Every finding on record at The Gardens

Based on interview, document review, and facility policy review, the facility failed to implement the interdisciplinary water management process described in their policy and failed to conduct a facility-specific risk assessment of its water system to identify vulnerabilities to water-borne pathogens. These deficient practices had the potential to affect all 65 residents who currently resided in the facility.Findings included: A facility policy titled, Legionella Water Management Program revised 07/2017, indicated, 1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. 2. The water management team will consist of at least the following personnel: a. The infection preventionist; b. The administrator; c. The medical director (or designee); d. The director of maintenance; and e. The director of environmental services. The policy specified, 5. The water management program included the following elements: a. An interdisciplinary water management team; b. Reviewing the areas of potential risk for Legionella including the following: 1) Receiving; 2) Cold water distribution; 3) Heating; 4) Hot water distribution; and 5) Waste. c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including: 1) Storage tanks; 2) Water heaters; 3) Filters; 4) Aerators; 5) Showerheads and hoses; 6) Misters, atomizers, air washers and humidifiers; 7) Hot tubs; 8) Fountains; and 9) Medical devices such as CPAP [continuous positive airway pressure] machines, hydrotherapy equipment; etc. [et cetera, and the rest] d. The identification of situations that can lead to Legionella growth, such as: 1) Construction; 2) Water main breaks; 3) Changes in municipal water quality; 4) The presence of biofilm, scale or sediment; 5) Water temperature fluctuations; 6) Water pressure changes; 7) Waters stagnation and; 8) Inadequate disinfection. The facility Water Safety Audit dated 06/02/2026, revealed a general checklist of items to include water temperatures, flushing activities, plumbing review, aerosol-generating devices, and construction considerations. The audit did not identify facility-specific water system components, facility-specific risk areas, or vulnerabilities within the facility water system that could encourage the growth and spread of Legionella and other waterborne pathogens. The audit further did not describe the facility's water distribution system to include the receipt of incoming water, cold water distribution, heating, hot water distribution, or waste systems as identified in the facility policy. The facility Monthly Flushing of Inactive Plumbing Fixtures revealed a checklist of monthly flushes for Hall 100, Hall 200, Hall 300, Hall 400, the kitchen, outside faucets, common areas, drinking fountains, and flushed water heaters. The checklist indicated the staff conducted flushes but provided no other details for how the facility had identified where its water system was vulnerable to Legionella or other waterborne pathogens. During an interview on 07/17/2026 at 9:07 AM, the Environmental Services Director (ESD) stated every Tuesday she tested and flushed taps in the facility and inspected every hot water tank and every line, but did not document the weekly flushes. The ESD stated there was no documentation that she identified areas in the water system that could encourage the growth and spread of Legionella or other waterborne pathogens. The ESD stated she not able to explain how the facility water system worked. During an interview on 07/17/2026 at 9:43 AM, the ESD stated she could not verify the facility did anything to prevent Legionella or waterborne pathogens beyond flushing. During an interview on 07/17/2026 at 10:32 AM, the Infection Preventionist stated she had no involvement in the water management plan. During an interview on 07/17/2026 at 11:32 AM, the Director of Nursing stated she had no involvement in the water management plan, did not know about a facility-specific water system assessment, and did not know who was supposed to be on the water management team. During an interview on 07/17/2026 at 1:38 PM, the Administrator stated she could not speak to whether the facility had a risk assessment of its water system. Per the Administrator, her role in the water management team was to check the county report to see if there were any concerns in the municipal water supply.

Based on interview, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) for 3 (Residents #9, #46, and #57) of 5 sampled residents reviewed for unnecessary medications.Findings included: A facility policy titled, Resident Assessment Instrument, revised 09/2010, indicated A comprehensive assessment of a resident's needs shall be made within fourteen days of the resident's admission. The policy specified, 7. All persons who have completed any portion of the MDS Resident Assessment Form MUST sign such document attesting to the accuracy of such information. 1. An admission Record revealed the facility admitted Resident #46 on 08/02/2024. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease and dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/17/2026, revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident received an antipsychotic medication during the last seven days of the assessment period. Resident #46's Order Recap Report for the timeframe 01/01/2026 - 07/31/2026, revealed no evidence of an order for a antipsychotic medication. During an interview on 07/17/2026 at 2:15 PM, the Director of Nursing (DON) stated she had been made aware of the MDS issue. The DON stated her expectation was that MDS assessments were completed accurately.2. An admission Record revealed the facility admitted Resident #9 on 09/11/2017. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease and dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/30/2026, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident received an antipsychotic medication during the last seven days of the assessment period. Resident #9's Order Recap Report for the timeframe 01/01/2026 - 07/31/2026, revealed no evidence of an order for a antipsychotic medication. During an interview on 07/16/2026 at 3:07 PM, the Nurse Assessment Coordinator (NAC) reviewed Resident #9's physician orders and confirmed that Resident #9 did not receive an antipsychotic medication during the last seven days of the assessment period for the quarterly MDS, with an ARD of 04/30/2026. The NAC stated the coding of an antipsychotic medication for Resident #9 was a mistake. During an interview on 07/17/2026 at 1:46 PM, the Administrator stated she would expect MDS staff to code a resident's MDS assessments correctly. 3. An admission Record revealed the facility admitted Resident #57 on 10/01/2025. According to the admission Record, the resident had a medical history that included diagnoses of generalized anxiety disorder, cognitive communication deficit, and dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/15/2026, revealed Resident #57 had a Brief Interview for Mental Status (BIMS) of 0, which indicated the resident had severe cognitive impairment. The MDS indicated the resident received an antipsychotic medication during the last seven days of the assessment period. Resident #57's Order Recap Report for the timeframe 01/01/2026 - 07/31/2026, revealed no evidence of an order for a antipsychotic medication. During an interview on 07/16/2026 at 3:07 PM, the Nurse Assessment Coordinator (NAC) stated regarding Resident #57, she coded the use of the medication memantine (a medication used to treat dementia linked to Alzheimer's disease) as an antipsychotic medication on the resident's quarterly MDS, with an ARD of 04/15/2026. The NAC that was an error on her part as memantine was not an antipsychotic medication. During an interview on 07/16/2026 at 11:32 AM, the Director of Nursing stated memantine was not an antipsychotic and should not be coded as such on a resident's MDS. During an interview on 07/17/2026 at 1:46 PM, the Administrator stated she would expect MDS staff to code a resident's MDS assessments correctly.

Based on interview, record review, document review, and facility policy review, the facility failed to timely report an allegation of abuse to the state agency for 1 (Resident #77) of 2 sampled residents reviewed for abuse.Findings included: A facility policy titled, Abuse Investigation and Reporting revised 07/2017, indicated, 2. An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury. An admission Record revealed the facility admitted Resident #77 on 09/01/2024. According to the admission Record, the resident had a medical history that included a diagnosis of dementia. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/24/2025, revealed Resident #77 had a Brief Interview for Mental Status score of 3, which indicated the resident had severe cognitive impairment. Resident #77's Progress Note authored by Licensed Practical Nurse (LPN) #1 and dated 12/16/2025 at 8:42 AM, indicated LPN #1 recorded that she would notify the resident's family of the statement made by the resident. An undated incident report form revealed on 12/16/2025 the facility reported to the state survey agency an allegation of abuse/mistreatment. Per the incident report form, a charge nurse was informed by a day shift certified nursing assistant (CNA) and hospice aide that resident stated they was raped. The incident report form further indicated, On 12/16/25 [Resident #77] informed day shift 6-2 CNA and Hospice Aide that [he/she] raped, Aides informed charge nurse. Nurse verified statement with [Resident #77]. Nurse contacted [name] PA-C [physician assistant-certified] to make aware of the statement, nurse was giving new orders for U.A. [urinalysis] and for psychiatrist to eval [evaluate] and treat. [Resident #77's] POA [power of attorney] was called and notified. According to the facsimile result report, the facility reported the allegation of abuse to the state survey agency on 12/16/2025 at 3:07 PM. During an interview on 07/15/2026 at 10:26 AM, the Administrator stated the facility reported allegations of abuse to the state survey agency within two hours. The Administrator stated she did not remember when she reported the allegation of abuse to the state survey agency regarding Resident #77. During an interview on 07/15/2026 at 10:54 AM, the Infection Preventionist stated the facility became aware of Resident #77's allegation of abuse on 12/16/2025 at approximately 9:00 AM. During an interview on 07/15/2026 at 11:32 AM, the Director of Nursing (DON) the facility should report allegations of the abuse to the state survey agency within two hours of becoming aware of the allegation. The DON states she was unsure why Resident #77's abuse allegation was reported late.

Based on interview, record review, and facility policy review, the facility failed to implement wound treatment when a resident was assessed to have shearing on their coccyx for 1 (Resident #76) of 2 sampled residents reviewed for pressure ulcer/injury.Findings included: A facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol revised 03/2014, revealed, 3. The staff will examine the skin of a new admission for ulcerations or alterations in skin. 4. The physician will assist the staff to determine etiology and characteristics of the skin alteration. The policy specified, 1. The physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings, and application of topical agents if indicated for type of skin alteration. An admission Record revealed the facility admitted Resident #76 on 07/01/2024. According to the admission Record, the resident had a medical history that included diagnoses of obesity and hypertension. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (AR) of 06/25/2025, revealed Resident #76 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident was at risk of developed pressure ulcers/injuries, had moisture associated skin damage (MASD), but no unhealed pressure ulcers. Resident #76's Care Plan Report included a focus area initiated 08/01/2025 that indicated the resident had a pressure injury to their skin or a potential for pressure injury. Interventions directed staff to administer treatment as ordered and monitor effectiveness (initiated 08/01/2025). Resident #76's Skin/Wound Note dated 05/29/2025 at 12:35 PM, indicated the resident had no skin tears and no opened areas. Resident #76's admission Summary dated 06/19/2025, revealed Resident #76 returned from the hospital and had no opened areas, but shearing was noted on their coccyx that was red in color. Resident #76's Skin/Wound Note dated 06/26/2025 at 12:02 PM, indicated the resident had an opened area on their right buttock that measured 8 centimeters (cm) by 6 cm and connected to the left buttocks wound which measured 5.5 cm by 4.5 cm, and an opened area on the left center of their buttocks that measured 1 cm by 1 cm. The Skin/Wound Note indicated a treatment of zinc oxide was applied as ordered. Resident #76's medical record revealed no evidence of a wound treatment order for shearing noted on the resident's coccyx on 06/19/2025. During an interview on 07/16/2026 at 2:30 PM, Licensed Practical Nurse #1 stated she could not recall if the resident had a treatment in place for the shearing identified on 06/19/2025. During an interview on 07/17/2026 at 9:45 AM, the Infection Preventionist (IP) stated the facility would normally implement zinc oxide cream as a treatment for shearing, but the resident's physician should be notified of the skin concern because a physician's order would be needed for wound treatment. The IP reviewed Resident #76's medical record and confirmed that a wound treatment was not implemented when shearing was identified on the resident's coccyx on 06/19/2025. During an interview on 07/17/2026 at 10:32 AM, the Director of Nursing stated if skin conditions were identified, she would expect the nursing staff to contact the resident's physician because a wound treatment would require a physician's order. During an interview on 07/17/2026 at 11:33 AM, Nurse Practitioner #5 stated if a resident had shearing, there would normally be a treatment of zinc oxide or skin prep ordered. During an interview on 07/17/2026 at 1:49 PM, the Administrator stated she would expect the nursing staff to contact the resident's physician to obtain an order for treatment.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff cleaned and stored respiratory equipment after each use for 1 (Resident #28) of 21 sampled residents. Findings included: A facility policy titled, A1A6 Administering Medication through a Small Volume Nebulizer revised 10/2010, revealed, 27. Rinse and disinfect the nebulizer equipment according to facility protocol, or: a. Wash pieces with warm, soapy water; b. Rinse with hot water; c. OR may clean with disinfectant if rinsed afterward. e. Allow to air day on a paper towel. 28. Wash and dry hands. 29. When equipment is completely dry, store it in a safe and sanitary manner. An admission Record revealed the facility admitted Resident #28 on 07/11/2025. According to the admission Record, the resident had a medical history that included a diagnosis of chronic obstructive pulmonary disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/17/2026, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Resident #28's Order Summary Report with active orders as of 07/11/2025, revealed an order dated 07/11/2025, for levalbuterol hydrochloride inhalation nebulization solution 1.25 milligram per 0.5 milliliter, one vial inhale orally by way of a nebulizer three times a day for chronic obstructive pulmonary disease. During an observation on 07/13/2026 at 9:28 AM, Resident #28's nebulizer mask was noted not to be stored in a bag. During an interview on 07/14/2026 at 4:00 PM, Resident #28 stated the nurses had not cleaned their nebulizer. During a concurrent interview and observation on 07/14/2026 at 4:17 PM, the Director of Nursing (DON) confirmed Resident #28's nebulizer mask was not in a bag. The DON stated the nebulizer mask should have been cleaned, dried, and bagged after use. During an interview on 07/15/2026 at 11:50 AM, Licensed Practical Nurse #1 stated she administered Resident #28's nebulizer treatment and did not clean and bag the nebulizer mask after use. During an interview on 07/16/2026 at 4:00 PM, the Administrator stated she expected the nurse to clean the nebulizer after use and place it in a bag.

Based on observation, interview, and facility policy review, the facility failed to post the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, post the total number and actual hours for registered nurses responsible for resident care per shift, and maintain a minimum of 18 months of nurse staffing data. These deficient practices had the potential to affect all 65 residents who currently resided in the facility.Findings included: A facility policy titled, Staffing revised 04/2007, indicated 5. Inquires or concerns relative to our facility's staffing should be directed to the Administrator or his/her designee. During an observation on 07/16/2026 at 4:10 PM, the posted staffing information for the facility indicated the name of the facility, census, and the number of licensed nursing staff and certified nursing staff per shift directly responsible for resident care. The posted staffing information did not indicate the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift or the total number and actual hours for registered nurses responsible for resident care per shift. During an interview on 07/16/2026 at 4:16 PM, the Administrator stated the facility did not retain nurse staffing data. During an interview on 07/16/2026 at 4:24 PM, the Administrator stated she was responsible for posting the nurse staffing data and that she had never documented the actual hours worked by licensed and unlicensed staff on the form. During an interview on 07/16/2026 at 11:32 AM, the Director of Nursing stated she was not responsible for the posting of nurse staffing data and was not familiar with the expectation for the posting of nurse staffing data. During an interview on 07/16/2026 at 1:38 PM, the Administrator stated she was not aware of the requirement to post the actual hours worked by licensed and unlicensed staff or the requirement to maintain nurse staffing data for 18 months.

Based on observation, record review, and interview, the facility failed to perform hand hygiene during wound care and follow enhanced barrier precautions during wound care for one (Res #36) of three sampled residents reviewed for wounds. The administrator identified 61 residents resided in the facility. Findings: A hand washing/hand hygiene policy documented staff should cleanse their hands before applying non-sterile gloves and after removing gloves Res #36 had diagnoses which included diabetes, hypertension, presence of ostomy, and neuropathic bladder. On 09/12/24 at 10:09 a.m., LPN #1 was observed performing wound care for Res #36. The LPN did not perform hand hygiene after removing soiled gloves and before donning new gloves. The LPN was not wearing a PPE gown. On 09/12/24 at 10:18 a.m., LPN #1 stated they should have cleaned their hands between clean and dirty gloves. On 09/13/24 at 8:44 a.m., LPN #1 stated Res #36 was on enhanced barrier precautions because they have a foley and ostomy. They stated they did not follow enhanced barrier precautions during wound care on 09/12/24.

Based on record review and interview the facility failed to provide notices to Medicaid recipients trust account holder when balances was within $200 of the resource limit for a medicaid recipient resident for two (#1 and #17) of three sampled residents reviewed for active trust account balances. The Business office manger identified seven residents that have money in the trust account, were current residents and had Medicaid as their payer source. Findings: The facility policy Notification of Certain Balances read in part, .It is the policy of this facility to notify Residents or their legal representatives when their trust fund balances approach the limits of Medicaid eligibility .written notification of trust fund balance .will be mailed/delivered to Residents or their legal representative . 1. A review of Resident #17 current trust account ledger balance documented the resident had a balance of $2,229.24 as of 09/11/2024. A review of Resident #17 face sheet indicated they had a payor source of Medicaid. There was no documentation to indicate the facility provided Resident #17 with a notice their balance was within $200 of the medicaid resource limit. 2. A review of Resident #3 current trust account ledger balance documented the resident had a balance of $2,264.92 as of 09/11/2024. A review of Resident #3 face sheet indicated they had a payor source of Medicaid. There was no documentation to indicate the facility provided Resident #17 with a notice their balance was within $200 of the medicaid resource limit. On 09/13/24 at 10:11 a.m., the business office manager stated the resource limit for medicaid was $2,000. They stated it was important the resident did not go over that limit to ensure they were not taken off their medicaid. The business office manager then stated they would need to check and see about providing notices when they were within $200 of the limit and it had not been completed for Resident #17 and #3. On 09/13/24 at 10:55 a.m., the administrator confirmed the facility had not been providing notices to the residents when they were within $200 of the resource limit.

Based on record review and interview, the facility failed to close out trust accounts and convey funds within 30 days for three (#108, 109, 110 and #11) of four residents reviewed for open trust accounts and had been discharged from the facility over 30 days. The Business Office Director identified eight residents who no longer resided in the facilty and trust accounts were not closed out within 30 days. Findings: The facility policy Conveyance of Funds Upon a Residents Death read in part, .It is the policy of this facility that upon death of a Resident with personal funds on deposit with the facility, the facility will promptly convey such funds, along with a final accounting of such funds .accounting will be made within thirty (30) days of the death . The facility policy Closing Resident Fund Accounts and Release of Funds read in part, .It is the policy of this facility to release to a resident or his/her representative the Residents trust funds upon discharge, transfer or resident request the facility will process refunds to discharged residents within thirty (30) days of the date of discharge . 1. Resident #108 discharge summary, dated 12/04/22 indicated they passed away and the body was released to the funeral home on 12/04/22. A review of the recipient trust account balance, dated 09/11/24, documented Resident #108 had a current balance of $6,890.62. Resident #108 trust account remained opened 647 days after their death. 2. Resident #109 progress's notes, dated 10/01/23, documented the resident was sent to the hospital unresponsive. A review of the recipient trust account balance, dated 09/11/24, indicated Resident #109 had a current balance of $8,859.20. Resident #109 trust account remained opened 346 days after their death. 3. Resident #110 discharge summary, dated 04/12/24, documented they passed away and the body was released to the funeral home. A review of the recipient trust account balance, dated 09/11/24, indicated Resident #110 had a current balance of $6,455.87 Resident #110 trust account remained opened 122 days after their death. 4. Resident #111 face sheet documented they were discharged on [DATE]. A review of the recipient trust account balance, dated 09/11/24, indicated Resident #111 had a current balance of $3,253.78 Resident #111 trust account remained opened 39 days after they were discharged from the facility. On 09/13/24 at 10:11 a.m., the Business Office Manager stated the facility had thirty days to close out accounts to make sure everyone had been paid. The Business Office Manager stated the requirement had not been met and there were currently eight accounts that were not closed out within 30 days. On 09/13/24 at 10:55 a.m., the administrator was made aware of the trust accounts not being closed out within 30 days. The administrator acknowledged and confirmed the accounts were still open over 30 days.

Based on record review and interview, the facility failed to ensure residents had access to their trust account money on nights and weekends for three (#3, 17, and #34) of three residents reviewed for access to their trust account money. The business office manager identified seven current residents who had money in the trust account. Findings: The facility policy Trust Fund Petty Cash Imprest Fund. read in part, .cash is disbursed to Residents from the trust fund petty cash imprest fund Monday through Friday, 9:00 a.m. to 4:00 p.m. daily, excluding weekends and holidays . On 09/11/24 at 9:26 a.m., Resident #34 stated they could not get money on weekends or at night, and they had to ask in advance if they wanted money on the weekends. On 09/10/24 at 1:42 p.m., Resident #17 stated they could not get money on the weekends because no one was at the facility to provide the money. Resident #17 stated if they wanted money for the weekend they would need to get it on Friday. On 09/13/24 at 9:32 a.m., Resident #3 stated they could not get money during the night and on the weekends because the office was closed and no one had access to the money. On 09/13/24 at 10:11 a.m., the business office manager stated they and the administrator were the only ones that had access to resident petty cash funds and money was not available when they were not working or at the facility. On 09/13/24 at 10:55 a.m., the administrator confirmed they and the business office manager were the only one that had access to funds and they did not have anything in place for the night and weekends.

Based on record review and interview the facility failed to document a discharge summary for one (#55) of three sampled residents reviewed for closed records. The administrator identified 61 residents resided in the facility. Findings: Res #55 was discharged from the facility on 06/21/24. A discharge summary was not documented in the EHR. On 09/13/24 at 12:11 p.m., the administrator stated there was no discharge summary for Res #55.

Based on observation, record review and interview, the facility failed to ensure a resident with a newly identified diagnosis of psychosis and hallucination after admission, submitted a PASRR with the new diagnosis for one (#34) of two sampled residents reviewed for pre-admission screening and resident review. MDS Coordinator #1 identified 35 residents who currently had a diagnosis of a serious mental health condition. Findings: Resident # 34 had a level one pre-admission screening and resident review (PASARR) completed on 07/22/22 with a primary diagnosis of neuropathy and a secondary of obesity. The level one did not indicate Resident #34 had a serious mental health diagnosis. A review of the care plan, and the current diagnosis list with onset dates, indicated the resident had new diagnosis of psychosis and hallucinations on 03/27/2024. A review of the clinical record contained no PASARR with the new serious mantel health diagnosis of hallucinations and psychosis. On 09/12/24 at 10:20 a.m. Minimum Data Set (MDS) Coordinator #1, stated they were responsible for completing pre-admission screening and resident review and they were to be completed within ten days of admission. The MDS coordinator stated Resident #34 had a new serious mental health diagnosis in March 2024 and the PASARR was not completed with the new diagnosis. They then stated, It was an oversight on my behalf.

Based on record review and interview, the facility failed to notify a resident's representative of an involuntary discharge for one (#55) of three sampled residents reviewed for closed records. The administrator identified 61 residents resided in the facility. Findings: A facility Transfer or Discharge, Emergency policy documented in the event of an emergency transfer or discharge the representative or other family member should be notified. Res #55 had diagnoses which included Parkinsonism Res #55 was involuntarily discharged from the facility on 06/21/24. On 09/13/24 at 8:36 a.m., the social services director stated they had started Res #55's discharge because they had started to be aggressive with staff. They stated the administrator and DON had taken over the discharge because there were complications with the family. On 09/13/24 at 10:05 a.m., the administrator stated Res #55 was discharged because the facility could not meet their needs. They stated the resident had been approved at a facility that had required an evaluation to ensure the patient was medically stable for transfer due to the distance the resident would have to travel to get to the new facility. They stated they were unsure if the POA/representative had been notified in writing before the discharge happened. On 09/13/24 at 10:39 a.m., the administrator stated the facility did not provide written notice of discharge to Res #55's representative.

Based on observation, interview, and record review, the facility failed to ensure a U-bar was accommodated for residents needs for two (#158 and #164) of two sampled residents who wanted the rail for steadying and repositioning. The Administrator identified 61 residents resided in the facility. Findings: A policy, titled, bed safety, documented, .side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified . A resident council form, dated 08/01/24, docmented, .issue presented .U-bars removed per state regulation .response .evaluation and consent . On 09/10/24 at 12:14 p.m., resident #164 stated they needed railings to turn while in bed. They also stated they were blind so the railings could assist with perception. On 09/11/24 at 8:54 a.m., resident #158's family stated they wanted them to have a u bar since they were unsteady and for repositioning since they had fallen at home. They stated there were told they couldn't. They stated they would get a doctor note, if needed. On 09/12/24 at 12:20 p.m., LPN #2 stated it was their understanding that they couldn't have them anymore because they were restraints. So they were removed. On 09/13/24 9:06 a.m., CMA #1 stated they were told they needed a doctor note to help stand or turn otherwise they were not allowed to have. On 09/13/24 at 10:01 a.m., the Administrator stated they don't use bedrails. They used positioning enablers. They stated a lot of buildings had been tagged for them. On 09/13/24 at 11:00 a.m., Resident #164 stated when she asked for a rail the staff stated they could not provide a rail because of the State. On 09/13/24 at 12:40 p.m., during exit, MDS coordinator #1 stated neither resident had been assessed for bed safety rails.

Based on record review and interview, the facility failed to ensure the physician received monthly drug regimen reviews, and acted upon recommendations by the pharmacist, for two (#2 and #34) of five residents reviewed for unnecessary medications. The Resident Census and Condition of Residents form, dated 07/17/23, documented 48 residents resided in the facility. Findings: A facility policy, Medication Regimen Reviews, revised 2007, documented in part, .The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately .The Consultant Pharmacist will provide the Director of Nursing Services and Medical Director with a written, signed and dated copy of the report, listing the irregularities found and recommendations for their solutions .Copies of drug/medication regimen review reports, including physician responses, will be maintained as part of the permanent medical record . 1. Resident #2 had diagnoses which included chronic respiratory failure, chronic obstructive pulmonary disease, rheumatoid arthritis, type 2 diabetes mellitus, delusional disorders, depression, and anxiety. A monthly drug regimen review, dated 01/30/23, documented the pharmacist requested the physician to consider a reduction of risperidone 1 mg and alprazolam 1 mg. There was no indication the form had been provided to the physician, and the form documented no response or signature. A quarterly MDS assessment, dated 05/16/23, documented the resident was cognitively intact. The assessment documented the resident received antipsychotics, antianxiety medications, antidepressants, anticoagulants, diuretics, and opioids seven of seven days previous. A monthly drug regimen review, dated 05/30/23, documented a recommendation to reduce Amitriptyline 20 mg daily to 10 mg daily. There was no indication the form had been provided to the physician, and the form documented no response or signature. On 07/18/23 at 2:48 p.m., the Pharmacy Consultant was interviewed regarding monthly drug regimen reviews and was asked to review resident #2's medical record. The Pharmacy Consultant stated there was a request in January 2023 to evaluate a couple of the resident's medications. He checked the medical record and was unable to locate any documentation with a response from the physician. He stated he could put in another request since it was time for the resident's medications to be reviewed again. 2. Resident #34 was admitted with diagnoses which included chronic obstructive pulmonary disease, peripheral vascular disease, arterial embolism, type 2 diabetes mellitus, chronic pain, anxiety, and depression. A monthly drug regimen review, dated 01/30/23, documented in part, .please consider ordering and obtaining a yearly lipid panel if clinically indicated . There was no indication the form had been provided to the physician, and the form documented no response or signature. A quarterly MDS assessment, dated 04/26/23, documented resident #34 was cognitively intact. The assessment documented the resident received injections, antidepressants, and diuretics seven of seven days previous. On 07/19/23 at 11:20 a.m., the DON was interviewed regarding the process for ensuring monthly drug regimen reviews were reviewed by the physicians. The DON stated they had boxes near the nurse's station where the requests were placed to be reviewed by the physicians. The DON stated the physician should review, sign, and give new orders if indicated to the charge nurse or place in the DON's box. The DON stated she had not received any drug regimen review recommendations during the time she had worked at the facility, and stated she started in May of 2023. The DON reported she had just received a stack of drug regimen reviews for June 2023 and she would place these in the physician boxes. The DON stated she had recognized an issue with their current process and had been working on trying to improve the process to ensure drug regimen reviews were addressed in a timely manner.

Based on record review and interview, the facility failed to ensure residents received their showers/baths as scheduled for three (#13, 32, and #34) of three sampled residents who were reviewed for showers/baths. The administrator identified 10 residents who were dependent on staff for bathing. Findings: 1. Resident (Res) #13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 04/29/21, read in parts, .Focus .I require assistance with adls .Interventions .assist me with bathing as needed . The quarterly MDS assessment, dated 10/29/21, documented the resident was cognitively intact, utilized a wheelchair for mobility, and required physical help with part of bathing activity. On 01/10/22 at 11:28 a.m., Res #13 stated she had not received a shower since 12/24/21. A review of Res #13's electronic clinical record revealed documentation of one bath in the last 30 days. A review of the shower schedule provided by the facility revealed Res #13's showers/baths were scheduled Monday and Thursday on the 2:00 p.m. - 10:00 p.m. shift. A review of bath/shower sheets provided by the facility revealed Res #13 received a whirlpool bath on 01/10/22. 2. Resident (Res) #32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 09/02/21, read in parts, .Focus .I require assistance with adls .Interventions .assist me with bathing as needed . The quarterly MDS assessment, dated 12/01/21, documented the resident was cognitively intact, utilized a walker and wheelchair for mobility, and required one person physical help with transfers while bathing. On 01/10/22 at 11:38 a.m., Res #32 stated she had not received a shower in two weeks. Res #32 stated she needed her hair washed and could not keep herself clean with paper towels and soap in the sink. A review of Res #32's electronic clinical record revealed documentation of two baths in the last 30 days. A review of the shower schedule provided by the facility revealed Res #32's showers/baths were scheduled Tuesday and Friday on the 6:00 a.m. - 2:00 p.m. shift. A review of bath/shower sheets provided by the facility revealed Res #32 received a bath/shower on 01/10/22. 3. Resident (Res) #34 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 09/03/21, read in parts, .Focus .I require assistance with adls .Interventions .assist me with bathing as needed . The quarterly MDS assessment, dated 12/02/21, documented the resident was cognitively intact, utilized a walker and wheelchair for mobility, and required physical help with part of bathing activity. On 01/05/22 at 2:54 p.m., Res #34 stated she had not received a bath in a week. The resident stated they do not have enough staff to give baths. A review of Res #34's electronic clinical record revealed documentation of one bath in the last 30 days. A review of the shower schedule provided by the facility revealed Res #34's showers/baths were scheduled Tuesday and Friday on the 6:00 a.m. - 2:00 p.m. shift. On 01/06/22 at 1:30 p.m., during a resident council meeting six alert and oriented residents stated they had not received their baths/showers as scheduled. They stated they might receive a bath/shower once a week even though they were scheduled twice a week. During a confidential interview, a staff member stated there was not enough staff to give residents their scheduled baths. On 01/11/22 between 10:16 a.m. and 10:25 a.m. three staff members (CNA, CMA, and LPN) were asked if they were giving resident showers that day. They all stated no. The CNA and CMA both stated they had not been assigned showers. On 01/11/22 at 10:31 a.m., CMA #1 stated she had not given any showers yesterday (1/10/22) or today. CMA #1 was asked if residents had complained about not receiving their showers. She stated yes. On 01/12/22 at 2:25 p.m., LPN #1 stated every resident had a bath scheduled at least twice weekly. She stated they have had shower aides in the past but now CNAs were responsible for assisting residents with showers. LPN #1 was asked where showers were documented. The LPN stated the CNAs would complete a shower sheet for each resident and submit them to the DON. The LPN stated the CNA would document the shower in the electronic clinical record. LPN #1 stated the charge nurse was responsible to ensure residents received their scheduled showers. LPN#1 was asked why residents had not received their scheduled showers. She stated We are so understaffed. LPN #1 was asked if residents had complained about not receiving their scheduled showers. She stated yes. She stated when a resident complained about not receiving a shower she would ensure that resident received a shower that day.

Based on observation, record review, and interview, the facility failed to ensure the resident received treatment and services for three (#8, 14, and #32) of four sampled residents who were reviewed for wound and skin care. The facility failed to: a. document the assessment of a wound for one (#8) of two sampled residents whose records were reviewed for wound assessments; b. ensure the physician's orders were implemented for one (#14) of one sampled resident whose records were reviewed for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] c. complete wound treatments as the physician had ordered for one (#32) of two sampled residents whose records were reviewed for wound care. The administrator identified three residents who received wound care and six residents with skin conditions not identified as wounds. Findings: The Wound Care policy, revised October 2010, read in parts, .Purpose .to provide guidelines for the care of wounds to promote healing .Verify that there is a physician's order for this procedure .Mark tape with initials, time, and date and apply to dressing .The following information should be recorded in the resident's medical records .All assessment data (i.e., would bed, color, size, drainage, etc.) obtained when inspecting the wound . 1. Resident (Res) #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS assessment, dated 10/06/21, documented the resident was severely impaired in cognitive skills for daily decision making, dependent on staff for ADLs, and had one unstageable pressure ulcer. A weekly skin/wound note, dated 12/19/21, documented a wound on the left lateral (outer) malleolus (bony prominence on either side of the ankle) that measured 3 x 3 cm with open area 1.2 x 1.2 cm approximately in center, with circular wound red in color in contrast to adjacent tissue. The monthly physician orders, dated January 2022, read in part, .cleanse left outer malleolus with dermal wound cleanser pat dry apply petroleum gauze cut to fit wound bed as primary dressing and cover and secure with opti-foam dressing every other day and PRN soilage or dislodgement until resolved . A care plan, dated 01/11/22, read in parts, .Focus .I have pressure injury to my skin or potential for pressure injury .Administer treatments as my Dr. has ordered and monitor for effectiveness . A review of Res #8's clinical record did not reveal an assessment or description of the left lateral (outer) malleolus wound after 12/19/21. On 01/12/22 at 11:43 a.m., LPN #6 stated she performed wound care on Res #8. LPN #6 stated wound care instructions were documented on the TAR. Following completion of the wound care the TAR would be initialed and have a check mark to indicate wound care had been completed. LPN #6 was asked where the assessment and description of the wound was documented. The LPN stated she had not documented a description of the wound. LPN #6 was asked how nursing would know if the wound was getting better or worse without a description of the wound. She stated, I don't know. 2. Resident (Res) #14 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change assessment, dated 11/02/21, documented the resident was severely impaired in cognition, and was dependent on staff for bed mobility, transfers, toileting, and personal hygiene. A physician order, dated 12/20/21 read in part, .Cleanse open areas to back, on pain pump, with wound cleanser, pat dry, cut [MEDICATION(S)] to fit wound bed & cover with [MEDICATION(S)] Q [every] day and PRN [as needed] soilage or dislodgement, one time a day . On 01/10/22 at 12:25 p.m., Res #14 was observed to have a dressing on her back. The dressing was dated 01/07/22 and was initialed by an LPN. CNA #1 verified the date on the dressing was 01/07/22 and the initials of the LPN. On 01/11/22 at 2:26 p.m., LPN #4 stated she performed Res #14's wound care on 01/10/22. She stated the dressing she removed on 01/10/22 was dated 01/07/22. LPN #4 stated the wound care was supposed to be done daily. The LPN stated the wound care had not been done since 01/07/22. 3. Resident (Res) #32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS assessment, dated 12/01/21, documented the resident was cognitively intact, and had no documented skin problems. On 01/05/22 at 10:22 a.m., Res #32 was noted to have red spots on her left cheek. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Res #32's clinical record did not reveal documentation to support the physician's order had been implemented. On 01/12/22 at 2:33 p.m., LPN #1 stated the charge nurse was responsible to ensure physician orders, documented on the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] LPN #1 was asked how physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she did not know. LPN #1 stated she did not know why the physician's order for Res #32's [MEDICATION(S)] medication had not been implemented. On 01/12/22 at 2:56 p.m., the corporate clinical director stated the nurse in charge of the resident's care was responsible to ensure physician orders, documented on the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] The corporate clinical director was asked how physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated a process was in place for electronic physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The corporate clinical director stated staff should have been notified of this process.

Based on record review and interview, the facility failed to ensure psychoactive medications were gradually reduced and/or discontinued, unless it was clinically contraindicated, for one (#8) of five sampled residents who were reviewed for unnecessary medications. Resident Census and Conditions Report identified 31 residents who received psychoactive medication. Findings: The Tapering Medications and Gradual Drug Dose Reduction policy, revised April 2007, read in parts, .Within the first year after a resident is admitted on an antipsychotic medication or after the resident has been started on an antipsychotic medication, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, the facility shall attempt a GDR at least annually, unless clinically contraindicated . During the first year in which a resident is admitted on a psychopharmacological medication (other than an antipsychotic or a sedative/hypnotic), or after the facility has initiated such medication, the facility will attempt to taper the medication during at least two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, tapering will be attempted at least annually, unless clinically contraindicated . Resident (Res) #8 had diagnoses which included depression, [CONDITION(S)], personal history of [CONDITION(S)], [CONDITION(S)], unspecified [CONDITION(S)] not due to a substance or known physiological condition, and anxiety. A pharmacist's Note To Attending Prescriber, dated 09/30/20, read in part, .CMS guidelines recommend evaluation of new/recent admissions or readmissions who are receiving [CONDITION(S)] medications. Please note this recent admission is receiving the following [CONDITION(S)] medications: [MEDICATION(S)] [medication in the class of drugs called atypical antipsychotics used to treat mental health disorders] 25 mg per tube at bedtime . The physician documented the rationale for continued use of the medication. A review of the monthly pharmacy medication regimen reviews, located in Res #8's clinical record, dated 10/01/20 to 11/11/21, did not reveal a GDR recommendation for [MEDICATION(S)] 25 mg. During the survey, the pharmacist provided the surveyor a Note To Attending Physician/Prescriber, dated 08/27/21, which read in parts, .Facility records indicate the following [CONDITION(S)] medication(s) has/have been ordered and in place routinely for greater than or approaching 6 months without a gradual dose reduction. Please consider, if appropriate, such a reduction of one of these agents: [MEDICATION(S)] (brand name [MEDICATION(S)]) 25mg nightly ([CONDITION(S)]) .Please consider reducing to 12.5mg nightly when current supply is exhausted .Physician/Prescriber Response [blank] . The Physician/Prescriber did not address the dose reduction request for [MEDICATION(S)] (brand name [MEDICATION(S)]). The quarterly MDS assessment, dated 10/06/21, documented the resident was severely impaired in cognitive skills for daily decision making, and had received an antipsychotic, antianxiety, and antidepressant medication seven days of the seven day look back period. A pharmacist's Note To Attending Prescriber, dated 11/11/21, read in parts, .Please review the following medications for a possible reduction, if appropriate: [MEDICATION(S)] 30 mg daily - may we trial a reduction to 20 mg daily? [MEDICATION(S)] [medication used to treat depression] 150 mg daily .Agree, please reduce to .[blank] .Physician/Prescriber Response . The Physician/Prescriber signed and dated the document. The medication [MEDICATION(S)] 150 mg daily was not addressed on the document. A review of the clinical record revealed the medication [MEDICATION(S)] was reduced to 20 mg daily. Monthly physician's orders, dated January 2022, documented the resident was prescribed the following psychoactive medications: [MEDICATION(S)] tablet 25 mg one tablet via PEG-tube one time a day at 2100 (9:00 p.m.) for diagnosis of unspecified [CONDITION(S)] not due to a substance or known physiological condition, and [MEDICATION(S)] tablet 150 mg one tablet via PEG-tube one time a day for diagnosis of depression order date 08/26/20. On 01/11/22 at 10:58 a.m., the pharmacist stated they followed the CMS guidance on GDRs and would also assess the resident for change or decline. He stated for residents on psychoactive medications, GDRs were completed twice a year, as applicable. The pharmacist was asked who was responsible for ensuring the physician received the GDR requests. He stated the facility would forward the GDR requests to the physician and the DON was responsible for facilitation of the GDR requests. The pharmacist was asked why Res #8 had not had a GDR request for [MEDICATION(S)] since 9/30/20. He stated they had requested a reduction in the dosage of [MEDICATION(S)] 08/27/21 but had no documented response to the request. The pharmacist stated they would follow-up on GDR requests during their monthly MRR/GDR reviews. The pharmacist stated they would repeat the GDR request if they had not received a response. The pharmacist stated the pharmacist and the facility were responsible for follow-up when there was no response to GDR requests for psychoactive medications. The pharmacist stated the follow-up on the GDR request for [MEDICATION(S)], dated 08/27/21 had been missed. The pharmacist was asked why Res #8 had no GDR request for [MEDICATION(S)] 150 mg which was documented as ordered August 2020. He stated a request was submitted for [MEDICATION(S)] 150 mg 11/11/21 but it could have been worded better. The pharmacist was asked why a GDR had not been requested for [MEDICATION(S)] prior to 11/11/21. He stated it had been missed. On 01/12/22 at 2:47 p.m., the corporate clinical director was asked what the procedure was when the facility received MRRs with recommendations or GDR requests from the pharmacist. She stated the DON would receive the medication reviews from the pharmacist, they would be forwarded to the physician, as indicated, physician orders would be placed in the clinical record and implemented, as indicated, then all would be scanned into the clinical record. The corporate clinical director stated the DON was responsible to ensure GDR requests were conducted for residents who received psychoactive medication.

Based on record review and interview, the facility failed to provide sufficient staffing to ensure residents received their showers/baths as scheduled for three (#13, 32, and #34) of three sampled residents who were reviewed for showers/baths. The administrator identified 10 residents who were dependent on staff for bathing. Findings: 1. Resident (Res) #13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 04/29/21, read in parts, .Focus .I require assistance with adls .Interventions .assist me with bathing as needed . The quarterly MDS assessment, dated 10/29/21, documented the resident was cognitively intact, utilized a wheelchair for mobility, and required physical help with part of bathing activity. On 01/10/22 at 11:28 a.m., Res #13 stated she had not received a shower since 12/24/21. A review of Res #13's electronic clinical record revealed documentation of one bath in the last 30 days. A review of the shower schedule provided by the facility revealed Res #13's showers/baths were scheduled Monday and Thursday on the 2:00 p.m. - 10:00 p.m. shift. A review of bath/shower sheets provided by the facility revealed Res #13 received a whirlpool bath on 01/10/22. 2. Resident (Res) #32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 09/02/21, read in parts, .Focus .I require assistance with adls .Interventions .assist me with bathing as needed . The quarterly MDS assessment, dated 12/01/21, documented the resident was cognitively intact, utilized a walker and wheelchair for mobility, and required one person physical help with transfers while bathing. On 01/10/22 at 11:38 a.m., Res #32 stated she had not received a shower in two weeks. Res #32 stated she needed her hair washed and could not keep herself clean with paper towels and soap in the sink. A review of Res #32's electronic clinical record revealed documentation of two baths in the last 30 days. A review of the shower schedule provided by the facility revealed Res #32's showers/baths were scheduled Tuesday and Friday on the 6:00 a.m. - 2:00 p.m. shift. A review of bath/shower sheets provided by the facility revealed Res #32 received a bath/shower on 01/10/22. 3. Resident (Res) #34 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 09/03/21, read in parts, .Focus .I require assistance with adls .Interventions .assist me with bathing as needed . The quarterly MDS assessment, dated 12/02/21, documented the resident was cognitively intact, utilized a walker and wheelchair for mobility, and required physical help with part of bathing activity. On 01/05/22 at 2:54 p.m., Res #34 stated she had not received a bath in a week. The resident stated they do not have enough staff to give baths. A review of Res #34's electronic clinical record revealed documentation of one bath in the last 30 days. A review of the shower schedule provided by the facility revealed Res #34's showers/baths were scheduled Tuesday and Friday on the 6:00 a.m. - 2:00 p.m. shift. On 01/06/22 at 1:30 p.m., during a resident council meeting six alert and oriented residents stated they had not received their baths/showers as scheduled. They stated they might receive a bath/shower once a week even though they were scheduled twice a week. The residents were asked if they thought there was enough staff to provide their baths/showers. They stated no. During a confidential interview, a staff member stated there was not enough staff to give residents their scheduled baths. On 01/11/22 between 10:16 a.m. and 10:25 a.m. three staff members (CNA, CMA, and LPN) were asked if they were giving resident showers that day. They all stated no. The CNA and CMA both stated they had not been assigned showers. On 01/11/22 at 10:31 a.m., CMA #1 stated she had not given any showers yesterday (1/10/22) or today. CMA #1 was asked if residents had complained about not receiving their showers. She stated yes. On 01/12/22 at 2:25 p.m., LPN #1 stated every resident had a bath scheduled at least twice weekly. She stated they have had shower aides in the past but now CNAs were responsible for assisting residents with showers. LPN #1 was asked where showers were documented. The LPN stated the CNAs would complete a shower sheet for each resident and submit them to the DON. The LPN stated the CNA would chart the shower in the electronic clinical record. LPN#1 stated the charge nurse was responsible to ensure residents received their scheduled showers. LPN#1 was asked why residents had not received their scheduled showers. She stated We are so understaffed. LPN #1 was asked if residents had complained about not receiving their scheduled showers. She stated yes. She stated when a resident complained about not receiving a shower she would ensure that resident received a shower that day.

Based on record review and interview, the facility failed to ensure RN (registered nurse) coverage for eight consecutive hours for three of 14 days of staffing schedules reviewed. The administrator identified 48 residents who resided in the facility. Findings: Review of the facility staffing pattern for 12/16/21 through 12/29/21 revealed the following: 1. 12/19/21 the RN worked 0.50 hours on the first shift (6:00 a.m. - 2:00 p.m.) and 1.50 hours on the second shift (2:00 p.m. - 10:00 p.m.) for a total of two hours; 2. 12/25/21 there was no RN coverage; and 3. 12/26/21 there was no RN coverage. On 01/11/22 at 10:04 a.m., the administrator stated they did not have RN coverage in the building on the listed days but the DON/RN was on call. She stated they were actively recruiting nurses and have contacted agencies and sister facilities to obtain nursing coverage. On 01/12/22 at 10:43 a.m., the administrator stated they had no staffing or RN waivers.