered actual harm at the facility when she died of a food bolus when she was given hamburger at the facility despite having an order for nothing by mouth. Even though the facility did not serve the resident the meal they failed to protect the resident from others providing her with food. This deficient practice was identified for 10 of 30 sampled residents (Residents #93, #109, #8, #9, #110, #107, #17, #112, #1, and #85). Facility Census: 102 a) Resident #85 A review of Resident #85's medical record on 08/18/25 found the following physician orders: -- ANTIPSYCHOTIC side effect monitoring list #2 not limited to: insomnia, confusion. Akathisia: restlessness, pacing, inability to sit still, anxiety, sleep disturbances. Tardive dyskinesia: lip smacking/chewing, abnormal tongue movement, spasmodic movement of the arms/legs, rocking/swaying, blood abnormalities, sore throat, seizures, photosensitivity. --MOOD STABILIZER Side effect monitoring: Hives, a rash, fever, or swollen glands. Signs of [NAME]-[NAME] syndrome, which causes dangerous sores on the mucous membranes of the mouth, nose, genitals, and eyelids. Confusion. Slurred speech. Nausea, vomiting, and diarrhea. Trembling. Increased thirst and increased need to urinate. Weight gain in the first few months of use. Drowsiness. --ANTIPSYCHOTIC side effect monitoring list #1: Dystonia: torticollis(stiffness of neck), Anticholinegic symptoms:Dry Mouth, blurred vision, constipation, urinary retention. Hypotension, Sedation/drowsiness, increased falls/dizziness, Cardiac abnormalities(tachycardia, bradycardia, irregular H.R; NMS). Anxiety/agitation, blurred vision, sweating/rashes, headache, urinary retention/hesitancy,pseudoparkinsonism: cogwheel rigidity, bradykinesia, tremors, appetite change/weight change. --ANTIDEPRESSANT side effect monitoring not limited to: Dystonia: torticollis(stiffness of neck),Anticholinegic symptoms: Dry Mouth, blurred vision,constipation, urinary retention.Hypotension, Sedation/drowsiness,increased falls/dizziness,Cardiac abnormalities(tachycardia, bradycardia, irregular H.R; NMS).Anxiety/agitation, blurred vision, sweating/rashes, headache, urinary retention/hesitancy, weakness,tremors,appetite change/weight change,insomnia,confusion,tardive dyskinesia, suicidal ideations --ANTIANXIETY side effect monitoring but not limited to: Dystonia: torticollis(stiffness of neck), Anticholinegic symptoms: Dry Mouth, blurred vision, constipation, urinary retention. Hypotension, Sedation/drowsiness, increased falls/dizziness, Cardiac abnormalities (tachycardia, bradycardia, irregular H.R; NMS). Anxiety/agitation, blurred vision, sweating/rashes, headache, urinary retention/hesitancy. Weakness, hangover effect. -- Lantus Subcutaneous Solution 100 Units /ML In ject 10 ML subcutaneously in the morning. -- Fasting blood sugar every day in the morning. Further review of the Medication Administration Record for the months of 06/2025, 07/2025, and 08/2025 found the following occasions when the aforementioned physician orders were not followed: On the following dates and times the side effect monitoring was not completed: 05/05/25, 05/06/25, 05/11/25 Day shift 06/26/25 day shift. 07/15/25 on day shift. 07/18/25, 07/19/25, 07/20/25 evening shift. On 06/23/25 the fasting blood sugar was not obtained nor was his insulin administered according to the MAR. On 08/18/25 the residents blood sugar was obtained and was 94. The nurse held the residents insulin despite not having a physician's order to do so. An interview with the Director of Nursing (DON) at 12:30 pm on 08/18/25 confirmed the above findings and no further information was provided. b) Resident #107 Resident #107 had diagnoses of a recent myocardial infarction, atherosclerotic heart disease, diabetes mellitus, chronic kidney disease, hypertensive heart disease, and chronic obstructive heart disease. On 08/16/25 at 11:48 AM, the on-call telemedicine physician service assessed Resident #107 due to the nurse's report that the resident had swelling of the face and legs. The resident was not experiencing shortness of breath or chest pain. The resident's vital signs and oxygen saturation were within normal limits. The nurse reported the resident's lung sounds were clear bilaterally. The on-call physician's plan was as follows: - Order a comprehensive metabolic panel (CMP), complete blood count (CBC) with differential, and a B-type natriuretic peptide (BNP) to assess for heart failure. - Elevate lower extremities to manage edema.- Monitor fluid status carefully to avoid dehydration.- Order a chest X-ray to assess for pulmonary congestion.The patient was to remain in the facility for continued monitoring and management of her fluid status and renal function. Nursing staff were to continue elevating the resident's legs and monitoring for any changes in condition. On 08/16/25 at 6:43 PM, the on-call provider evaluated the resident's laboratory testing results and determined the patient is stable with improved laboratory results and no significant change in symptoms that would necessitate altering the current treatment plan. The provider noted the chest x-ray was pending. The resident was described as having faint wheezing upon expiration. The plan was as follows: - Continue current medications, including Lasix 20 milligrams (mg) twice daily - Daily weights to monitor for fluid retention, with notification if weight gain exceeds two (2) pounds (lbs) - Schedule chest x-ray for Monday - Inpatient provider to evaluate the patient on Monday - Monitor and report and worsening symptoms The x-ray was obtained on Sunday, 08/17/25. The report at 12:48 PM showed bilateral lower lobe infiltrates. A handwritten note on the report stated, Calling [on-call service] 08/17/25 at 1:14 PM. The report was signed by the facility's medical director on 08/18/25. A nursing note written on 8/17/2025 at 12:54 PM stated the chest x-ray results showed bilateral lower lobe infiltrates. The note stated the on-call service would be notified. A nursing note written on 8/17/2025 at 1:41 PM stated the resident's medical power of attorney (MPOA) was notified regarding the resident's x-ray results and that the on-call service planned to order antibiotics for pneumonia. A nursing note written on 08/17/25 at 2:59 PM stated the facility was waiting for an order for antibiotics to be placed. A nursing note written on 08/17/25 at 7:02 PM stated the on-call service was messaged. The note also stated there were no new orders as of yet and the facility was awaiting an antibiotic order for the resident. Nursing notes showed the on-call service had been re-called on 08/17/25 at 7:14 PM and nursing was waiting for a response. A follow-up progress note was written by the on-call service on 08/19/25 at 11:52 PM. The resident's chest x-ray was not mentioned in the progress note. The plan was as follows: - Reinforce importance of Thrombo-Embolic Deterrent (TED) hose - Monitor daily weights and report any rapid increases - Continue Lasix as prescribed, but review with nephrology due to end-stage renal disease (ESRD) status - Monitor for symptoms of decompensation (shortness of breath, orthopnea, chest pain, rapid weight gain) - Continue close monitoring due to elevated BNP - Monitor labs and electrolytes as indicated for chronic kidney disease and ESRD - Avoid nephrotoxic medications - Encourage mobility as tolerated to reduce risk of further edema - Monitor for skin breakdown in edematous areas A nursing note written 8/20/2025 at 7:00 AM stated, Resident dyspneic, audible wheeze, O2 sats < 50%. Placed on NRB [non-rebreather oxygen]. Call to [on-call service] waiting in queue. [MPOA's name] aware and requested resident sent to [hospital]. On 08/20/2025 at 10:46 AM, the Director of Nursing stated the facility's physician does not see acutely-ill residents and did not see Resident #107. She stated nursing staff had reached out to the on-call service to inquire about treatment for the lung infiltrates identified on the chest x-ray. However, the on-call service did not respond. The DON stated the resident was receiving a broad spectrum antibiotic for Clostridium difficile (C. Diff) infection. The resident's physician's orders showed she was receiving the antibiotic Vancomycin orally. According an on-line article published by the National Institutes of Health titled Vancomycin, although oral Vancomycin is effective to treat C. Diff infections, Vancomycin has poor oral bioavailability and is typically administered intravenously to treat most infections. No futher information was provided through the completion of the survey process. c) Resident #112 Review of Resident #112's physician's orders showed an order written on 08/04/25 for Midodrine, 5 milligrams (mg) by mouth, three (3) times a day for hypotension. The medication was to be held for blood pressure readings greater than 110. Review of Resident #112's Medication Administration Record (MAR) for August 2025 showed Midodrine had been administered on three (3) occasions when the resident's blood pressure was greater than 110. These occasions were as follows: - 08/05/25 at 12:00 PM, when the resident's blood pressure was126/74. - 08/05/25 at 4:00 PM, when the resident's blood pressure was 118/64. - 08/12/25 at 12:00 PM, when the resident's blood pressure was 112/65. On 08/13/2025 at 2:00 PM, the Director of Nursing confirmed Resident #112's Midodrine had been administered when the blood pressure was greater than 110. d) Resident #17 Review of Resident #17's physician's orders showed an order written on 07/28/25 for Midodrine, 5 milligrams (mg) by mouth, three (3) times a day for hypotension. The medication was to be held for systolic blood pressure readings greater than 110. Review of Resident #17''s Medication Administration Record (MAR) for July 2025 showed Midodrine had been administered on two (2) occasions when the resident's blood pressure was greater than 110. These occasions were as follows: - 07/28/25 at 5:00 PM, when the resident's blood pressure was112/70. - 07/29/25 at 8:00 AM, when the resident's blood pressure was114/72. Review of Resident #17''s Medication Administration Record (MAR) for August 2025 showed Midodrine had been administered on three (3) occasions when the resident's blood pressure was greater than 110. These occasions were as follows: - 08/05/25 at 8:00 AM, when the resident's blood pressure was113/68. - 08/05/25 at 5:00 PM, when the resident's blood pressure was129/74. - 08/12/25 at 12:00 PM, when the resident's blood pressure was114/75 On 08/13/2025 at 2:00 PM, the DON Director of Nursing confirmed Resident #17's Midodrine had been administered when the systolic blood pressure was greater than 110. e) Resident #17 Review of Resident #17's physician's orders showed an order written on 01/24/25 for gabapentin (Neurontin) 600 mg, three (3) times a day for pain. Review of Resident #17's controlled substance administration record for January 2025 showed two (2) occasions when gabapentin had been dispensed four (4) times instead of the three (3) times ordered by the physician. On 01/26/25, gabapentin was dispensed at 5:20 AM, 9:44 AM, 12:10 PM, and 8:30 PM. The Medication Administration Record (MAR) showed the resident received gabapentin three (3) times a day as ordered. On 01/29/25, gabapentin was dispensed at 5:30 AM, 9:31 AM, 12:04 PM, and 9:04 PM. The Medication Administration Record (MAR) showed the resident received gabapentin three (3) times a day as ordered. On 08/19/2025 at 5:28 PM, the Director of Nursing (DON) confirmed the gabapentin discrepancies. She stated the resident received four (4) doses of gabapentin on those days but had no explanation as to why this occurred. f) Resident #1 Review of Resident #1's physician's orders showed an order written on 10/17/24 for gabapentin (Neurontin) 300 mg, three (3) times a day for neuropathy. Review of Resident #1's controlled substance administration record for January 2025 showed one (1) occasion when gabapentin had been dispensed four (4) times instead of the three (3) times ordered by the physician. On 01/07/25, gabapentin was dispensed at 6:05 AM, 8:36AM, 2:00 PM, and 9:20 PM. The Medication Administration Record (MAR) showed the resident received gabapentin three (3) times a day as ordered. On 08/19/2025 at 5:28 PM, the Director of Nursing (DON) confirmed the gabapentin discrepancy. She stated the resident received four (4) doses of gabapentin on those days but had no explanation as to why this occurred. g) Resident #93 Record review completed on 08/19/25 revealed the following notes a nursing note dated 08/01/25 at 05:58 AM showed staff documented the resident’s urine output from the Foley catheter was thick, mucous-like, and dark golden in color. No evidence of physician notification or further assessment was documented. A behavior note dated 08/04/25 at 06:01 AM showed the resident was screaming out during the shift. The resident was repositioned and provided fluids; however, no additional assessment or physician notification was documented. A behavior note dated 08/08/25 at 05:46 AM showed the resident yelled aloud for the majority of the shift. The documentation reflected “all needs were met” with redirection, snacks, and fluids offered, but no assessment for pain, infection, or other medical issues was documented. On 08/09/25 at 10:05 AM, the resident was noted to have labored shallow respirations, decreased alertness, and oxygen saturation of 68% with oxygen in place. A PRN Duoneb treatment was given without improvement. The nurse practitioner was notified, and an order was received to send the resident to the ER. On 08/09/25 at 14:43 PM, hospital staff reported the resident was on a ventilator and diagnosed with respiratory failure, urinary tract infection, and aspiration pneumonia. Interview 08/18/2025 10:47 AM during an interview the Director of nursing stated she could not find where the doctor was notified The facility’s failure to assess and notify the physician when the resident presented with abnormal urinary output and repeated episodes of yelling and distress delayed treatment and resulted in the resident requiring hospitalization for respiratory failure, UTI, and aspiration pneumonia h) Resident #9 Record review completed on 08/14/29 revealed the following blood sugar 7/10/2025 17:22401.0 mg/dL An interview was conducted with Unit Manager #41 on 08/14/25 at 10:00 AM regarding notifying the Doctor for blood sugars, she stated if below 60 or above 400. On 08/18/2025 at 10:47 AM an interview with the director of nursing was completed, when asked to provide more information of what was done for Resident #9 having a blood sugar of 401 the DON stated I find where the doctor was notified, i can only look back f16 days in the secure messaging system, the nurse should have completed a progress note after contacting the doctor, i can't find anything else. i) Resident #8 08/19/2025 5:30 PM resident #48 states he's had no medication for hemorrhoids for the past two months AN interview on 08/20/25 at 9:30 AM with Licensed Practical Nurse (LPN)#16 stated (I offer him the cream I think he gets every six (6) hours, and showed this surveyor the tube of cream with Resident #8's name on it. Record review completed on 08/20/25 of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the month of July and August revealed no documentation that Resident #8 had got had any hemorrhoid cream Interview with the director of nursing was completed on 08/20/25 at 11:00AM when asked to provide more supporting documentation that resident#8 did get the hemorrhoid cream for rectum, she stated I can not provide that, it was not documented on the MAR or TAR. j) Resident #110 On 06/13/25 at 10:40 PM, an initial reporting of allegations was reported to the Office of Health Facility Licensure and Certification. The description of the allegation was as follows: Resident [#110] was coded by facility staff. CPR [cardiopulmonary resuscitation] and AED [automated external defibrillator] administered. EMS [emergency medical services] arrived at 8:45 PM to transport resident while still performing CPR. Call back from facility by paramedic at 9:18 PM to inform facility that resident has 2 quarter [NAME] [size] pieces of hamburger extracted from throat. The steps taken immediately to ensure the alleged victim was protected was to place the alleged perpetrator on 1:1 observation by staff. The five (5) day follow up investigation as follows: Resident [#110] was coded by staff. CPR and AED was administered. EMS arrived to transport resident to the hospital. Alleged perpetrator [#61] was immediately placed on 1:1 observation by staff. A statement was obtained from [Resident #61] (alleged perpetrator). PTSD [post traumatic stress disorder] screening has been completed with alleged perpetrator, with no adverse outcomes reported at this time. Nursing assignment sheets have been reviewed. PCC [point click care] documentation has been reviewed to ensure that residents dietary order for NPO was in and correct. Dietary tickets were reviewed and confirmed to ensure resident did not receive a ticket. Statements obtained from all nursing staff on shift at the time of the incident occurred. Interviews verified no tray was observed with [Resident #110]. Statements were obtained from the dietary staff that was bringing the trays to the floors. Interviews verified that no tray was prepared. Statements have been collected from all staff that have been completing 1:1 observation with alleged perpetrator following this incident. A statement was obtained from resident [#35] who is alert and oriented x 3, that was in the room speaking with the alleged perpetrator when this incident occurred. Resident [#35] stated that she did not witness anyone feed [#110] . After a complete investigation, this incident has been found to not be verified. After reviewing statements obtained from staff, no one observed any staff, resident's roommate, or visitors feeding or attempting to feed Resident [#110]. Alleged perpetrator adamantly denies that she attempted to feed the alleged victim at anytime. Resident [#35] also reports that they did not witness anyone attempt to feed the alleged victim prior to this incident. All witness statements support [Resident #61] and [Resident #35] statements of no one was seen feeding [Resident #110]. Due to the incident being found to be not verified, no further actions will be taken by the facility. According to the death certificate, the death injury occurred on 06/13/25 at 8:28 PM. The cause of death was choked on food bolus. Resident #110 had experienced a stroke and had an order to receive nothing by mouth (NPO). She received all her nutrition via enteral feeding. A speech therapy evaluation completed on 06/13/2025, documented the resident had profound/absent swallowing abilities, with little to no attempts to initiate/participate and profound global aphasia with no verbalizations or voicing noted during the assessment. A physical therapy evaluation completed on 06/13/2026, documented Clinical Impression stated, Patient is very weak, is bed bound, unable to sit or stand, needs a lot of assistance with bed mobility, is at risk for falls and is very limited with her mobility and independence. Resident #61's meal ticket was reviewed. She had received meatloaf the evening of 06/13/2025. This information was not included in the facility's investigation of the matter. Resident #35's statement was as follows: I was in the room talking to [Resident #61] when [Resident #110] was having trouble breathing. The nurses and aides started working on her and I left the room at that time. I did not try to feed [Resident #110] anything and I did not see [Resident #61] try to feed her anything. I was not in or near her room at dinner time. I did not see a food tray in the room when I was in there. Resident #61 stated on 06/13/25, I did not help her eat dinner but she was hungry. No one helped her eat dinner. Is she dead? She is dead, isn't she? She died, didn't she? Resident #61 stated on 06/17/25, She did not tell me that she was hungry. She had not ate anything in two days. No one tried to feed her, so she had to be hungry. I did not try to feed her. No one told me she was NPO. Resident #61 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) and was determined to not have capacity. On 08/12/2025 at approximately 03:00 PM, the Administrator and Director of Nursing were interviewed by the State Surveyor concerning a Facility Reported Incident concerning Resident #110 and #61 on 06/13/2025. The Administrator reported the resident’s oxygen saturations decreased and she was sent to the hospital. The Director of Nursing (DON) reported, generally they contact physician when oxygen saturations decrease. Following the report from the hospital, the Administrator reported Resident #61 was placed on 1:1 observation because we weren’t 100% sure she didn’t provide any food by mouth. The Administrator stated, the investigation led to the conclusion a meal was not served and that they could not solidly conclude Resident #61 did it. The Administrator reported the was no follow-up education for other NPO residents. The Administrator reported she was unsure of the follow-up for the incident until she looked at the Facility Reported Incident. On 08/12/2025 at 04:25 PM, the Administrator reported they brought before the Quality Assurance and Performance Improvement (QAPI) committee review of NPO residents to be with like residents (NPO) or residents that take their meals in the dining room. There was no education outlined for residents with modified diets in the QAPI plan.

Based on record review, staff interview and observation, the facility failed to ensure food was stored in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 102Findings included: a) The facility's policy and procedure for Receiving and Storage of Food stated, Date the food packages and store them properly. when receiving items, Dry Foods - Store opened packages in closed, labeled containers. and Frozen Food - tightly wrap open bags and boxes to prevent freezer burn. The facility's policy and procedure for Storage of Resident Food included: Daily monitoring for refrigerated storage duration and discard of any food item that may have been stored for >7 days. Regional Dietary Manager #155 confirmed dating for opened items was seven (7) days for thickened liquids and food items. b) On 08/11/2025 at 10:18 AM, the kitchen investigation was initiated with Regional Dietary Manager (RDM) #155. The following items were found: b1) Imperial Thickened Liquid - Lemon Water - opened and no use by date.b2) [NAME] Spaghetti not sealed with no use by date. RDM #155 stated, I'll just discard these. b3) Pancake Syrup - opened and no use by date b4) Frozen green beans - not labeled and no use by date.b5) Chicken pot pie mix - not labeled or dated. c) On 08/13/2025 at 09:05 AM, LPN # 16 confirmed the following items in the nourishment pantry for C and D Halls: c1) Simply Thick Easy Mix - opened and no use by date.c2) Foldgers Classic Roast Instant Coffee - Opened and not dated.c3) [NAME] [NAME] Whole Grain Bread - opened and not sealed. d) On 08/13/2025 at 09:15 AM, Licensed Practical Nurse (LPN) # 79 confirmed the following items in the nourishment pantry for A and B Halls: d1) Talenti Dairy Free Sorbetto - opened and not dated.d2) Nestle Cookie Dough Ice Cream by Toll House - opened and not dated.d3) [NAME] Deluxe Chocolate Ice Cream - opened and not dated.d4) Great Value Sweet Relish - opened and not dated.d5) Hidden Valley Ranch Dressing - opened and dated 05/19/2025-05/21/2025.d6) Thickened Sweetened Tea with Lemon Flavor -opened with no use by date.d7) LiquaCel - dated 7/23 - no use by date.d8) Powerade - opened and no use by date.d9) Simply Thick Easy Mix - opened and no use by date.

Based on record review, observation and staff interview, the facility failed to ensure a dignified dining experience by providing plastic silverware to residents during meals and failed to announce/knock on the door before entering a resident's room. This failed policy had the potential to affect more than a limited number of resident's. Resident Identifier : #20. Facility census: 102. Findings included: a) On 08/11/2025 at 11:52 AM, the Dining Room observation was initiated by the state surveyor. Nineteen (19) out of twenty residents (20) in the main dining room were served their lunch meal with plastic silverware. On 08/11/2025 at 12:40 PM, Registered Nurse (RN) #81 stated, not usually when asked if they use plastic silverware. The Employee Life Cycle Manager stated, I was told by the kitchen they ran out of clean silverware. On 08/13/2025 at 1:25 PM, plastic silverware was observed to be placed on the resident trays going to the last halls. [NAME] #138 stated they were out of regular silverware and would have to use plastic. [NAME] #137 stated, it was too late to wrap (regular silverware) because it was not washed in time. [NAME] #138 stated that the delivery truck came on Monday and delivered silverware. At 1:26 PM, when brought to the attention of staff by state surveyor, plastic silverware was removed from the trays and regular silverware was bagged during tray line and placed on the remaining trays. The Regional Dietary Manager #155 educated the kitchen staff on plastic silverware being a resident dignity issue. On 08/12/25 at 1:42 PM, during an interview with Resident #20, Nurse Aide (NA) #39 opened the door to the resident’s room while talking to another resident. NA#39 then turned, saw the surveyor in the room, and closed the door without knocking or announcing themselves prior to entry. During an interview on 08/14/25 at 1:55 PM with Unit Manager #41, when asked about the incident, the Unit Manager stated: “No, she should have knocked, I will talk to her about it now. A record review of the facility’s Policies and Standard Procedures dated 08/14/25 revealed the following under Procedure, Section B – “When providing care” “i. Knock before entering the resident room if the door is closed – Wait for answer.” “ii. If no answer, knock a second time before entering and announce your entrance.” The facility failed to follow its policy and ensure resident privacy and dignity when staff entered Resident #20’s room without knocking.

Based upon record review and staff interviews, the facility failed to ensure reported irregularities from the Pharmacist were reviewed and addressed by the Resident's physician. This was found to be true for three (3) of five residents reviewed during the annual survey process. Resident identifiers: #10, #12, and #85. Facility census: 102.a) Resident #10 The Long Term Care Pharmacist Recommendation completed in accordance with monthly Medication Record Review (MRR) dated 04/30/25, stated (First name of Resident) has orders for both Meloxicam tabs and Voltaren gel. Since these medications are both NSAIDs, and taking them together increases risk of side effects, please consider discontinuing one of these orders. This recommendation was not reviewed by the resident's medical provider and no action was taken on the recommendation. This was reviewed with the Nursing Home Administrator on 08/12/25 at 4:31 PM, and she was asked if she had anything showing the Physician had reviewed this recommendation. She indicated she would look and get back with me. This was reviewed again with the Director of Nursing and Nursing Home Administrator on 08/19/25, and asked if there was any additional information. None was provided. b) Resident #23 The facility's policy and procedure titled Medication Regimen Review with effective date February 2025 stated the prescriber was to accept and act upon the pharmacist's suggestion or reject the suggestion and provide an explanation for disagreement. Review of Resident #23's physician's orders showed an order written on 04/28/25 for Unisom sleep tabs (doxylamine succinate), 25 mg at bedtime for insomnia. Further review of Resident 23's medical records showed a pharmacist recommendation written on 04/30/25. The recommendation stated, [Resident] has a new order for Unisom for insomnia. He is on a number of medications that can cause anticholinergic side effects (Unisom, Olanzapine, Bupropion, and Zyrtec.) Combining all these medications can increase risk of confusion, falls, urinary retention, etc. He has a dx [diagnosis] of dementia and is also taking Flomax for urinary retention. Recommendation: Please consider discontinuing the Unisom to reduce the risk of anticholinergic side effects. The recommendation form had space for the physician/prescriber response. There were boxes for the provider to check for Agree, Disagree, and Other. There was an area for the physician to write notes, as well as a line for physician signature and date. The physician response areas, signature, and date were blank on the form. On 08/18/2025 at 1:05 PM, the Director of Nursing (DON) stated she had no documentation the physician had reviewed and responded to the pharmacist recommendation. No further information was provided through the completion of the survey process. c) Resident #85 A review of Resident #85's medical record on 08/18/25 found a Long Term Care Pharmacist Recommendation dated 06/30/25 which read as follows, (First Name of Resident #85) was started on Metformin 500 mg (milligrams) BID (twice daily) on 06/19/25. It is recommended to check a BMP at baseline and then Q(every) 6 months when taking this medication. The last BMP I could find in (Name of Electronic Record) was from 08/21/24. Please consider obtaining a BMP now. Further review of this form found the attending physician marked agree and signed the form on 07/05/25 indicating he wanted the BP to be done now as recommended by the pharmacist. Further review of the medical record found no BMP results since 08/21/24. An interview with the Director of Nursing (DON) on 08/18/25 confirmed the BMP was not completed.

Based on observation, record review, staff interview and resident interview, the facility failed to ensure menus were followed and distributed and residents received the foods they wanted/ordered. This failed practice had the potential to affect more than a limited number of residents. Resident identifier: #112. Facility Census: 102 Findings included: a) On 08/11/2025 the morning resident communication stated, Always Available: Ham & Cheese Sandwich, Turkey & Cheese Sandwich, Bologna & Cheese. At 12:08 AM, Activity Leaders #72 and #80 confirmed, the kitchen was out of lunch meat the last couple of days. On 08/13/2025, the lunch menu stated: chicken tenders, green beans, mashed potatoes, rolls and ice cream. At 1:00 PM, the kitchen ran out of chicken tenders during the tray line. The Regional Dietary Manager contacted the Registered Dietician and and substituted chicken patties. During the wait for the chicken patties to bake, two staff members came into the kitchen to request more chicken tenders. At 1:15 PM, another staff member came in the kitchen to request eight (8) chicken tenders for a resident waiting on his tray and a yogurt. [NAME] # 138 stated they were out of yogurt. On 08/13/2025, Regional Dietary Manager #155 confirmed there was no lunch meat until the delivery truck arrived on Monday, 08/11/2025. On 08/14/2025, the menu/recipe called for Zucchini, Parmesan Baked (fresh). The zucchini served and tasted by the state surveyors was boiled without flavor/spices added. Corporate Recipe Number 1462 listed the ingredients and procedures as follow: Amount 24 lb - Squash, Zucchini, Fresh 1 1/3 Tbsp. - Spice, Pepper, Black , Ground 2 Cup - oil, Olive, Blend 1/1/2 Qt - Cheese, Parmesan, Grated 1 Cup - Garlic, Minced/Chopped, In Water Procedures: 1. Wash, cut ends, wash and slice squash into 1 inch slices. 2. Toss lightly with olive oil and pepper. 3. Combine the parmesan cheese and minced/chopped garlic. Mix and sprinkle over the zucchini. 4. Bake at 400'F for about 15 minutes or until the zucchini are tender and the cheese is browned. On 08/14/2025 at approximately 1:30 PM, the state surveyor Interviewed [NAME] #38 who reported there was no parmesan and stated, We did not have it. and the zucchini was not baked. [NAME] #38 reported, I didn't know we had recipes. b) Resident #112 During an interview on 08/11/2025 at 11:33 AM, Resident #112 stated, the food sucks, but did not elaborate. On 08/14/2025 at 12:04 PM, Resident #112 was observed eating lunch in his room. He stated he did not like spaghetti, which was on the menu for the day. He stated he received two (2) peanut butter sandwiches but ,I'm getting tired of peanut butter. Review of the resident's tray ticket showed he was to get double fruit portions for lunch and dinner. The tray ticket also stated he was to get one (1) garlic bread, one (1) vanilla ice cream, coffee or tea and whole milk. PBJS w/ chips was also hand-written on the tray ticket. Observation of the resident's tray showed he had received the following: two (2) peanut butter and jelly sandwiches, chips, one (1) fruit cocktail cup, a carton of milk, and a hot beverage. He also had a bowl with a lid. When the resident opened the bowl, it was found to have a piece of garlic bread in it. The resident did not have the ice cream that was indicated on the ticket. He also did not have the double fruit portions that were indicated on the ticket. The resident stated he liked fruit and ice cream and would eat them if provided. On 08/14/2025 at 12:17 PM, the Administrator confirmed the resident had not received double portions of fruit or vanilla ice cream. The resident stated he would like to have them. The Administrator stated she would get them for the resident.

Based on observations, staff interview and resident interview, the facility failed to ensure food was prepared by methods that conserve nutritive value, flavor, and appearance and provide food that is palatable, attractive, and at a safe and appetizing temperature. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #35, #20, #112, and #115. Facility Census: 112. a) Resident #115 During an interview with Resident #115 on 08/11/25 at 12:17 pm he stated, the food was not good. He indicated it was always ice cold when he got it. He stated he never gets what supposed to be on the menu it is always different and not as good as what is on the menu. b) On 08/14/2025 at 12:55 PM, a test tray containing spaghetti with meat sauce, parmesan baked zucchini, garlic bread and ice cream, was provided to the state surveyors. The zucchini was not prepared per the recipe. The zucchini was not baked, but was boiled. The zucchini was sliced with seeds and skins. The zucchini was judged by state surveyors to be bitter, tough, hard to chew, watery, stringy and rubbery by the state surveyors and was unable to be mashed with a fork. Recipe provided by the Regional Dietary Manager #155 was for seasoned, baked zucchini. On 08/14/2025, the menu/recipe called for Zucchini, Parmesan Baked (fresh). Corporate Recipe Number 1462 listed the ingredients and procedures as follow: Amount 24 lb - Squash, Zucchini, Fresh 1 1/3 Tbsp. - Spice, Pepper, Black , Ground 2 Cup - oil, Olive, Blend 1/1/2 Qt - Cheese, Parmesan, Grated 1 Cup - Garlic, Minced/Chopped, In Water Procedures: 1. Wash, cut ends, wash and slice squash into 1 inch slices. 2. Toss lightly with olive oil and pepper. 3. Combine the parmesan cheese and minced/chopped garlic. Mix and sprinkle over the zucchini. 4. Bake at 400'F for about 15 minutes or until the zucchini are tender and the cheese is browned. On 08/14/2025 at approximately 01:30 PM, the state surveyor Interviewed [NAME] #38 who reported there was no parmesan and stated, We did not have it. and the zucchini was not baked. On 08/14/2025, the state surveyor interviewed [NAME] #138 concerning diet menus and [NAME] #138 replied they don't use menus and stated I didn't know we had a recipe. [NAME] #138 reported they don't use recipes. When asked what they use to determine consistencies, [NAME] #138 reported the Regional Dietary Manager (RDM) checks it. The Garlic Bread was judged to be tough on the outside edges. Last tray from cart temped by DM #158, new tray requested for the resident - had to make more puree secondary to being out. On 08/18/25 at 12:52 PM, the temperatures of the last tray served on D hall were confirmed and taken by Dietary Manager #158. The temperatures were as follows for the puree tray: Carrots 111 degrees Pot Pie 109 degrees Bread 107 degrees Pudding 75 degrees On 08/11/2025 at 12:21 PM, during the initial screening process, Resident #35 reported the food served was cold and tough. She reported there was an argument in the kitchen yesterday and they did not get their ordered food. The resident also stated, the food is cold because they leave it out there (indicating the hallway) and do not deliver until late. c) Resident #112 During an interview on 08/11/2025 at 11:33 AM, Resident #112 stated, The food sucks, but did not elaborate. Upon further questioning, the resident stated he always ate in his room and the food was not always hot when he received his tray. d) Resident #20 An interview on 08/11/2025 at 3:00 PM with Resident #20 who stated, The food is horrible, and they do not give you enough. We don't get to choose something different because they never have what is on the alternate. I am supposed to get 2 eggs bacon and a slice of toast for breakfast. However, I do not always get them even though that's what my ticket says. Resident #20 continued to say, And whatever we do get is served cold.

Based on record review, observation, resident interview and staff interview, the facility failed to ensure meals were provided at regular times for the residents and failed to ensure a resident received breakfast and lunch on his dialysis days. This failed practice had the potential to affect more that a limited number of residents. Resident Identifier: #33. Facility Census: 102. b) Resident #33 During an interview with Resident #3 on 08/11/25 at 3:22 PM the resident stated, the facility does not consistently send him a lunch to dialysis he stated sometimes the aide will make him one but it is not very often. A review of Resident #33's medical record found a physician's order which read as follows: DIalysis services provided by (Name of Dialysis Center) at (Address of Dialysis Center) phone number (Phone number of dialysis Center) EMS (Emergency Medical Services) to transport Pick up time 5:45 am. Scheduled on Tuesday, Thursday an Saturday chair time 6:45 am. Schedule is subject ot change weekly. Send a bagged breakfast and lunch to go with and come back from dialysis every day shift for kidney failure. During an Interview with the Corporate Registered Nurse at 2:00 PM on 08/13/25, she stated they initial on the Treatment Administration Record (TAR) that Resident #33 takes a lunch with him. She stated, we believe he is eating it before he goes. An interview with Dietary Staff #44 in the late afternoon of 08/13/25 she stated they send Resident #33 a bagged lunch. When asked if he gets one (1) or 2 (two) meals sent with him she stated, We only send one for lunch. The Director of Nursing (DON) was notified of this interview with the kitchen staff later in the afternoon of 0813/25. No further information was provided. The facility provided a schedule of mealtimes to the state surveyor. The meal times were listed as follows: Breakfast :7:30-8:30 Lunch: 11:20-12:30 Dinner: 5:30-6:30 On 08/13/2025 at 1:45 PM, the last ray was delivered on 'D hall and food temperatures were taken by the Regional Dietary Manager #155. On 08/18/2025 at 12:14 PM, resident lunch trays from the halls were brought to the main dining room and placed on a cart. At 12:52 PM , the last tray from the cart was served and Dietary Manger #158 tested the pureed tray temperatures. On 08/19/2025 at 12:46 PM, tray service for the main dining room was initiated. At 1:15 PM, Nurse Aide (NA) #31 confirmed the kitchen sent out the trays and didn't have enough pears and reported the kitchen was going to send them out later.

Based on observation, record review, and staff the facility failed to establish and maintain an infection prevention and control program designed toprovide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Transmission based precautions were not followed for two (2) of three (3) residents reviewed for transmission based precautions. Proper hand hygiene was not performed for one (1) of two (2) dressing change observations. Resident Identifiers: #43 and #107. Facility census: 102. Findings included:a) Resident #43 The facility's skills checklist for competency titled Uncomplicated Dressing Change, with no implementation date given, stated to remove perform hand hygiene after removing soiled gloves and donning additional gloves. The facility's policy and procedure titled Standard Precautions, with no implementation date given, stated to perform hand hygiene when moving from a contaminated body site to a clean body site. An example given was when performing perineal care and then performing a dressing change. On 08/13/2025 at 3:32 PM, observation was made of Licensed Practical Nurse (LPN) #16 performing Resident #43's pressure ulcer dressing changes. The Infection Preventionist was assisting with positioning of the resident. LPN #16 removed the dressing on the resident's left trochanter pressure ulcer. He changed gloves but did not perform hand hygiene. He then cleansed the wound and changed gloves again without performing hand hygiene. After applying the new dressing, LPN #16 again changed gloves without performing hand hygiene. The resident was incontinent of stool. LPN #16 performed incontinent care with wet wipes and changed the resident's brief. Following this, he changed gloves but did not perform hand hygiene. LPN #16 then changed the dressing on the resident's left ischium. He changed gloves after removing the old dressing and after cleansing the wound. However, he did not perform hand hygiene. Following the completion of the left ischium dressing change, LPN #16 removed his gloves a final time and performed hand hygiene using hand sanitizer. When questioned, LPN #16 acknowledged he did not perform hand hygiene when changing gloves during the dressing changes and after incontinence care. No further information was provided through the completion of the survey process. Review of Resident #43's physician's orders showed an order written on 08/19/25 for contact isolation for extended-spectrum beta-lactamase (ESBL) infection of the urinary tract. Prior to this, the resident was on enhanced barrier precautions due to having an indwelling urinary catheter and wounds with dressings. Outside the resident's room was a sign stating the resident was in contact precautions and staff must gown and glove at the door. On 08/20/2025 at 9:00 AM, Nursing Assistant (NA) #109 was observed feeding Resident #43 in the resident's room. NA #109 was sitting in a chair beside the resident's bed and not wearing a gown or gloves. When questioned, NA #109 stated she didn't know the resident was now in contact isolation. She said she didn't notice the sign change from enhanced barrier precautions to contact isolation. b) Resident #107 Review of Resident #107's physician's orders showed an order written on 08/08/25 for contact isolation and enteric precautions due to Clostridioides difficile or C diff. Outside the resident's room was a sign stating the resident was in contact enteric precautions and staff must gown and glove at the door. The sign also stated to clean hands with sanitizer when entering the room and wash with soap and water upon leaving the room. (Because C. diff forms spores that are resistant to hand sanitizer, soap and water is a more effective method of hand hygiene.) On 08/19/25 at approximately 1:00 PM, NA #82 was observed taking Resident #107's lunch tray into the room. NA #82 was not wearing a gown or gloves. While she was in the resident's room, NA #82 set up Resident #107's meal tray,. While in the room, she also touched the resident's shoulder, wheelchair, and the resident's bed control. Upon leaving the room, NA #82 did not wash her hands with soap and water. Instead, she used hand sanitizer located in the hallway. When questioned, NA #82 stated the precautions only applied to resident care, not to tray delivery. On 08/19/2025 at 2:04 PM, the Director of Nursing (DON) confirmed contact enteric precautions applied to all staff entering Resident #107's room.

Based on record review and staff interview, the facility failed to provide influenza and pneumococcal vaccines within accepted standards of practice. The facility failed to retain documentation that residents or their resident representatives received education regarding the vaccines and failed to retain documentation as to whether the vaccines were accepted or refused. These deficient practices had the potential to affect three (3) of five (5) residents reviewed for the care area of influenza and pneumococcal immunizations. Resident Identifiers: #20, #33, #107. Facility census: 102.Findings Included: Policy ReviewThe facility's policy titled Resident Immunization Overview with no implementation or revision date given stated the resident or resident party will be asked to accept or decline influenza and pneumococcal vaccinations by completing the influenza and pneumococcal consent or declination forms. a) Resident #20Review of Resident #20's medical record showed an immunization report that stated the resident received influenza vaccination on 10/22/24. However, the resident's record did not contain a vaccination consent or refusal form which would have contained information that the resident or resident representative were informed of the benefits and potential side effects of the immunization and whether the vaccination was accepted or refused. b) Resident #33 Review of Resident #33's medical record showed an immunization report that stated the resident received influenza vaccination on 10/08/24. However, the resident's record did not contain an influenza vaccination consent or refusal form which would have contained information that the resident or resident representative were informed of the benefits and potential side effects of the immunization and whether the vaccination was accepted or refused. Review of Resident #33's medical record showed an immunization report that stated the resident refused pneumococcal vaccination. However, the resident's record did not contain a pneumococcal vaccination consent or refusal form which would have contained information that the resident or resident representative were informed of the benefits and potential side effects of the immunization and whether the vaccination was accepted or refused. c) Resident #107 Review of Resident #107's medical record showed an immunization report that stated the resident refused pneumococcal vaccination. However, the resident's record did not contain a pneumococcal vaccination consent or refusal form which would have contained information that the resident or resident representative were informed of the benefits and potential side effects of the immunization and whether the vaccination was accepted or refused. On 08/13/2025 at 9:29 AM, the Director of Nursing (DON) stated they do not have these immunization consents or refusals. She stated the prior Infection Preventionist's immunization consents and refusals could not be located.

Based on observation, record review, staff interview and resident interview, the facility failed to ensure food preparation/food service areas and resident rooms were free from visible signs of insects. This failed practice had the potential to affect more than a limited number of residents: Resident identifiers: #26 and #112. Facility Census:102 Findings included: On 08/14/25 at 9:45 AM, the administrator reported there was a Quality Assurance and Performance Improvement (QAPI) for flies with increased services added bi-weekly May-October. Three (3) large fly lights were installed at 2 exit doors to courtyard and main facility entrance. The Administrator reported there was no specific policy and procedure for pest control. On 08/13/25 at 9:55 AM, a fly was observed in the dishwasher area. At 12:25 PM, a fly was in the kitchen area around the food service area, near plates and food, and tray line. [NAME] #137 confirmed there was a fly in the area and stated, Yes, he targets me. On 08/20/25 at 11:36 AM, during the initial interview process, Resident #26 stated, I'm alright if the fly goes away. The resident reported, A nurse came in and killed four (4) of them. The resident stated he had been looking for the fly swatter he kept in his room. d) Resident #112 During an interview on 08/11/2025 at 11:32 AM, Resident #112 was noted to have a flyswatter on his overbed table. He stated the flyswatter was for the flies that were always in his room. Two (2) flies were noted in his room at that time.

Based on observation and staff interview, the facility failed to provide a homelike dining environment by having soiled air conditioning vents in the main dining room area. This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 102. Findings included: a) On 08/18/2025 at 12:15 PM, soiled, portable air conditioner vents were observed by the state surveyor. The dining room contained three, large, portable air conditioners. Two (2) out of three (3) large flexible hoses/vents were observed to have a dark, dusty, blackish substance on them. Air was blowing out of the vents into the dining room. b) On 08/18/2025 at 12:20 PM, the Administrator confirmed the soiled vents and stated, I will remedy that immediately.

Based on record review and staff interviews, the facility failed to ensure the continuing competence of nurse aides by not providing at least twelve (12) hours of continuing education per year. This was found to be true for three (3) of five (5) nurse aide training records reviewed during the annual survey process. Nurse Aide (NA) identifiers: #5, #10, and #77. Facility census: 102. Findings included: a) Nurse Aide (NA) #5 Nurse Aide #5 was hired on 01/05/24. The facility provided a Relias transcript for the period of 08/01/24 through 07/31/25. A review of this transcript records 8.35 hours of education completed during this period including 1.5 hours of training related to Alzheimer's disease or dementia. b) Nurse Aide (NA) #10, Nurse Aide (NA) #10's date of hire was 05/19/20. The facility provided a Relias transcript for the period of 08/01/24 through 07/31/25. A review of this transcript records 9.1 hours of education completed during this period including 2.5 hours of training related to Alzheimer's disease or dementia. c) Nurse Aide (NA) #77 Nurse Aide #77 was hired on 12/11/18. The facility provided a Relias transcript for the period of 08/01/24 through 07/31/25. A review of this transcript records revealed no hours of education completed during this period including 0 hours of training related to Alzheimer's disease or dementia. These findings were reviewed with Life Cycle Manager (LCM) #35, on 08/18/25 at approximately 5:00 PM. She stated she was new to her role and would make sure new hires are getting their required education within an employee's first 30 days of employment. She further stated she would follow-up on these nurse aides who were not in compliance. These findings were also reviewed with the Director of Nursing and the Nursing Home Administrator on 08/19/25 at approximately 4:22 pm. There was no additional information provided by them, and they had no comment to make.

Based on record review and staff interview, the facility failed to ensure medical records were maintained accurately in accordance with accepted professional standards for residents in the facility as evidenced by the following: The facility failed to ensure correct diagnosis was given for an ordered medication, The facility failed to document physician follow-up from a related psychological consultation and orders given by the physician,The facility failed to correctly document dates on a Facility Reported Incident (FRI),The facility failed to add a diagnosis to the medical record,The facility failed to obtain signature date on a Physician Orders for Scope of Treatment (POST) form,The facility failed to provide a correct diagnosis for medication,The facility failed to order a dressing for the correct foot,The facility failed to document meal intakes consistently,These failed practices had the potential to affect more than a limited number of residents. Resident identifiers: #35, #38, #82, and #43. Facility Census: 102. Findings included: a) Resident #35 On 08/19/2025 at 04:46 PM, Resident #35's Determination of Capacity was reviewed by the state surveyor. Resident #35's Physician's Determination of Capacity was marked was marked Demonstrated CAPACITY to make decisions. and was also marked under demonstrated incapacity :duration: Long Term. The Administrator and Director of Nursing confirmed the resident was capacitated and stated it was a clerical error. b) Resident #38 On 07/31/25, Cimetidine (Tagamet) was ordered and started with a diagnosis of Gastroesophageal Reflux Disease (GERD) without esophagitis. On 08/14/25 at 12:05 PM, the Director of Nursing confirmed the order stated for GERD, but reported it was started for sexual behaviors. On 07/27/25, a Behavioral Health and Psychology Note recommended, -Consider Decreasing Trazodone from 100 mg QHS to 75 mg QHS. Monitor for rebound insomnia, mood destabilization, or irritability. On 08/14/2025 at 12:05 PM, the Director of Nursing stated she remembered the physician said to keep Trazodone and start Tagamet. No documentation was found to support this. The Director of Nursing stated, I don't remember getting recommendations, but she wrote it. - referring to psychologist recommendations. An initial Facility Reported Incident (FRI) was faxed on 05/01/25. The date of the incident on the initial report was 05/02/25 at 11:AM. Three witness statements obtained by the facility were dated 05/01/25. Abuse interviews were conducted on 05/02/25 per the documentation. On 08/18/25 at 10:08 AM, the Director of Nursing confirmed the inaccurate dates of the incident's documentation dated 05/02/25. On 08/18/2025 at 10:08 AM, the Director of Nursing confirmed there was no diagnosis of dementia on the resident's diagnosis list, but dementia was listed on the resident's Pre admission Screening and Resident Review (PASARR) and Physician's Determination of Capacity. The Director of Nursing confirmed there was no diagnosis of dementia on the resident's medical chart or on the resident's care plan when the records were given to the state surveyor on 08/14/25. c) Resident #83 On 08/11/25 at 2:07 PM, Resident #83's (Physician Orders for Scope of Treatment form (POST) was reviewed by the state surveyor. Resident #83's Health Care Surrogate (HCS) signed the POST form but not dated the POST form. The missing date was confirmed by the Director of Nursing on 08/18/2025 at 10:08 AM. d) Resident #43 Review of Resident #43's physician's orders showed an order written on 07/11/25 for divalproex sodium (Depakote), 250 milligrams (mg), give one (1) tablet by mouth three (3) times a day for anticonvulsant. Divalproex sodium can be used as an anticonvulsant [seizure prevention] or for mood stabilization. Review of Resident #43's diagnoses list did not show a diagnosis of seizures for the resident. Resident #43's comprehensive care plan stated, The resident uses, mood stabilizing medication (depakote) r/t [related to] schizophrenia, restlessness & agitation, dementia with mood disturbance, anxiety disorder. On 08/19/2025 at 5:25 PM, the Director of Nursing (DON) stated the indication for Resident #43's divalproex sodium was incorrect as written. The DON stated the resident was receiving the medication for mood stabilization and not as an anticonvulsant. On 08/13/2025 at 3:32 PM, Resident #43 was noted to have a dressing on her left medial foot. The Nurse Practitioner's wound note written on 08/18/25 indicated the resident had a pressure injury to left medial foot, Review of Resident #43's physician's orders showed an order written on 07/14/25 for wound care of the right medial foot. On 08/19/2025 at 5:25 PM, the Director of Nursing (DON) confirmed Resident #43's foot dressing change order was incorrect, and should have given the location as the left foot. Review of Resident #43's meal percentage intakes for the past 30 days revealed the resident's meal intake had not been recorded every meal on 13 days. These dates were as follows: - On 07/23/25, meal intakes for only two (2) meals were recorded. - On 07/28/25, meal intakes for only two (2) meals were recorded. - On 08/01/25, meal intakes for only two (2) meals were recorded. - On 08/02/25, meal intakes for only two (2) meals were recorded. - On 08/03/25, meal intakes for only two (2) meals were recorded. - On 08/05/25, meal intakes for only one (1) meal was recorded. - On 08/06/25, meal intakes for only two (2) meals were recorded. - On 08/07/25, meal intakes for only two (2) meals were recorded. - On 08/08/25, meal intakes for only two (2) meals were recorded. - On 08/11/25, meal intakes for only two (2) meals were recorded. - On 08/12/25, meal intakes for only two (2) meals were recorded. - On 08/15/25, meal intakes for only two (2) meals were recorded. - On 08/17/25, meal intakes for only two (2) meals were recorded. On 08/20/25 at 9:32 AM, the Director of Nursing (DON) confirmed Resident #43's meal intakes had not been recorded at every meal during the last 30 days.

Based upon record review and staff interview, the facility failed to inform a resident's representative of the benefits and risks of psychotropic medication. This was found to be true for one (1) of five (5) residents reviewed during the annual survey process. Resident identifier: #6. Facility census: 102a) Resident #6A review of the Resident's medical record, Section entitled Orders, documented the following psychotropic medications being given: Zyprexa Oral Tablet 15 MG (Olanzapine)Give 15 mg by mouth at bedtime for schizoaffective disorder04/03/25The Resident did not have capacity to make her own Informed consents, so the representative signed and acknowledged consent specifying the benefits and risks affiliated with the following medications on 12/04/24 for Lorazepam, Zoloft, Haloperidol.There was no informed consent in the medical record for Zyprexa, so this was requested during the survey. The Director of Nursing (DON) verified on 08/13/25 at 10:35 AM that she could not locate a consent form for Zyprexa.

Based on record review and staff interview, the facility failed to honor residents' rights to establish directives regarding end-of-life care. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of advanced directives. Resident Identifier: #23. Facility census: 102. Findings included:a) Resident #23The facility's policy titled, Advance Directive (Resident's Right to Choose), with no implementation date or revision dates given, stated, Any decision making regarding the resident's choices in their medical order for life-sustaining treatment and/or advance directive will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care.Review of Resident #23's electronic health record (EHR) showed a Physician's Determination of Capacity dated [DATE]. The physician determined the resident had the capacity to make medical decisions. Further review of Resident #23's EHR showed a [NAME] Virginia Physician's Order for Scope of Treatment (POST) form dated [DATE]. A POST form is a medical order that specifies a resident's specific end-of-life treatment preference. On this POST form, Resident #23 specified that he wanted cardio-pulmonary resuscitation (CPR) in the event of pulselessness and breathlessness and full attempts to sustain life by all medically effective means. The resident's previous POST form indicated the resident wished to not be resuscitated in the event of cardiac arrest. Resident #23's physician orders showed a physician's order written on [DATE] for DNR, or do not resuscitate. On [DATE] at 2:10 PM, the Director of Nursing (DON) acknowledged that Resident #23's code status order was not updated when the resident completed a new POST form indicating his end-of-life wishes had changed. No further information was provided through the completion of the survey process.

Based on record review and staff interview, the facility failed to thoroughly investigate an allegation of resident to resident abuse for one(1) of nine (9) residents sampled during the facility's annual survey review . This failed practice had the potential to affect a limited number of residents. Resident identifier: #110. Facility Census: 102.Findings included:On 06/13/25 at 10:40 PM, an initial reporting of allegations was reported to the Office of Health Facility Licensure and Certification. The description of the allegation was as follows:Resident [#110] was coded by facility staff. CPR [cardiopulmonary resuscitation] and AED [automated external defibrillator] administered. EMS [emergency medical services] arrived at 8:45 PM to transport resident while still performing CPR. Call back from facility by paramedic at 9:18 PM to inform facility that resident has 2 quarter [NAME] [size] pieces of hamburger extracted from throat.The steps taken immediately to ensure the alleged victim was protected was to place the alleged perpetrator on 1:1 observation by staff. The five (5) day follow up investigation as follows:Resident [#110] was coded by staff. CPR and AED was administered. EMS arrived to transport resident to the hospital. Alleged perpetrator [#61] was immediately placed on 1:1 observation by staff. A statement was obtained from [Resident #61] (alleged perpetrator). PTSD [post traumatic stress disorder] screening has been completed with alleged perpetrator, with no adverse outcomes reported at this time. Nursing assignment sheets have been reviewed. PCC [point click care] documentation has been reviewed to ensure that residents dietary order for NPO was in and correct. Dietary tickets were reviewed and confirmed to ensure resident did not receive a ticket. Statements obtained from all nursing staff on shift at the time of the incident occurred. Interviews verified no tray was observed with [Resident #110]. Statements were obtained from the dietary staff that was bringing the trays to the floors. Interviews verified that no tray was prepared. Statements have been collected from all staff that have been completing 1:1 observation with alleged perpetrator following this incident. A statement was obtained from resident [#35] who is alert and oriented x 3, that was in the room speaking with the alleged perpetrator when this incident occurred. Resident [#35] stated that she did not witness anyone feed [#110] .After a complete investigation, this incident has been found to not be verified. After reviewing statements obtained from staff, no one observed any staff, resident's roommate, or visitors feeding or attempting to feed Resident [#110]. Alleged perpetrator adamantly denies that she attempted to feed the alleged victim at anytime. Resident [#35] also reports that they did not witness anyone attempt to feed the alleged victim prior to this incident. All witness statements support [Resident #61] and [Resident #35] statements of no one was seen feeding [Resident #110].Due to the incident being found to be not verified, no further actions will be taken by the facility. According to the death certificate, the death injury occurred on 06/13/25 at 8:28 PM. The cause of death was choked on food bolus. Resident #110 had experienced a stroke and had an order to receive nothing by mouth (NPO). She received all her nutrition via enteral feeding.A speech therapy evaluation completed on 06/13/2025, documented the resident had profound/absent swallowing abilities, with little to no attempts to initiate/participate and profound global aphasia with no verbalizations or voicing noted during the assessment.A physical therapy evaluation completed on 06/13/2026, documented Clinical Impression stated, Patient is very weak, is bed bound, unable to sit or stand, needs a lot of assistance with bed mobility, is at risk for falls and is very limited with her mobility and independence.Resident #61's meal ticket was reviewed. She had received meatloaf the evening of 06/13/2025. This information was not included in the facility's investigation of the matter. Resident #35's statement was as follows: I was in the room talking to [Resident #61] when [Resident #110] was having trouble breathing. The nurses and aides started working on her and I left the room at that time. I did not try to feed [Resident #110] anything and I did not see [Resident #61] try to feed her anything. I was not in or near her room at dinner time. I did not see a food tray in the room when I was in there. Resident #61 stated on 06/13/25, I did not help her eat dinner but she was hungry. No one helped her eat dinner. Is she dead? She is dead, isn't she? She died, didn't she? Resident #61 stated on 06/17/25, She did not tell me that she was hungry. She had not ate anything in two days. No one tried to feed her, so she had to be hungry. I did not try to feed her. No one told me she was NPO. On 08/12/2025 at approximately 03:00 PM, the Administrator and Director of Nursing were interviewed by the State Surveyor concerning a Facility Reported Incident concerning Resident #110 and #61 on 06/13/2025. The Administrator reported the resident's oxygen saturations decreased and she was sent to the hospital. The Director of Nursing (DON) reported, generally they contact physician when oxygen saturations decrease. Following the report from the hospital, the Administrator reported Resident #61 was placed on 1:1 observation because we weren't 100% sure she didn't provide any food by mouth. The Administrator stated, the investigation led to the conclusion a meal was not served and that they could not solidly conclude Resident #61 did it. The Administrator reported the was no follow-up education for other NPO residents. The Administrator reported she was unsure of the follow-up for the incident until she looked at the Facility Reported Incident.

Based upon record review and staff interview, the facility failed to update the Preadmission Screening and Resident Review (PASARR) when a new diagnosis of a major mental disorder occurred. This was found to be true for one (1) of ten (10) residents reviewed during the annual survey process. Resident identifier: #6. Facility census: 102.Findings Included:A) Resident #6The Resident's PASARR was completed on 11/07/24 by the facility. At that time the resident had the following diagnoses Bipolar Disorder, unspecified and Generalized Anxiety Disorder. Section V of the PASARR is Supplemental Questions. Question 40 is Major Mental Illness or suspected MI, with a list of options to check. Checked on this question was:#F for Schizoaffective Disorder and#H for Other. Other was specified to be Bipolar disorder, unspecified and Generalized Anxiety Disorder. A Level II evaluation was not required. A review of the Resident's medical record, Section entitled Medical Diagnoses listed the following mental health diagnoses: BIPOLAR DISORDER, UNSPECIFIED 5/18/2022 DX #11 During StayGENERALIZED ANXIETY DISORDER 2/28/2024 DX #17 During StayMAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE 1/29/2025 DX #19 During StaySCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE 6/11/2021 DX #19 Admitting DxThe Minimum Data Set (MDS) for the Resident was last updated on 07/28/25. Section I of the MDS is Active Diagnoses, under the Sub-section entitled Psychiatric/Mood Disorder, the following were checked as applying to this resident:Anxiety DisorderDepression (other than bipolar)Bipolar DisorderSchizophreniaComparing the PASARR and the MDS, the PASARR should have been updated on 01/20/25 when the diagnosis for Major Depressive Disorder, Recurrent, Moderate was added by the facility.This was reviewed with the Director of Nursing (DON) and the Nursing Home Administrator on 08/19/25 at 4:20 PM, and asked if they had any additional information to clarify this finding. Neither said they had anything.

Based on record review and staff interview the facility failed to implement Resident #33's care plan in regards to weights and Resident #85's care plan in regards to pain management. This was true for two (2) of 37 sampled residents reviewed during the long term care process. Resident Identifier: #33 and #85. Facility Census #102. Findings Include: a) Resident #33 A review of Resident 33's medical record on 08/11/25 found the following focus statement on the care plan: -- Resident with potential for altered nutrition status/nutrition related problems d/t diabetes obesity vitamin d deficiency, need for vitamin supplements, c/o heartburn w. nausea at times. He has the potential for weight fluctuations r/t kidney failur w/HD. Planned weight loss program r/t scheduled paracentesis. The goal associated with this practice statement read as follows: Resident will maintain adequate nutritional status through review dates as evidenced by consuming 75% of meals. The interventions related to this focus statement included: -- No facility weights unless patient in a readmission. Use only dialysis post weights. This intervention was added to the care plan on 11/21/23. A review of Resident #33's weights contained in the electronic medical record from 02/01/25 through current found the resident was weighed by the facility on the following days: -- 02/09/25 -- 02/10/25 -- 02/14/25-- 02/16/25 -- 02/18/25 -- 02/22/25 -- 02/23/25 -- 03/01/25 -- 03/08/25 -- 03/22/25 -- 04/05/25 -- 04/19/25 -- 05/17/25 -- 05/31/25 -- 06/14/25 -- 07/12/25 -- 07/19/25 and-- 07/29/25. An interview with the Corporate Registered Nurse (CRN) in the afternoon of 08/13/25 confirmed the resident care plan had not been implemented. b) Resident #85 1) Pain Management A review of Resident #85's care plan found the following focus statement: The resident c/o pain r/t impaired mobility, low back pain, headache Date Initiated: 07/31/2024 Revision on: 04/21/2025. The goal associated with this care plan read as follows: Resident will be able to verbalize relief of pain, through target date Date Initiated: 07/31/2024 Target Date: 10/20/2025 Interventions included: Administer non-pharmacological interventions 1.attempt repositioning 2. encourage rest period 3. dim lighting in room [ROOM NUMBER]. check for well fitting clothing and shoes Date Initiated: 07/31/2024 Revision on: 04/21/2025 NS CNA ACST SS TPM Complete pain assessment on admission / re-admission, quarterly, significant change, and PRN. Date Initiated: 07/31/2024 NS Follow Physician orders for complaint of pain Date Initiated: 07/31/2024 NS Monitor for adverse side effects to pain medication: change in mental status, NS delirium, falling, constipation, anorexia, excessive drowsiness Date Initiated: 04/21/2025 Observe for pain every shift. Date Initiated: 07/31/2024 NS Pain level Q shift (1-3 mild) (4-7 moderate) (8-10 severe) pain of 1-3 with no prn: contact practitioner, >= 4 with no prn or prn non-effective or new onset pain: contact practitioner. Document non-pharmacological pain intervention prior to PRN pain medication administration. Date Initiated: 05/05/2025 NUR Provide medication per orders. Monitor for s/sx of side effects. Evaluate effectiveness of medication. Date Initiated: 08/16/2024 Revision on: 07/21/2025 A review of Resident #85's medical record found the following physician orders related to pain: -- Non Pharmacological Interventions: 1. Attempt Repositioning. 2. Encourage Rest Periods. 3. Dim lighting in the room. 4. Check for well fitting clothing and shoes as needed. Order effective date 04/20/25 and current at the time of this review. -- Pain level q (every shift) (1-3 mild) (4-7 moderate) (8-10 severe) pain 1-3 with no PRN (As needed): contact practitioner, greater than or equal to 4 with no PRN or PRN not effective or new onset pain contact practitioner. Document non-pharmacological pain intervention prior to PRN pain medication administration. Order effective date 04/21/25 and current at the time of this review. -- Tylenol Oral Tablet 325 MG give 650 MG by mouth every 6 hours as needed for pain. This order had an effective date of 01/30/25 and was discontinues on 05/16/25 when an new Tylenol order was entered. -- Acetaminophen Extra strength oral tablet 500 mg Give 2 tablets by mouth every eight (8) hours as needed for pain. Order effective date 05/16/25 and current at the time of this review. A review of the medication administration records for the months of 05/2025, 06/2025, 07/2025 and 08/2025 found the following occasions when Registered Nurse (RN) #44 documented the resident was experiencing pain but provided no interventions to treat the pain nor did she contact the practitioner about the resident experiencing pain. Day Shift: --05/05/25 pain score of 5. -- 05/06/25 pain score of 5.-- 05/11/25 pain score of 10. -- 05/14/25 pain score of 8. -- 05/23/25 pain score of 2. -- 05/29/25 pain score of 2. -- 06/07/25 pain score of 2. -- 06/16/24 pain score of 3. -- 06/17/24 pain score of 3. --06/23/25 pain score of 2. -- 07/04/25 pain score of 1. -- 07/05/25 pain score of 8. -- 07/10/25 pain score of 2. -- 07/20/25 pain score of 3. -- 07/21/25 pain score of 2. -- 07/28/25 pain score of 8. -- 07/29/25 pain score of 3. -- 08/01/25 pain score of 3. -- 08/06/25 pain score of 3. -- 08/07/25 pain score of 3. Nigh Shift: -- 07/29/25 pain score of 3. Further review of the MAR's for this time period found the non- pharmacological interventions nor the PRN pain medications was never provided by RN #44. A review of the progress notes found no indication the physician was notified of the residents reports of pain. During an interview with the Director of Nursing (DON) in the afternoon of 08/20/25 she confirmed there was no further information she could provide related to Resident #85's complaints of pain. She agreed the care plan had not been implemented in regards to pain management.

39571 Based on observation, record review, and staff interview the facility failed to establish 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 diseases and infections, during a confirmed COVID 19 outbreak. This failure to protect the residents from the spread of COVID 19, resulted into an Immediate jeopardy with the potential to cause illness and/or death to the residents who reside in the facility. Facility census: 111. Findings included: a) Upon entrance to the facility on [DATE] at 10:45 AM, the survey team was told by Assistant Business Office Worker #14 the facility was not currently in a COVID-19 outbreak. On 10/25/23 at 12:07 PM, the Surveyor entered an employee restroom. A sign on the back of the restroom door stated, Employee Covid rapid testing will continue Mondays, Wednesdays, and Fridays until 10/28/23. If another positive case occurs the date will extend. Please remember to test if you are working those days; (Typed as written.) The sign was signed by the Infection Preventionist (IP). According to the COVID-19 staff line listing provided by the IP, the following staff members tested positive for COVID-19 by rapid Point of Care (POC) testing: Nursing Assistant (NA) #89 tested positive on 09/30/23. The staff member had worked in the facility that day. Registered Nurse (RN) #91 tested positive on 09/30/23. RN #91 had worked from 6:56 AM to 8:06 PM, before becoming symptomatic with a runny nose, cough, congestion, and fatigue and testing positive for COVID-19. NA #50 tested positive on 10/02/23. The staff member had not worked in the facility that day. Housekeeper #65 tested positive on 10/06/23. The staff member had not worked in the facility that day. The staff member had worked two (2) days prior to testing positive. Housekeeper #91 tested positive on 10/13/23. The staff member had not worked in the facility that day. The staff member had worked two (2) days prior to testing positive. NA #45 tested positive on 10/20/23. NA #45 had worked from 6:05AM to 11:08 PM before becoming symptomatic with cough and shortness of breath and testing positive for COVID-19. During a follow-up interview on 10/25/23 at 1:45 PM, the DON and IP confirmed no staff members had been wearing masks. The DON and IP confirmed no signage had been placed at the facility door to indicate the facility had an outbreak of COVID-19. It was also confirmed that residents had not been tested . On 10/23/23, 10/24/23 and the morning and afternoon of 10/25/23 no staff members were observed wearing masks. The survey team was not advised to wear masks. b) According to Centers for Disease Control and Prevention (CDC) guidelines titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 05/08/23. Asymptomatic patients with close contact with someone with COVID 19 infection should have a series of three viral tests for COVID 19 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. c) Additionally, the CDC guidelines of 05/08/23, states the source control (or masks) should be worn, those residing or working on a unit or area of the facility experiencing a COVID 19 or other outbreak of respiratory infection; universal use of source control could be discontinued as a mitigation measure once the outbreak is over (e.g., no new cases of COVID 19 infection have been identified for 14 days). d) The facilities policy titled Criteria for COVID-19 Requirements with effective date 10/11/21 and most recent revision 05/11/23 stated in part as follows: Source control should be worn by employees who are being tested as part of outbreak testing. The definition of a COVID-19 outbreak is when a single new case of Covid-19 occurs among residents or staff. Ensure all who enter the facility are aware of the recommended Infection Prevention Control (IPC) practices in the facility. Post signs and visuals at the entrance, lobby, elevators, break rooms, therapy, activity rooms, and on the units that include instructions about the current infection prevention and control recommendations (when to use source control and hand hygiene). Residents who have been exposed to a positive person with COVID 19 and is asymptomatic, will be tested immediately (not earlier than 24 hours). If the tests are negative, repeat in 48 hours (testing should be done day one (1), day three (3) and day five (5)). e) The facility was first notified of the Immediate Jeopardy (IJ) at 3:23 PM, on 10/25/23. The state agency (SA) received the Plan of Correction (POC) at 4:45 PM on 10/25/23. The SA accepted the POC on10/25/23 at 5:47 PM. On 10/25/23 at 5:50 PM, a tour of the facility was started and noted all staff were wearing a mask. Interviews with the staff found they were informed of being in a COVID 19 outbreak and must wear their mask always covering their nose and mouth. f) On 10/25/23 the Nursing Home Administrator and Director of Nursing implemented the following plan: 1.Upon discovery of alleged deficiency, door signage was placed at 2:30 PM to indicate facility outbreak of COVID-19. Health Department notified at 2:00 PM on 10/25/2023 of outbreak status. All facility residents to immediately be tested by nursing staff to ensure no further positive COVID 19 cases. Facility to begin notification to all residents/responsible parties of positive COVID cases amongst employees. All staff to immediately begin wearing masks thru 11/4/23. Staff will continue to test until 11/4/23. If further positive cases are identified, masking and testing will continue. PPE made available at front entrance of facility for any visitor wishing to utilize it. 2. All residents have the potential to be affected by this alleged deficient practice. 3. Immediate written education provided to all on duty staff. Education will be provided to all staff prior to start of next shift. 4. DNS or designee will audit any positive staff or resident to ensure COVID 19 policies are followed in their entirety 5 times a week for 8 weeks and then randomly thereafter to ensure compliance with plan of correction. DNS or designee will report audit findings to the QA committee monthly for review and revision of plan and/or educational requirements to ensure future compliance. g) On 10/26/23 at 8:00 AM, the Administrator provided employee signed in-services, containing information on COVID 19 outbreak and mask use. Also, all staff were provided with a copy of the COVID 19 policy. h) The SA observed for the implementation of the POC and the IJ was abated on 10/26/23 at 9:08 AM. Post abatement the deficiency was reduced to scope and severity of F. i) Resident #70 During observation of Resident #70's room on 10/23/23 at 1:19 PM, no signage of any kind was noted at the entrance to the resident's room or on the resident's door. Review of Resident #70's physician's orders showed an order written on 09/28/23 for contact isolation precautions for Vancomycin-resistant Enterococci infection of the knee. On 10/23/23 at 1:55 PM, the Director of Nursing confirmed Resident #70 was in contact isolation precautions, but the resident's room did not have signage to communicate this to staff and others. j) Resident #70 - appropriate personal protective equipment On 10/25/23 at 11:55 AM, Social Services Designee #128 was noted to be speaking to Resident #70 in her room. She was wearing no personal protective equipment such as gown and gloves. k) Resident #70's room had a sign on the door, which read as follows: Stop Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. l) On 10/26/23 at 11:59 PM, Social Services Designee #128 left Resident #70's room. Social Services Designee #128 stated had been reviewing the care plan with the resident. She stated she did not know the resident was in contact isolation precautions and she did not see the contact isolation sign on the resident's door. m) Resident #167 - contact precautions signage During observation of Resident #167's room on 10/23/23 at 2:36 PM, no signage of any kind was noted at the entrance to the resident's room or on the resident's door. Review of Resident #167's physician's orders showed an order written on 10/20/23 for contact isolation precautions for Methicillin-resistant Staphylococcus aureus in the foot. On 10/23/23 at 2:48 PM, the Director of Nursing confirmed Resident #167 was in contact isolation precautions, but the resident's room did not have signage to communicate this to staff and others. n) Resident #167 - appropriate personal protective equipment On 10/25/23 at 12:09 AM, Nursing Assistant (NA) #40 was noted to be in Resident #167's room, standing outside the bathroom in the resident's room. She was wearing no personal protective equipment such as gown and gloves. o) Resident #167's room had a sign on the door, which read as follows: Stop Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. p) NA #40 left the resident's room on 10/25/23 at 12:15 PM. NA #40 stated she had been assisting Resident #167 in the bathroom. She stated she did not know the resident was in contact isolation precautions and she did not see the contact isolation sign on the resident's door. q) laundry room On 10/26/23 at 9:15 AM, a tour of the laundry room with Director of Plant Maintenance (DPM) #76. DPM #76 confirmed using a paper towel at the bottom of the door, that the airflow was going from the soiled laundry room to the clean laundry room. DPM #76 stated his exhaust fan in the soiled room must not be working properly. On 10/26/23 at 12:03 PM, the Administrator was informed of the above findings. r) During a dining observation, on A Hall on 10/24/23 beginning at 11:53 AM, the observation revealed the lunch trays arrived at 11:54 AM. Nurse Aide (NA) # 35 were observed passing two (2) noon meal trays. During the observations hand hygiene was not offered to the residents prior to receiving their noon meal. NA # 50 was observed passing two (2) noon meal trays. During the observations hand hygiene was not offered to the residents prior to receiving the noon meal. This surveyor intervened and inquired about hand hygiene. During an interview, on 10/24/23 at 12:00 PM, NA #35 stated no hand hygiene was performed prior to the meal being served. During an interview, on 10/24/23 at 12:00 PM, NA #50 stated no hand hygiene was performed prior to the meal being served. Hand sanitizer wipes were not placed on the meal trays. There were no hand sanitizer bottles observed near the serving areas. During an interview, on 10/25/23 at 11:04 AM, the DON was made aware of the above situation. She stated, We hand wipes for the residents. I do not why they are not utilizing them. 45174